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Cochrane Database of Systematic Reviews

Compulsory community and involuntary outpatient treatment for people with severe mental disorders

Information

DOI:
https://doi.org/10.1002/14651858.CD004408.pub5Copy DOI
Database:
  1. Cochrane Database of Systematic Reviews
Version published:
  1. 17 March 2017see what's new
Type:
  1. Intervention
Stage:
  1. Review
Cochrane Editorial Group:
  1. Cochrane Schizophrenia Group

Copyright:
  1. Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Authors

  • Steve R Kisely

    Correspondence to: School of Medicine, The University of Queensland, Woolloongabba, Australia

    [email protected]

    [email protected]

  • Leslie A Campbell

    Department of Community Health and Epidemiology, Dalhousie University, Halifax, Canada

  • Richard O'Reilly

    Western University, London, Ontario, Canada

Contributions of authors

1. 2016 search

SK independently inspected citations from the new electronic search and identified relevant abstracts. SK also inspected full articles of the abstracts meeting inclusion criteria. SK updated results and discussion in light of new search.

LAC provided comments on the search strategy and the updated review.

ROR is a new review author who provided comments on the search strategy and the updated review.

2. 2012 and 2013 searches

SK independently inspected citations from the new electronic search and identified relevant abstracts. SK also inspected full articles of the abstracts meeting inclusion criteria. SK carried out the reliability check of all citations from the new electronic search, updated results and discussion in light of new search.

LAC provided comments on the search strategy and the updated review.

3. Original review

SK formulated the review question, initially developed the search strategy, selected trials, conducted the analysis and wrote the first draft of the review. SK also wrote the first draft of the updated review.

LAC selected trials, reviewed and provided comments on the search strategy and review, and assisted the analysis.

Sources of support

Internal sources

  • Health Outcomes Unit, Capital District Health Authority, Halifax, Canada.

  • Dalhousie University, Halifax, Canada.

  • Fremantle Hospital, Australia.

  • University of Western Australia, Australia.

  • University of Queensland, Australia.

  • Faculty of Medicine, Western University, London, Ontario, Canada.

External sources

  • No sources of support supplied

Declarations of interest

SK: none known.

LAC: this review was supported by a Nova Scotia Health Research Foundation Knowledge Programs Grant.

ROR: none known.

Acknowledgements

SK is employed by the University of Queensland, Australia and previously by Dalhousie University, Canada and the University of Western Australia.

LAC is employed by Capital District Health Authority, Halifax, Canada.

RO'R is employed by the Faculty of Medicine, Western University, London, Ontario, Canada.

We also wish to thank Neil Preston from Fremantle Hospital, Western Australia who was an author on earlier versions of this review. The principal investigators of two groups who conducted RCTs in this area kindly confirmed that we had all the relevant papers and supplied additional data.

The Cochrane Schizophrenia Group provides a standard template for its Methods, which we have used and adapted for this update.

Version history

Published

Title

Stage

Authors

Version

2017 Mar 17

Compulsory community and involuntary outpatient treatment for people with severe mental disorders

Review

Steve R Kisely, Leslie A Campbell, Richard O'Reilly

https://doi.org/10.1002/14651858.CD004408.pub5

2014 Dec 04

Compulsory community and involuntary outpatient treatment for people with severe mental disorders

Review

Steve R Kisely, Leslie A Campbell

https://doi.org/10.1002/14651858.CD004408.pub4

2011 Feb 16

Compulsory community and involuntary outpatient treatment for people with severe mental disorders

Review

Steve R Kisely, Leslie Anne Campbell, Neil J Preston

https://doi.org/10.1002/14651858.CD004408.pub3

2005 Jul 20

Compulsory community and involuntary outpatient treatment for people with severe mental disorders

Review

Steve R Kisely, Leslie Anne Campbell, Neil J Preston

https://doi.org/10.1002/14651858.CD004408.pub2

2003 Oct 20

Compulsory community treatment and involuntary outpatient treatment for people with severe mental disorders

Protocol

Steve R Kisely, Neil J Preston

https://doi.org/10.1002/14651858.CD004408

Differences between protocol and review

1. Overall loss of credibility

We now think that the 35% cut‐off was inadvisable and prefer 50%. However, this decision was taken only after seeing the data and leaves all subsequent analyses very prone to the inclusion of bias (see Potential biases in the review process). We also added a comparison of CCT with supervised discharge.

