Carer experience of Community Treatment Orders: implications for rights based/recovery-oriented mental health legislation

Vine, Ruth; Komiti, Angela

doi:10.1177/1039856214568216

Cited by 12 publications

(10 citation statements)

References 14 publications

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“… 8 , 11 However, some studies have reported preference among patients for CCT if the alternative is admission to hospital, 12 and carers also support use of CCT. 13 , 14 The benefits of CCT might also result from community services being obliged to provide care instead of any direct effect on patient behaviour. 15 …”

Section: Introductionmentioning

confidence: 99%

Compulsory community treatment to reduce readmission to hospital and increase engagement with community care in people with mental illness: a systematic review and meta-analysis

Barnett

Matthews

Lloyd‐Evans

et al. 2018

The Lancet Psychiatry

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SummaryBackgroundCompulsory community treatment (CCT) aims to reduce hospital readmissions among people with mental illness. However, research examining the usefulness of CCT is inconclusive. We aimed to assess the effectiveness of CCT in reducing readmission and length of stay in hospital and increasing community service use and treatment adherence.MethodsFor this systematic review and meta-analysis, we searched three databases (PsycINFO, MEDLINE and Embase) for quantitative studies on CCT published in English between Jan 1, 1806, and Jan 4, 2018. We included both randomised and non-randomised designs that compared CCT with no CCT, and pre-post designs that compared patients before and after CCT. Studies were eligible if they had been peer-reviewed, if 50% or more of patients had severe mental illness, and if CCT was the intervention. Trials in which CCT was used in response to a criminal offence were excluded. We extracted data on study characteristics and length of follow-up, patient-level data on diagnosis, age, sex, race, and admission history, and outcomes of interest (readmission to hospital, inpatient bed-days, community service use, and treatment adherence) for meta-analysis, for which we extracted summary estimates. We used a random-effects model to compare disparate outcome measures and convert effect size statistics into standardised mean differences. This systematic review is registered with PROSPERO, number CRD42018086232.FindingsOf 1931 studies identified, 41 (2%) met inclusion criteria and had sufficient data for analysis. Before and after CCT comparisons showed significant large effects on readmission to hospital (standardised mean difference 0·80, 95% CI 0·53–1·08; I2=94·74), use of community services (0·83, 0·46–1·21; I2=87·26), and treatment adherence (2·12, 1·69–2·55; I2=0), and a medium effect on inpatient bed-days (0·66, 0·46–0·85; I2=94·12). Contemporaneous controlled comparison studies (randomised and non-randomised) showed no significant effect on readmission, inpatient bed-days, or treatment adherence, but a moderate effect on use of community services (0·38, 0·19–0·58; I2=96·92). A high degree of variability in study quality was found, with observational study ratings ranging from three to nine. Bias most frequently centred on poor comparability between CCT and control participants.InterpretationWe found no consistent evidence that CCT reduces readmission or length of inpatient stay, although it might have some benefit in enforcing use of outpatient treatment or increasing service provision, or both. Future research should focus on why some people do not engage with treatment offered and on enhancing quality of the community care available. Shortcomings of this study include high levels of variability between studies and variation in study quality.FundingNational Institute for Health Research.

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Section: Introductionmentioning

confidence: 99%

Compulsory community treatment to reduce readmission to hospital and increase engagement with community care in people with mental illness: a systematic review and meta-analysis

Barnett

Matthews

Lloyd‐Evans

et al. 2018

The Lancet Psychiatry

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“…The process of recalling people to hospital may involve emergency services, including police (19). Reform of mental health legislation in Victoria has been driven by a range of concerns including the apparent overuse of CTO, concerns about their effectiveness, and human rights issues (13). The reform also intended to promote the Act’s role in supporting recovery and improve the participation of people receiving mental health treatment and care in decision-making (13).…”

