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

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

doi:10.1002/14651858.CD004408.pub5

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Figure 1

Study flow diagram.

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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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Figure 3

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

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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.

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Analysis 1.2

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

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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).

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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.

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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.

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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.

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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.

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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.

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Analysis 3.2

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

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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.

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Analysis 3.4

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

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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.

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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)	⊕⊕⊝⊝ Low^1,2	‐
	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)	⊕⊕⊝⊝ Low^1,2	‐
	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)	⊕⊕⊝⊝ Low^1,2	‐
	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)	⊕⊕⊝⊝ Low^1,2	‐
	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)	⊕⊕⊝⊝ Low^1,2	‐
	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)	⊕⊕⊝⊝ Low^1,3	‐
	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)	⊕⊕⊝⊝ Low^1,2	‐
	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.

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

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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)	⊕⊕⊕⊝ Moderate^1,2	‐
	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)	⊕⊕⊕⊝ Moderate^1,2	‐
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)	⊕⊕⊕⊝ Moderate^1,2	‐
Health service outcomes: 4. Number with multiple readmissions by 12 months	Study population		RR 0.56 (0.27 to 1.17)	333 (1 study)	⊕⊕⊕⊝ Moderate^1,2	‐
	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)	⊕⊕⊕⊝ Moderate^1,2	‐
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)	⊕⊕⊕⊝ Moderate^1,2
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)	⊕⊕⊕⊝ Moderate^1,2
	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.

Summary of findings 2. COMMUNITY TREATMENT ORDERS compared with SUPERVISED DISCHARGE (SECTION 17) for people with severe mental disorders

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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)	⊕⊕⊕⊝ Moderate^1,2	‐
	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)	⊕⊕⊕⊝ Moderate^1,2	‐
Health service outcomes: 3. Number with multiple readmissions by 12 months	Study population		RR 1.0 (0.6 to 1.66)	485 (2)	⊕⊕⊕⊝ Moderate^1,2	‐
	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)	⊕⊕⊕⊝ Moderate^1,2
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)	⊕⊕⊕⊝ Moderate^1,2	‐
	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.

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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]

Comparison 1. COURT ORDERED OUTPATIENT COMMITMENT compared with ENTIRELY VOLUNTARY CARE

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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]

Comparison 2. COMMUNITY TREATMENT ORDERS compared with SUPERVISED DISCHARGE (SECTION 17)

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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]

Comparison 3. COMPULSORY COMMUNITY TREATMENT compared with STANDARD CARE

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