2. Funnel plot

In our protocol (Kisely 2004), we stated that data from all included studies would be entered into a funnel graph (trial effect against trial size) in an attempt to investigate the likelihood of overt publication bias (Egger 1997). Because there were never more than three studies for each outcome, we were unable to use this technique to investigate publication bias.

3. Updating of Methods and inclusion of 'Summary of findings' and 'Risk of bias' tables

In our protocol, we stated that we would only compare CCT with standard voluntary care. However, the scarcity of randomised trials in the assessment of CCT meant that we subsequently extended inclusion criteria to studies that compared different types of compulsory treatment in the community.

In addition, we added 'Risk of bias' and a 'Summary of findings' tables, and updated some of the methods and layout of text to reflect the updated structure of Cochrane Reviews.

4. Outcomes: global state added

The new trial provided useable data from a global state scale.

5. Reordering and rewording of health service contact and utilisation

We have reworded two outcomes to clarify meaning, and reordered them in the outcome list. We have not changed the type of outcome measured.

1. Compliance with treatment to Compliance with medication

2. Readmissions to Number with multiple readmissions

6. Reordering of outcomes in SOF list changed to match order of outcomes in Secondary Outcomes

Keywords

MeSH

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Study flow diagram.
Figures and Tables -
Figure 1

Study flow diagram.

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figures and Tables -
Figure 2

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
Figures and Tables -
Figure 3

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

Comparison 1 COURT ORDERED OUTPATIENT COMMITMENT compared with ENTIRELY VOLUNTARY CARE, Outcome 1 Health service outcomes: 1. Readmission to hospital ‐ by 11 to 12 months.
Figures and Tables -
Analysis 1.1

Comparison 1 COURT ORDERED OUTPATIENT COMMITMENT compared with ENTIRELY VOLUNTARY CARE, Outcome 1 Health service outcomes: 1. Readmission to hospital ‐ by 11 to 12 months.

Comparison 1 COURT ORDERED OUTPATIENT COMMITMENT compared with ENTIRELY VOLUNTARY CARE, Outcome 2 Health service outcomes: 2. Hospital bed‐days.
Figures and Tables -
Analysis 1.2

Comparison 1 COURT ORDERED OUTPATIENT COMMITMENT compared with ENTIRELY VOLUNTARY CARE, Outcome 2 Health service outcomes: 2. Hospital bed‐days.

Comparison 1 COURT ORDERED OUTPATIENT COMMITMENT compared with ENTIRELY VOLUNTARY CARE, Outcome 3 Health service outcomes: 3. Number with multiple readmissions by 12 months.
Figures and Tables -
Analysis 1.3

Comparison 1 COURT ORDERED OUTPATIENT COMMITMENT compared with ENTIRELY VOLUNTARY CARE, Outcome 3 Health service outcomes: 3. Number with multiple readmissions by 12 months.

Comparison 1 COURT ORDERED OUTPATIENT COMMITMENT compared with ENTIRELY VOLUNTARY CARE, Outcome 4 Health service outcomes: 4. Compliance with medication by 11 to 12 months.
Figures and Tables -
Analysis 1.4

Comparison 1 COURT ORDERED OUTPATIENT COMMITMENT compared with ENTIRELY VOLUNTARY CARE, Outcome 4 Health service outcomes: 4. Compliance with medication by 11 to 12 months.

Comparison 1 COURT ORDERED OUTPATIENT COMMITMENT compared with ENTIRELY VOLUNTARY CARE, Outcome 5 Participant level outcomes: 1. Mental state ‐ psychiatric symptoms and global state at 11 to 12 months.
Figures and Tables -
Analysis 1.5

Comparison 1 COURT ORDERED OUTPATIENT COMMITMENT compared with ENTIRELY VOLUNTARY CARE, Outcome 5 Participant level outcomes: 1. Mental state ‐ psychiatric symptoms and global state at 11 to 12 months.

Comparison 1 COURT ORDERED OUTPATIENT COMMITMENT compared with ENTIRELY VOLUNTARY CARE, Outcome 6 Participant level outcomes: 2. Social functioning: trouble with police by 11 to 12 months.
Figures and Tables -
Analysis 1.6

Comparison 1 COURT ORDERED OUTPATIENT COMMITMENT compared with ENTIRELY VOLUNTARY CARE, Outcome 6 Participant level outcomes: 2. Social functioning: trouble with police by 11 to 12 months.