Section: Cto Use In Victoriamentioning

confidence: 99%

“…CTOs are also considered “deskilling” and forming a substitute for more innovative, well-resourced and intensive services (12). Yet, informal family supporters have tended to support the use of CTOs and have identified that these orders can assist them (13). The most recent Cochrane review of the evidence for compulsory community and involuntary outpatient treatment for people with severe mental disorders concluded that despite three randomized control trials there was still no evidence that CTOs were effective in reducing clinical outcomes such as hospital readmission and quality of life (8).…”

Section: Introductionmentioning

confidence: 99%

Community Treatment Orders and Supported Decision-Making

et al. 2019

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This paper presents findings from an interdisciplinary project undertaken in Victoria, Australia, investigating the barriers and facilitators to supported decision-making (SDM) for people living with diagnoses including schizophrenia, psychosis, bipolar disorder, and severe depression; family members supporting them; and mental health practitioners, including psychiatrists. We considered how SDM can be used to align Australian laws and practice with international human rights obligations. The project examined the experiences, views, and preferences of consumers of mental health services, including people with experiences of being on Community Treatment Orders (CTOs), in relation to enabling SDM in mental health service delivery. It also examined the perspectives of informal family members or carers and mental health practitioners. Victoria currently has high rates of use of CTOs, and the emphasis on SDM in the Mental Health Act, 2014, is proposed as one method for reducing coercion within the mental health system and working towards more recovery-oriented practice. Our findings cautiously suggest that SDM may contribute to reducing the use of CTOs, encouraging less use of coercive practices, and improving the experience of people who are subject to these orders, through greater respect for their views and preferences. Nonetheless, the participants in our study expressed an often ambivalent stance towards CTOs. In particular, the emphasis on medication as the primary treatment option and the limited communication about distressing side effects, alongside lack of choice of medication, was a primary source of concern. Fears, particularly among staff, about the risk of harm to self and others, and stigma attached to complex mental health conditions experienced by consumers and their families, represent important overarching concerns in the implementation of CTOs. Supporting the decision-making of people on CTOs, respecting their views and preferences about treatment, and moving towards reducing the use of CTOs require system-wide transformation and a significant shift in values and practice across mental health service delivery.

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“…The applications of a CTO may support paternalistic practice, 25 and thus have an impact on the psychiatrist's role as a patient supporter, therefore limiting their influence on the patient. Many patients do not know that they are under a CTO, are not fully informed or do not understand the regulations of a CTO. 26 CTOs are favoured by relatives and carers, 27 possibly to force patients to comply with their wishes; this may on some occasions be in their own, but not necessarily in the patient's, best interest. The functional split between in-patient and out-patient consultants makes regulations and administration difficult. An in-patient consultant may utilise a CTO for one purpose, such as with a view to shorten an in-patient admission, without proper consultation with the psychiatrist and team who will have the task of implementing the order in the community over the longer term.…”

Section: Some Practical Points To Considermentioning

confidence: 99%

“…CTOs are favoured by relatives and carers, 27 possibly to force patients to comply with their wishes; this may on some occasions be in their own, but not necessarily in the patient's, best interest.…”

Section: Some Practical Points To Considermentioning

confidence: 99%

Little evidence for community treatment orders – a battle fought with heavy weapons

2016

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This editorial discusses the pros and cons of community treatment orders (CTOs) from the perspective of community general adult psychiatry. There is little scientific evidence supporting the application of CTOs. Preconditions of a CTO to work are likely to be met by few patients. The time for the application of a CTO may be better spent for patient-centred care until there is sufficient new and robust evidence that identifies the patients that might profit.

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Carer experience of Community Treatment Orders: implications for rights based/recovery-oriented mental health legislation

Abstract: Mental health legislation is shifting to bring a greater focus on rights, individual choice and autonomy in line with recovery-oriented care. This study describes the impact of severe mental illness and decisions in relation to CTOs on carers.

Cited by 12 publications

References 14 publications

Compulsory community treatment to reduce readmission to hospital and increase engagement with community care in people with mental illness: a systematic review and meta-analysis

Compulsory community treatment to reduce readmission to hospital and increase engagement with community care in people with mental illness: a systematic review and meta-analysis

Community Treatment Orders and Supported Decision-Making

Little evidence for community treatment orders – a battle fought with heavy weapons

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