Compulsory community and involuntary outpatient treatment for people with severe mental disorders
Abstract
Background
There is controversy as to whether compulsory community treatment (CCT) for people with severe mental illness (SMI) reduces health service use, or improves clinical outcome and social functioning.
Objectives
To examine the effectiveness of CCT for people with SMI.
Search methods
We searched the Cochrane Schizophrenia Group’s Trials Register and Science Citation Index (2003, 2008, and 2012). We obtained all references of identified studies and contacted authors where necessary. We further updated this search on the 8 November 2013.
Selection criteria
All relevant randomised controlled clinical trials (RCTs) of CCT compared with standard care for people with SMI (mainly schizophrenia and schizophrenia‐like disorders, bipolar disorder, or depression with psychotic features). Standard care could be voluntary treatment in the community or another pre‐existing form of compulsory community treatment such as supervised discharge.
Data collection and analysis
Review authors independently selected studies, assessed their quality and extracted data. We used The Cochrane Collaboration’s tool for assessing risk of bias. For binary outcomes, we calculated a fixed‐effect risk ratio (RR), its 95% confidence interval (CI) and, where possible, the weighted number needed to treat statistic (NNT). For continuous outcomes, we calculated a fixed‐effect mean difference (MD) and its 95% CI. We used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to create a 'Summary of findings' table for outcomes we rated as important and assessed the risk of bias of included studies.
Main results
All studies (n=3) involved patients in community settings who were followed up over 12 months (n = 752 participants).
Two RCTs from the USA (total n = 416) compared court‐ordered 'Outpatient Commitment' (OPC) with voluntary community treatment. OPC did not result in significant differences compared to voluntary treatment in any of the main outcome indices: health service use (2 RCTs, n = 416, RR for readmission to hospital by 11‐12 months 0.98 CI 0.79 to 1.21, low grade evidence); social functioning (2 RCTs, n = 416, RR for arrested at least once by 11‐12 months 0.97 CI 0.62 to 1.52, low grade evidence); mental state; quality of life (2 RCTs, n = 416, RR for homelessness 0.67 CI 0.39 to 1.15, low grade evidence) or satisfaction with care (2 RCTs, n = 416, RR for perceived coercion 1.36 CI 0.97 to 1.89, low grade evidence). However, risk of victimisation decreased with OPC (1 RCT, n = 264, RR 0.50 CI 0.31 to 0.80). Other than perceived coercion, no adverse outcomes were reported. In terms of numbers needed to treat (NNT), it would take 85 OPC orders to prevent one readmission, 27 to prevent one episode of homelessness and 238 to prevent one arrest. The NNT for the reduction of victimisation was lower at six (CI 6 to 6.5).
One further RCT compared community treatment orders (CTOs) with less intensive supervised discharge in England and found no difference between the two for either the main outcome of readmission (1 RCT, n = 333, RR for readmission to hospital by 12 months 0.99 CI 0.74 to 1.32, medium grade evidence), or any of the secondary outcomes including social functioning and mental state. It was not possible to calculate the NNT. The English study met three out of the seven criteria of The Cochrane Collaboration’s tool for assessing risk of bias, the others only one, the majority being rated unclear.
Authors' conclusions
CCT results in no significant difference in service use, social functioning or quality of life compared with standard voluntary care. People receiving CCT were, however, less likely to be victims of violent or non‐violent crime. It is unclear whether this benefit is due to the intensity of treatment or its compulsory nature. Short periods of conditional leave may be as effective (or non‐effective) as formal compulsory treatment in the community. Evaluation of a wide range of outcomes should be considered when this legislation is introduced. However, conclusions are based on three relatively small trials, with high or unclear risk of blinding bias, and evidence we rated as low to medium quality.
PICOs
Plain language summary
Compulsory community and involuntary outpatient treatment for people with severe mental disorders
Compulsory community treatment (CCT) for people with severe mental health problems is used in many countries, including Australia, Israel, New Zealand, the United Kingdom, and the United States. Supporters of this approach suggest that it is less restrictive and better to compulsorily treat someone in the community than to subject them to repeated hospital admissions. They also argue that it is effective in bringing stability to the lives of people with severe mental illness. Opponents of CCT fear treatment and support will be replaced by a greater emphasis on control, restraint, and threat. CCT may also undermine the relationship between healthcare professionals and patients, leading to feelings of mistrust and being controlled, which may drive people with severe mental illnesses away from services.
Given the widespread use of such powers, which effectively force people in the community to compulsorily undergo treatment, it is important to assess the benefits, effectiveness or possible hazards of compulsory treatment.
Update searches for randomised trials were run in 2012 and 2013 and this review now includes three trials with a total of 752 people. Two of these trials compared a form of CCT called 'Outpatient Commitment' (OPC) versus standard care and the third trial compared a form of CCT called Community Treatment Order to supervised discharge. The review authors rated the quality of evidence for the main outcomes to be low to medium grade. Results from the trials showed overall CCT was no more likely to result in better service use, social functioning, mental state or quality of life compared with standard 'voluntary' care. People receiving CCT were less likely to be victims of violent or non‐violent crime. It is unclear whether this benefit is due to the intensity of treatment or its compulsory nature. Other than feelings of coercion or being controlled, there were no other negative outcomes. Short periods of conditional leave may be as effective (or non‐effective) as compulsory treatment in the community. However, there is very limited information available, all results are based on three relatively small trials of low to medium quality, making it difficult to draw firm conclusions, so further research into the effects of different types of compulsory community treatment is much needed.
Ben Gray, Senior Peer Researcher, McPin Foundation http://mcpin.org/.