Comparison 1 COURT ORDERED OUTPATIENT COMMITMENT compared with ENTIRELY VOLUNTARY CARE, Outcome 7 Participant level outcomes: 3. Social functioning: homeless by 11 to 12 months.
Figures and Tables -
Analysis 1.7

Comparison 1 COURT ORDERED OUTPATIENT COMMITMENT compared with ENTIRELY VOLUNTARY CARE, Outcome 7 Participant level outcomes: 3. Social functioning: homeless by 11 to 12 months.

Comparison 1 COURT ORDERED OUTPATIENT COMMITMENT compared with ENTIRELY VOLUNTARY CARE, Outcome 8 Participant level outcomes: 4. Quality of life: Lehman Quality of Life Scale.
Figures and Tables -
Analysis 1.8

Comparison 1 COURT ORDERED OUTPATIENT COMMITMENT compared with ENTIRELY VOLUNTARY CARE, Outcome 8 Participant level outcomes: 4. Quality of life: Lehman Quality of Life Scale.

Comparison 1 COURT ORDERED OUTPATIENT COMMITMENT compared with ENTIRELY VOLUNTARY CARE, Outcome 9 Participant level outcomes: 5. Quality of life: victimisation by 11 to 12 months.
Figures and Tables -
Analysis 1.9

Comparison 1 COURT ORDERED OUTPATIENT COMMITMENT compared with ENTIRELY VOLUNTARY CARE, Outcome 9 Participant level outcomes: 5. Quality of life: victimisation by 11 to 12 months.

Comparison 1 COURT ORDERED OUTPATIENT COMMITMENT compared with ENTIRELY VOLUNTARY CARE, Outcome 10 Participant level outcomes: 6. Satisfaction with care: perceived coercion by 11 to 12 months.
Figures and Tables -
Analysis 1.10

Comparison 1 COURT ORDERED OUTPATIENT COMMITMENT compared with ENTIRELY VOLUNTARY CARE, Outcome 10 Participant level outcomes: 6. Satisfaction with care: perceived coercion by 11 to 12 months.

Comparison 2 COMMUNITY TREATMENT ORDERS compared with SUPERVISED DISCHARGE (SECTION 17), Outcome 1 Health service outcomes: 1a. Readmission to hospital ‐ by 12 months.
Figures and Tables -
Analysis 2.1

Comparison 2 COMMUNITY TREATMENT ORDERS compared with SUPERVISED DISCHARGE (SECTION 17), Outcome 1 Health service outcomes: 1a. Readmission to hospital ‐ by 12 months.

Comparison 2 COMMUNITY TREATMENT ORDERS compared with SUPERVISED DISCHARGE (SECTION 17), Outcome 2 Health service outcomes. 1b. Readmission to hospital by 36 months.
Figures and Tables -
Analysis 2.2

Comparison 2 COMMUNITY TREATMENT ORDERS compared with SUPERVISED DISCHARGE (SECTION 17), Outcome 2 Health service outcomes. 1b. Readmission to hospital by 36 months.

Comparison 2 COMMUNITY TREATMENT ORDERS compared with SUPERVISED DISCHARGE (SECTION 17), Outcome 3 Health service outcomes: 2. Hospital bed‐days by 12 months.
Figures and Tables -
Analysis 2.3

Comparison 2 COMMUNITY TREATMENT ORDERS compared with SUPERVISED DISCHARGE (SECTION 17), Outcome 3 Health service outcomes: 2. Hospital bed‐days by 12 months.

Comparison 2 COMMUNITY TREATMENT ORDERS compared with SUPERVISED DISCHARGE (SECTION 17), Outcome 4 Health service outcomes: 3. Number of readmissions by 12 months.
Figures and Tables -
Analysis 2.4

Comparison 2 COMMUNITY TREATMENT ORDERS compared with SUPERVISED DISCHARGE (SECTION 17), Outcome 4 Health service outcomes: 3. Number of readmissions by 12 months.

Comparison 2 COMMUNITY TREATMENT ORDERS compared with SUPERVISED DISCHARGE (SECTION 17), Outcome 5 Health service outcomes: 4. Number with multiple readmissions by 12 months.
Figures and Tables -
Analysis 2.5

Comparison 2 COMMUNITY TREATMENT ORDERS compared with SUPERVISED DISCHARGE (SECTION 17), Outcome 5 Health service outcomes: 4. Number with multiple readmissions by 12 months.

