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Study flow diagram of trial selection.
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Figure 1

Study flow diagram of trial selection.

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

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

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'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study
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Figure 3

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

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Comparison 1 COMPULSORY COMMUNITY TREATMENT vs STANDARD CARE, Outcome 1 Health service outcomes: 1. Readmission to hospital ‐ by 11‐12 months.
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Analysis 1.1

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

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Comparison 1 COMPULSORY COMMUNITY TREATMENT vs STANDARD CARE, Outcome 2 Health service outcomes: 2. Compliance with medication ‐ by 11‐12 months.
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Analysis 1.2

Comparison 1 COMPULSORY COMMUNITY TREATMENT vs STANDARD CARE, Outcome 2 Health service outcomes: 2. Compliance with medication ‐ by 11‐12 months.

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Comparison 1 COMPULSORY COMMUNITY TREATMENT vs STANDARD CARE, Outcome 3 Patient level outcomes: 1a. Social functioning: trouble with police ‐ by 11‐12 months.
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Analysis 1.3

Comparison 1 COMPULSORY COMMUNITY TREATMENT vs STANDARD CARE, Outcome 3 Patient level outcomes: 1a. Social functioning: trouble with police ‐ by 11‐12 months.

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Comparison 1 COMPULSORY COMMUNITY TREATMENT vs STANDARD CARE, Outcome 4 Patient level outcomes: 1b. Social functioning: homeless ‐ by 11‐12 months.
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Analysis 1.4

Comparison 1 COMPULSORY COMMUNITY TREATMENT vs STANDARD CARE, Outcome 4 Patient level outcomes: 1b. Social functioning: homeless ‐ by 11‐12 months.

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Comparison 1 COMPULSORY COMMUNITY TREATMENT vs STANDARD CARE, Outcome 5 Patient level outcomes: 2. Quality of life: victimisation ‐ by 11‐12 months.
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Analysis 1.5

Comparison 1 COMPULSORY COMMUNITY TREATMENT vs STANDARD CARE, Outcome 5 Patient level outcomes: 2. Quality of life: victimisation ‐ by 11‐12 months.

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Comparison 1 COMPULSORY COMMUNITY TREATMENT vs STANDARD CARE, Outcome 6 Patient level outcomes: 3. Satisfaction with care: perceived coercion ‐ by 11‐12 months.
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Analysis 1.6

Comparison 1 COMPULSORY COMMUNITY TREATMENT vs STANDARD CARE, Outcome 6 Patient level outcomes: 3. Satisfaction with care: perceived coercion ‐ by 11‐12 months.

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Comparison 2 COMMUNITY TREATMENT ORDERS vs SUPERVISED DISCHARGE (SECTION 17), Outcome 1 Health service outcomes: 1. Readmission to hospital ‐ by 12 months.
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Analysis 2.1

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

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Comparison 2 COMMUNITY TREATMENT ORDERS vs SUPERVISED DISCHARGE (SECTION 17), Outcome 2 Health service outcomes: 2. Hospital bed‐days.
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Analysis 2.2

Comparison 2 COMMUNITY TREATMENT ORDERS vs SUPERVISED DISCHARGE (SECTION 17), Outcome 2 Health service outcomes: 2. Hospital bed‐days.

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Comparison 2 COMMUNITY TREATMENT ORDERS vs SUPERVISED DISCHARGE (SECTION 17), Outcome 3 Health service outcomes: 3. Number of readmissions by 12 months.
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Analysis 2.3

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

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Comparison 2 COMMUNITY TREATMENT ORDERS vs SUPERVISED DISCHARGE (SECTION 17), Outcome 4 Health service outcomes: 4. Number with multiple readmissions by 12 months.
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Analysis 2.4

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

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Comparison 2 COMMUNITY TREATMENT ORDERS vs SUPERVISED DISCHARGE (SECTION 17), Outcome 5 Health service outcomes: 5. Days in community till first admission.
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Analysis 2.5

Comparison 2 COMMUNITY TREATMENT ORDERS vs SUPERVISED DISCHARGE (SECTION 17), Outcome 5 Health service outcomes: 5. Days in community till first admission.

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Comparison 2 COMMUNITY TREATMENT ORDERS vs SUPERVISED DISCHARGE (SECTION 17), Outcome 6 Patient level outcomes: 1. Mental state: BPRS.
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Analysis 2.6

Comparison 2 COMMUNITY TREATMENT ORDERS vs SUPERVISED DISCHARGE (SECTION 17), Outcome 6 Patient level outcomes: 1. Mental state: BPRS.

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Comparison 2 COMMUNITY TREATMENT ORDERS vs SUPERVISED DISCHARGE (SECTION 17), Outcome 7 Patient level outcomes: 2. Global state: GAF.
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Analysis 2.7

Comparison 2 COMMUNITY TREATMENT ORDERS vs SUPERVISED DISCHARGE (SECTION 17), Outcome 7 Patient level outcomes: 2. Global state: GAF.

