What Clinicians Say About the Experience of Working With Individuals on Community Treatment Orders

Corring, Deborah; O’Reilly, Richard; Sommerdyk, Christina; Russell, Elizabeth M.

doi:10.1176/appi.ps.201700492

Cited by 15 publications

(19 citation statements)

References 36 publications

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“…Consistent with previous qualitative research in Australia and elsewhere, service providers, family supporters, and consumers shared many similar perceptions regarding the experience of CTOs, as well as a mixed and often ambivalent stance about CTOs (10, 11, 25, 26). Most consumers described CTOs as wholly negative; both the process of being placed on a CTO and its impact.…”

Section: Discussionsupporting

confidence: 72%

“…They lead to a restriction of human rights including the rights to liberty and physical and mental integrity sometimes over many years, and evidence about their effectiveness remains weak despite randomized control trials (5, 8, 9). Corring et al (10, 11) have undertaken reviews of qualitative studies on the experience of people on CTOs and suggest that there are common themes among people on CTOs and clinicians (10, 11). They may, for example, see CTOs as helpful but remain concerned about the ethical and human rights implications of their use.…”

Section: Introductionmentioning

confidence: 99%

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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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Section: Discussionsupporting

confidence: 72%

Section: Introductionmentioning

confidence: 99%

Community Treatment Orders and Supported Decision-Making

et al. 2019

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“…Norwegian and international studies show that CTOs are often founded on patients’ lack of insight, to prevent psychotic relapse [ 12 ], which often has a disruptive effect on people’s quality of life and their capacity for independence. A Norwegian study showed that CTO practices vary [ 19 ] and that some RCs only met patients at yearly reviews, knew little about the content of local care services and the impact of CTOs on patients’ everyday lives.…”

Section: Discussionmentioning

confidence: 99%

“…There is an ongoing discussion as to whether the mandatory element of the CTO produces greater clinical benefits for patients than offering them the same package of services on a voluntary basis [ 5 , 10 , 11 ]. International and Norwegian studies show that the use of CTOs is often justified on the basis of patients’ lack of illness insight [ 12 ], and that they are mainly used to provide support and treatment following involuntary hospital admissions [ 12 – 14 ]. Studies show that patients have mixed views of coercion in general and CTOs in particular, while psychiatrists and patients’ relatives are more positive [ 15 – 17 ].…”

Section: Introductionmentioning

confidence: 99%

How clinicians make decisions about CTOs in ACT: a qualitative study

Stuen

Landheim

Rugkåsa

et al. 2018

Int J Ment Health Syst

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BackgroundThe first 12 Norwegian assertive community treatment (ACT) teams were piloted from 2009 to 2011. Of the 338 patients included during the teams’ first year of operation, 38% were subject to community treatment orders (CTOs). In Norway as in many other Western countries, the use of CTOs is relatively high despite lack of robust evidence for their effectiveness. The purpose of the present study was to explore how responsible clinicians reason and make decisions about the continued use of CTOs, recall to hospital and the discontinuation of CTOs within an ACT setting.MethodsSemi-structured interviews with eight responsible clinicians combined with patient case files and observations of treatment planning meetings. The data were analysed using a modified grounded theory approach.ResultsThe participants emphasized that being part of a multidisciplinary team with shared caseload responsibility that provides intensive services over long periods of time allowed for more nuanced assessments and more flexible treatment solutions on CTOs. The treatment criterion was typically used to justify the need for CTO. There was substantial variation in the responsible clinicians’ legal interpretation of dangerousness, and some clinicians applied the dangerousness criterion more than others.ConclusionsAccording to the clinicians, many patients subject to CTOs were referred from hospitals and high security facilities, and decisions regarding the continuation of CTOs typically involved multiple and interacting risk factors. While patients’ need for treatment was most often applied to justify the need for CTOs, in some cases the use of CTOs was described as a tool to contain dangerousness and prevent harm.

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“…First-generation compounds tend to be cheap while second-generation compounds tend to be expensive. Many states in the USA and some other countries 54 offer involuntary outpatient or community treatment laws that may facilitate the use of LAIs, but these forced outpatient treatment orders are not present in many European countries which, on the other hand, offer easy access to free psychiatric treatment including free medications.…”

Section: Measuring Medication Adherence In Psychiatrymentioning

confidence: 99%

<p>Self-Report for Measuring and Predicting Medication Adherence: Experts’ Experience in Predicting Adherence in Stable Psychiatric Outpatients and in Pharmacokinetics</p>

Cuevas

Leon

2020

PPA

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Poor adherence to appropriately prescribed medication is a global challenge for psychiatrists. Prior Studies: Measuring adherence is complicated. In our recent three-country naturalistic study including more than 1000 patients and their adherence to multiple medication prescriptions at the same time, patients' self-report of adherence to each specific drug was the only practical option for measuring adherence. Systematic literature reviews provide inconsistent results for sociodemographic, clinical and medication variables as predictors of adherence to psychiatric drugs. Our studies over the last 10 years in relatively stable psychiatric outpatients have shown that some self-reported health beliefs had consistent, strong effects and a better predictive role. Three dimensions of these health beliefs are characteristics of the individual: 1) attitudes toward psychiatric medication such as pharmacophobia (fear of taking drugs or medicines), 2) health locus of control (the belief patients have about who or what agent determines the state of their health), 3) psychological reactance (an emotional reaction in direct contradiction to rules or regulations that threaten or suppress certain freedoms in behavior). They can be measured by the Patient Health Beliefs Questionnaire on Psychiatric Treatment. The attitude toward each specific medication can be measured by the necessity-concern framework and summarized as the presence or absence of skepticism about that drug. After 25 years conducting pharmacokinetic studies in psychiatric drugs, particularly antipsychotics, we have limited understanding of how to use blood levels to predict the effects of non-adherence or to establish it. Expert Opinion on Future Studies: Future studies to predict adherence should include the inpatient setting and explore insight. Studying the pharmacokinetics associated with nonadherence in each psychiatric drug is a major challenge. Medication adherence is a complex and dynamic process changing over time in the same patient. Personalizing adherence using psychological or pharmacological variables are in their initial stages.

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What Clinicians Say About the Experience of Working With Individuals on Community Treatment Orders

Abstract: Clinicians view CTOs as providing benefits to their clients but struggle with the coercive nature of these tools.

Cited by 15 publications

References 36 publications

Community Treatment Orders and Supported Decision-Making

Community Treatment Orders and Supported Decision-Making

How clinicians make decisions about CTOs in ACT: a qualitative study

<p>Self-Report for Measuring and Predicting Medication Adherence: Experts’ Experience in Predicting Adherence in Stable Psychiatric Outpatients and in Pharmacokinetics</p>

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