Comparison 2 COMMUNITY TREATMENT ORDERS compared with SUPERVISED DISCHARGE (SECTION 17), Outcome 6 Health service outcomes: 5a. Days in community till first admission by 12 months.
Figures and Tables -
Analysis 2.6

Comparison 2 COMMUNITY TREATMENT ORDERS compared with SUPERVISED DISCHARGE (SECTION 17), Outcome 6 Health service outcomes: 5a. Days in community till first admission by 12 months.

Comparison 2 COMMUNITY TREATMENT ORDERS compared with SUPERVISED DISCHARGE (SECTION 17), Outcome 7 Health service outcomes: 5b. Days in community till first admission and mean duration of bed‐days by 36 months.
Figures and Tables -
Analysis 2.7

Comparison 2 COMMUNITY TREATMENT ORDERS compared with SUPERVISED DISCHARGE (SECTION 17), Outcome 7 Health service outcomes: 5b. Days in community till first admission and mean duration of bed‐days by 36 months.

Comparison 2 COMMUNITY TREATMENT ORDERS compared with SUPERVISED DISCHARGE (SECTION 17), Outcome 8 Participant level outcomes: 1. Mental state ‐ psychiatric symptoms at 12 months (BPRS).
Figures and Tables -
Analysis 2.8

Comparison 2 COMMUNITY TREATMENT ORDERS compared with SUPERVISED DISCHARGE (SECTION 17), Outcome 8 Participant level outcomes: 1. Mental state ‐ psychiatric symptoms at 12 months (BPRS).

Comparison 2 COMMUNITY TREATMENT ORDERS compared with SUPERVISED DISCHARGE (SECTION 17), Outcome 9 Participant level outcomes: 2. Global state: GAF at 12 months.
Figures and Tables -
Analysis 2.9

Comparison 2 COMMUNITY TREATMENT ORDERS compared with SUPERVISED DISCHARGE (SECTION 17), Outcome 9 Participant level outcomes: 2. Global state: GAF at 12 months.

Comparison 2 COMMUNITY TREATMENT ORDERS compared with SUPERVISED DISCHARGE (SECTION 17), Outcome 10 Participant level outcomes: 3. Satisfaction with care: perceived coercion at 11 to 12 months.
Figures and Tables -
Analysis 2.10

Comparison 2 COMMUNITY TREATMENT ORDERS compared with SUPERVISED DISCHARGE (SECTION 17), Outcome 10 Participant level outcomes: 3. Satisfaction with care: perceived coercion at 11 to 12 months.

Comparison 2 COMMUNITY TREATMENT ORDERS compared with SUPERVISED DISCHARGE (SECTION 17), Outcome 11 Participant level outcomes: 4. Satisfaction with care: leverage at 11 to 12 months.
Figures and Tables -
Analysis 2.11

Comparison 2 COMMUNITY TREATMENT ORDERS compared with SUPERVISED DISCHARGE (SECTION 17), Outcome 11 Participant level outcomes: 4. Satisfaction with care: leverage at 11 to 12 months.

Comparison 2 COMMUNITY TREATMENT ORDERS compared with SUPERVISED DISCHARGE (SECTION 17), Outcome 12 Participant level outcomes: 5. Social Outcomes Index at 12 months.
Figures and Tables -
Analysis 2.12

Comparison 2 COMMUNITY TREATMENT ORDERS compared with SUPERVISED DISCHARGE (SECTION 17), Outcome 12 Participant level outcomes: 5. Social Outcomes Index at 12 months.

Comparison 3 COMPULSORY COMMUNITY TREATMENT compared with STANDARD CARE, Outcome 1 Health service outcomes: 1. Readmission to hospital by 11 to 12 months.
Figures and Tables -
Analysis 3.1

Comparison 3 COMPULSORY COMMUNITY TREATMENT compared with STANDARD CARE, Outcome 1 Health service outcomes: 1. Readmission to hospital by 11 to 12 months.

Comparison 3 COMPULSORY COMMUNITY TREATMENT compared with STANDARD CARE, Outcome 2 Health service outcomes: 2. Hospital bed‐days.
Figures and Tables -
Analysis 3.2

Comparison 3 COMPULSORY COMMUNITY TREATMENT compared with STANDARD CARE, Outcome 2 Health service outcomes: 2. Hospital bed‐days.