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Summary of findings for the main comparison. COMPULSORY COMMUNITY TREATMENT compared with STANDARD CARE for people with severe mental disorders

COMPULSORY COMMUNITY TREATMENT compared with STANDARD CARE for people with severe mental disorders

Patient or population: people with severe mental disorders
Settings: patients in community settings
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 11‐12 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: 2. Compliance with medication ‐ by 11‐12 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)

Patient level outcomes: 1a. Social functioning: trouble with police ‐ by 11‐12 months ‐ at least one 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)

Patient level outcomes: 1a. Social functioning: trouble with police ‐ by 11‐12 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)

Patient level outcomes: 1b. Social functioning: homeless ‐ by 11‐12 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)

Patient level outcomes: 2. Quality of life: victimisation ‐ by 11‐12 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)

Patient level outcomes: 3. Satisfaction with care/adverse events: perceived coercion ‐ by 11‐12 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
2 Only 2 studies, both from the United States of America
3 Only 1 study

Figuras y tablas -
Summary of findings for the main comparison. COMPULSORY COMMUNITY TREATMENT compared with STANDARD CARE for people with severe mental disorders
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Summary of findings 2. COMMUNITY TREATMENT ORDERS compared with SECTION 17 for people with severe mental disorders

COMMUNITY TREATMENT ORDERS compared with SECTION 17 for people with severe mental disorders

Patient or population: people with severe mental disorders
Settings: patients in community settings
Intervention: COMMUNITY TREATMENT ORDERS
Comparison: 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. Total duration of psychiatric hospital stays over12 months

The mean health service outcomes: 2. total duration of psychiatric hospital stays over12 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)

Days in community till 1st admission

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

333
(1 study)

⊕⊕⊕⊝
moderate1,2

Patient level outcomes: BPRS

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

234
(1 study)

⊕⊕⊕⊝
moderate1,2

Patient level outcomes: GAF3

The mean patient level outcomes: GAF in the intervention groups was
0.7 lower
(3.91 lower to 2.51 higher)

237
(1 study)

⊕⊕⊕⊝
moderate1,2

*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 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 were reported

Figuras y tablas -
Summary of findings 2. COMMUNITY TREATMENT ORDERS compared with SECTION 17 for people with severe mental disorders
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Comparison 1. COMPULSORY COMMUNITY TREATMENT vs 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 11‐12 months Show forest plot

2

416

Risk Ratio (M‐H, Fixed, 95% CI)

0.98 [0.79, 1.21]

2 Health service outcomes: 2. Compliance with medication ‐ by 11‐12 months Show forest plot

2

416

Risk Ratio (M‐H, Fixed, 95% CI)

0.99 [0.83, 1.19]

3 Patient level outcomes: 1a. Social functioning: trouble with police ‐ by 11‐12 months Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3.1 at least one arrest

2

416

Risk Ratio (M‐H, Fixed, 95% CI)

0.97 [0.62, 1.52]

3.2 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]

4 Patient level outcomes: 1b. Social functioning: homeless ‐ by 11‐12 months Show forest plot

2

416

Risk Ratio (M‐H, Fixed, 95% CI)

0.67 [0.39, 1.15]

5 Patient level outcomes: 2. Quality of life: victimisation ‐ by 11‐12 months Show forest plot

1

264

Risk Ratio (M‐H, Fixed, 95% CI)

0.50 [0.31, 0.80]

6 Patient level outcomes: 3. Satisfaction with care: perceived coercion ‐ by 11‐12 months Show forest plot

2

416

Risk Ratio (M‐H, Fixed, 95% CI)

1.36 [0.97, 1.89]
Figuras y tablas -
Comparison 1. COMPULSORY COMMUNITY TREATMENT vs STANDARD CARE
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Comparison 2. COMMUNITY TREATMENT ORDERS vs SUPERVISED DISCHARGE (SECTION 17)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Health service outcomes: 1. 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: 2. Hospital bed‐days Show forest plot

1

333

Mean Difference (IV, Fixed, 95% CI)

‐8.70 [‐30.88, 13.48]

3 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]

4 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]

5 Health service outcomes: 5. Days in community till first admission Show forest plot

1

333

Mean Difference (IV, Fixed, 95% CI)

5.0 [‐21.74, 31.74]

6 Patient level outcomes: 1. Mental state: BPRS Show forest plot

1

234

Mean Difference (IV, Fixed, 95% CI)

‐0.10 [‐3.17, 2.97]

7 Patient level outcomes: 2. Global state: GAF Show forest plot

1

237

Mean Difference (IV, Fixed, 95% CI)

‐0.70 [‐3.91, 2.51]
Figuras y tablas -
Comparison 2. COMMUNITY TREATMENT ORDERS vs SUPERVISED DISCHARGE (SECTION 17)
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