Comparison 3 COMPULSORY COMMUNITY TREATMENT compared with STANDARD CARE, Outcome 3 Health service outcomes: 3. Number with multiple readmissions by 12 months.
Figures and Tables -
Analysis 3.3

Comparison 3 COMPULSORY COMMUNITY TREATMENT compared with STANDARD CARE, Outcome 3 Health service outcomes: 3. Number with multiple readmissions by 12 months.

Comparison 3 COMPULSORY COMMUNITY TREATMENT compared with STANDARD CARE, Outcome 4 Participant level outcomes: 1. global state: GAF at 12 months.
Figures and Tables -
Analysis 3.4

Comparison 3 COMPULSORY COMMUNITY TREATMENT compared with STANDARD CARE, Outcome 4 Participant level outcomes: 1. global state: GAF at 12 months.

Comparison 3 COMPULSORY COMMUNITY TREATMENT compared with STANDARD CARE, Outcome 5 Participant level outcomes: 2. Satisfaction with care: perceived coercion or leverage at 11 to 12 months.
Figures and Tables -
Analysis 3.5

Comparison 3 COMPULSORY COMMUNITY TREATMENT compared with STANDARD CARE, Outcome 5 Participant level outcomes: 2. Satisfaction with care: perceived coercion or leverage at 11 to 12 months.

Summary of findings for the main comparison. COURT ORDERED OUTPATIENT COMMITMENT compared with ENTIRELY VOLUNTARY CARE for people with severe mental disorders

COMPULSORY COMMUNITY AND INVOLUNTARY OUTPATIENT TREATMENT FOR PEOPLE WITH SEVERE MENTAL DISORDERS

Patient or population: people with severe mental disorders

Settings: patients in community settings

Intervention: COURT ORDERED OUTPATIENT COMMITMENT

Comparison: ENTIRELY VOLUNTARY CARE

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

VOLUNTARY CARE

COURT ORDERED OUTPATIENT COMMITMENT

Health service outcomes: 1. Readmission to hospital by 11 to 12 months

Study population

RR 0.98
(0.79 to 1.21)

416
(2 studies)

⊕⊕⊝⊝
Low1,2

460 per 1000

451 per 1000
(363 to 557)

Medium risk population

446 per 1000

437 per 1000
(352 to 540)

Health service outcomes: 4. Compliance with medication by 11 to 12 months

Study population

RR 0.99
(0.83 to 1.19)

416
(2 studies)

⊕⊕⊝⊝
Low1,2

505 per 1000

500 per 1000
(419 to 601)

Medium risk population

554 per 1000

548 per 1000
(460 to 659)

Participant level outcomes: 2. Social functioning: trouble with police by 11 to 12 months, at least 1 arrest

Study population

RR 0.97
(0.62 to 1.52)

416
(2 studies)

⊕⊕⊝⊝
Low1,2

158 per 1000

153 per 1000
(98 to 240)

Medium risk population

156 per 1000

151 per 1000
(97 to 237)

Participant level outcomes: 2. Social functioning: trouble with police by 11 to 12 months, ever arrested/picked up by police for violence against a person

Study population

RR 0.82
(0.56 to 1.21)

416
(2 studies)

⊕⊕⊝⊝
Low1,2

208 per 1000

171 per 1000
(116 to 252)

Medium risk population

156 per 1000

128 per 1000
(87 to 189)

Participant level outcomes: 3. Social functioning: homeless by 11 to 12 months

Study population

RR 0.67
(0.39 to 1.15)

416
(2 studies)

⊕⊕⊝⊝
Low1,2

134 per 1000

90 per 1000
(52 to 154)

Medium risk population

145 per 1000

97 per 1000
(57 to 167)

Participant level outcomes: 5. Quality of life: victimisation by 11 to 12 months

Study population

RR 0.5
(0.31 to 0.8)

264
(1 study)

⊕⊕⊝⊝
Low1,3

311 per 1000

156 per 1000
(96 to 249)

Medium risk population

311 per 1000

156 per 1000
(96 to 249)

Participant level outcomes: 6. Satisfaction with care/adverse events: perceived coercion by 11 to 12 months

Study population

RR 1.36
(0.97 to 1.89)

416
(2 studies)

⊕⊕⊝⊝
Low1,2

218 per 1000

296 per 1000
(211 to 412)

Medium risk population

227 per 1000

309 per 1000
(220 to 429)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RR: risk ratio.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Allocation concealment and blinding unclear: serious risk of bias, downgraded by one level.

2 Only 2 studies, both from the USA: serious imprecision, downgraded by one level.

3 Only 1 study: serious imprecision, downgraded by one level.

Figures and Tables -
Summary of findings for the main comparison. COURT ORDERED OUTPATIENT COMMITMENT compared with ENTIRELY VOLUNTARY CARE for people with severe mental disorders
Summary of findings 2. COMMUNITY TREATMENT ORDERS compared with SUPERVISED DISCHARGE (SECTION 17) for people with severe mental disorders

COMPULSORY COMMUNITY AND INVOLUNTARY OUTPATIENT TREATMENT FOR PEOPLE WITH SEVERE MENTAL DISORDERS

Patient or population: people with severe mental disorders

Settings: community

Intervention: COMMUNITY TREATMENT ORDERS

Comparison: SUPERVISED DISCHARGE (Section 17)

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

SECTION 17

COMMUNITY TREATMENT ORDERS

Health service outcomes: 1. Readmission to hospital by 12 months

Study population

RR 0.99
(0.74 to 1.32)

333
(1 study)

⊕⊕⊕⊝
Moderate1,2

359 per 1000

356 per 1000
(266 to 474)

Moderate risk population

359 per 1000

355 per 1000
(266 to 474)

Health service outcomes: 2. Hospital bed‐days by 12 months

The mean health service outcomes: 2. total duration of psychiatric hospital stays over 12 months in the intervention groups was
8.7 lower
(30.88 lower to 13.48 higher)

333
(1 study)

⊕⊕⊕⊝
Moderate1,2

Health service outcomes: 3. Number of readmissions by 12 months

The mean health service outcomes: 3. number of readmissions by 12 months in the intervention groups was
0.2 lower
(0.45 lower to 0.05 higher)

119
(1 study)

⊕⊕⊕⊝
Moderate1,2

Health service outcomes: 4. Number with multiple readmissions by 12 months

Study population

RR 0.56
(0.27 to 1.17)

333
(1 study)

⊕⊕⊕⊝
Moderate1,2

108 per 1000

60 per 1000
(29 to 126)

Moderate risk population

108 per 1000

60 per 1000
(29 to 126)

Health service outcomes: 5. Days in community to first admission by 12 months

The mean days in community to 1st admission in the intervention groups was
5 higher
(21.74 lower to 31.74 higher)

333
(1 study)

⊕⊕⊕⊝
Moderate1,2

Participant level outcomes: 1. Mental state ‐ psychiatric symptoms at 12 months (BPRS)

The mean patierticipant level outcomes: BPRS in the intervention groups was
0.1 lower
(3.17 lower to 2.97 higher)

234
(1 study)

⊕⊕⊕⊝
Moderate1,2

Participant level outcomes: 3. Satisfaction with care: perceived coercion at 11 ‐ 12 months

The mean participant level outcomes: Satisfaction with care: perceived coercion intervention groups was
0.5 lower
(1.71 lower to 0.71 higher)

182
(1 study)

⊕⊕⊕⊝
Moderate1,2

Other pre‐stated participant level outcomes of interest: Social functioning: trouble with police, homeless; Quality of life: victimisation; not reported

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
BPRS: Brief Psychiatric Rating Scale; CI: confidence interval; GAF: Global Assessment of Functioning Scale; RR: risk ratio.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Forty people (25%) allocated to Section 17 were subsequently placed on a CTO during the study.

2 35 people randomised to CTOs (22%) did not actually receive the intervention.

3 No adverse events reported.

Figures and Tables -
Summary of findings 2. COMMUNITY TREATMENT ORDERS compared with SUPERVISED DISCHARGE (SECTION 17) for people with severe mental disorders
Summary of findings 3. COMPULSORY COMMUNITY TREATMENT compared with STANDARD CARE for people with severe mental disorders

COMPULSORY COMMUNITY AND INVOLUNTARY OUTPATIENT TREATMENT FOR PEOPLE WITH SEVERE MENTAL DISORDERS

Patient or population: people with severe mental disorders

Settings: community

Intervention: COMPULSORY COMMUNITY TREATMENT

Comparison: STANDARD CARE

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

STANDARD CARE

COMPULSORY COMMUNITY TREATMENT

Health service outcomes: 1. Readmission to hospital by 11 to 12 months

Study population

RR 0.98
(0.83 to 1.17)

749
(3)

⊕⊕⊕⊝
Moderate1,2

415 per 1000

406 per 1000
(344 to 485)

Moderate

403 per 1000

395 per 1000
(334 to 472)

Health service outcomes: 2. Hospital bed‐days

The mean health service outcomes: 2. hospital bed‐days in the intervention groups was
3.35 lower
(15.14 lower to 8.44 higher)

597
(2)

⊕⊕⊕⊝
Moderate1,2

Health service outcomes: 3. Number with multiple readmissions by 12 months

Study population

RR 1.0
(0.6 to 1.66)

485
(2)

⊕⊕⊕⊝
Moderate1,2

111 per 1000

111 per 1000
(67 to 184)

Moderate

114 per 1000

114 per 1000
(68 to 189)

Participant level outcomes: 1. Global state: GAF at 12 months

The mean participant level outcomes: global state: GAF at 12 months in the intervention groups was
1.36 lower
(4.07 lower to 1.35 higher)

335
(2)

⊕⊕⊕⊝
Moderate1,2

Participant level outcomes: 2. Satisfaction with care: perceived coercion or leverage at 11 to 12 months

Study population

RR 1.3
(0.98 to 1.71)

645
(3)

⊕⊕⊕⊝
Moderate1,2

212 per 1000

275 per 1000
(207 to 362)

Moderate

200 per 1000

260 per 1000
(196 to 342)

Other pre‐stated participant level outcomes of interest: Social functioning: trouble with police, homeless; Quality of life: victimisation; not reported

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; GAF: Global Assessment of Functioning Scale; RR: risk ratio.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Forty people (25%) allocated to Section 17 were subsequently placed on a CTO during the study.

2 35 people randomised to compulsory community treatments (22%) did not actually receive the intervention.

3 No adverse events reported.

Figures and Tables -
Summary of findings 3. COMPULSORY COMMUNITY TREATMENT compared with STANDARD CARE for people with severe mental disorders
Comparison 1. COURT ORDERED OUTPATIENT COMMITMENT compared with ENTIRELY VOLUNTARY CARE

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Health service outcomes: 1. Readmission to hospital ‐ by 11 to 12 months Show forest plot

2

416

Risk Ratio (M‐H, Fixed, 95% CI)

0.98 [0.79, 1.21]

2 Health service outcomes: 2. Hospital bed‐days Show forest plot

1

264

Mean Difference (IV, Fixed, 95% CI)

‐1.24 [‐15.16, 12.68]

3 Health service outcomes: 3. Number with multiple readmissions by 12 months Show forest plot

1

152

Risk Ratio (M‐H, Fixed, 95% CI)

1.87 [0.87, 4.01]

4 Health service outcomes: 4. Compliance with medication by 11 to 12 months Show forest plot

2

416

Risk Ratio (M‐H, Fixed, 95% CI)

0.99 [0.83, 1.19]

5 Participant level outcomes: 1. Mental state ‐ psychiatric symptoms and global state at 11 to 12 months Show forest plot

1

98

Mean Difference (IV, Fixed, 95% CI)

‐3.0 [‐8.08, 2.08]

6 Participant level outcomes: 2. Social functioning: trouble with police by 11 to 12 months Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

6.1 at least 1 arrest

2

416

Risk Ratio (M‐H, Fixed, 95% CI)

0.97 [0.62, 1.52]

6.2 ever arrested/picked up by police for violence against a person

2

416

Risk Ratio (M‐H, Fixed, 95% CI)

0.82 [0.56, 1.21]

7 Participant level outcomes: 3. Social functioning: homeless by 11 to 12 months Show forest plot

2

416

Risk Ratio (M‐H, Fixed, 95% CI)

0.67 [0.39, 1.15]

8 Participant level outcomes: 4. Quality of life: Lehman Quality of Life Scale Show forest plot

2

406

Mean Difference (IV, Random, 95% CI)

‐0.22 [‐0.95, 0.50]

9 Participant level outcomes: 5. Quality of life: victimisation by 11 to 12 months Show forest plot

1

264

Risk Ratio (M‐H, Fixed, 95% CI)

0.50 [0.31, 0.80]

10 Participant level outcomes: 6. Satisfaction with care: perceived coercion by 11 to 12 months Show forest plot

2

416

Risk Ratio (M‐H, Fixed, 95% CI)

1.36 [0.97, 1.89]

Figures and Tables -
Comparison 1. COURT ORDERED OUTPATIENT COMMITMENT compared with ENTIRELY VOLUNTARY CARE
Comparison 2. COMMUNITY TREATMENT ORDERS compared with SUPERVISED DISCHARGE (SECTION 17)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Health service outcomes: 1a. Readmission to hospital ‐ by 12 months Show forest plot

1

333

Risk Ratio (M‐H, Fixed, 95% CI)

0.99 [0.74, 1.32]

2 Health service outcomes. 1b. Readmission to hospital by 36 months Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.1 Readmission

1

330

Odds Ratio (M‐H, Fixed, 95% CI)

0.71 [0.45, 1.11]

2.2 > 1 readmission

1

213

Odds Ratio (M‐H, Fixed, 95% CI)

1.07 [0.62, 1.85]

3 Health service outcomes: 2. Hospital bed‐days by 12 months Show forest plot

1

333

Mean Difference (IV, Fixed, 95% CI)

‐8.70 [‐30.88, 13.48]

4 Health service outcomes: 3. Number of readmissions by 12 months Show forest plot

1

119

Mean Difference (IV, Fixed, 95% CI)

‐0.20 [‐0.45, 0.05]

5 Health service outcomes: 4. Number with multiple readmissions by 12 months Show forest plot

1

333

Risk Ratio (M‐H, Fixed, 95% CI)

0.56 [0.27, 1.17]

6 Health service outcomes: 5a. Days in community till first admission by 12 months Show forest plot

1

333

Mean Difference (IV, Fixed, 95% CI)

5.0 [‐21.74, 31.74]

7 Health service outcomes: 5b. Days in community till first admission and mean duration of bed‐days by 36 months Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

7.1 Time to 1st readmission in days

1

330

Mean Difference (IV, Fixed, 95% CI)

60.0 [‐27.62, 147.62]

7.2 Mean duration of bed‐days

1

212

Mean Difference (IV, Fixed, 95% CI)

‐15.10 [‐89.39, 59.19]

8 Participant level outcomes: 1. Mental state ‐ psychiatric symptoms at 12 months (BPRS) Show forest plot

1

234

Mean Difference (IV, Fixed, 95% CI)

‐0.10 [‐3.17, 2.97]

9 Participant level outcomes: 2. Global state: GAF at 12 months Show forest plot

1

237

Mean Difference (IV, Fixed, 95% CI)

‐0.70 [‐3.91, 2.51]

10 Participant level outcomes: 3. Satisfaction with care: perceived coercion at 11 to 12 months Show forest plot

1

182

Mean Difference (IV, Fixed, 95% CI)

‐0.5 [‐1.71, 0.71]

11 Participant level outcomes: 4. Satisfaction with care: leverage at 11 to 12 months Show forest plot

1

229

Odds Ratio (M‐H, Fixed, 95% CI)

1.23 [0.66, 2.31]

12 Participant level outcomes: 5. Social Outcomes Index at 12 months Show forest plot

1

236

Mean Difference (IV, Fixed, 95% CI)

‐0.10 [‐0.40, 0.20]

Figures and Tables -
Comparison 2. COMMUNITY TREATMENT ORDERS compared with SUPERVISED DISCHARGE (SECTION 17)
Comparison 3. COMPULSORY COMMUNITY TREATMENT compared with STANDARD CARE

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Health service outcomes: 1. Readmission to hospital by 11 to 12 months Show forest plot

3

749

Risk Ratio (M‐H, Fixed, 95% CI)

0.98 [0.83, 1.17]

2 Health service outcomes: 2. Hospital bed‐days Show forest plot

2

597

Mean Difference (IV, Fixed, 95% CI)

‐3.35 [‐15.14, 8.44]

3 Health service outcomes: 3. Number with multiple readmissions by 12 months Show forest plot

2

485

Risk Ratio (M‐H, Random, 95% CI)

1.02 [0.31, 3.33]

4 Participant level outcomes: 1. global state: GAF at 12 months Show forest plot

2

335

Mean Difference (IV, Fixed, 95% CI)

‐1.36 [‐4.07, 1.35]

5 Participant level outcomes: 2. Satisfaction with care: perceived coercion or leverage at 11 to 12 months Show forest plot

3

645

Risk Ratio (M‐H, Fixed, 95% CI)

1.30 [0.98, 1.71]

Figures and Tables -
Comparison 3. COMPULSORY COMMUNITY TREATMENT compared with STANDARD CARE