Community treatment orders for people with severe mental illness: do they work?

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There is controversy as to whether compulsory community treatment (known in the UK as community treatment orders) for people with severe mental illnesses reduces health service use, or improves clinical outcome and social functioning. Given the widespread use of such powers it is important to assess the effects of this type of legislation.

Researchers from the University of Queensland have updated their Cochrane systematic review that examines the clinical and cost effectiveness of compulsory community treatment for people with severe mental illness.

They searched the Cochrane Schizophrenia Group Register and the Science Citation Index to find relevant randomised controlled trials (RCT) of compulsory community treatment compared with standard care for people with severe mental illness.

They only found two RCTs (total n = 416) of court-ordered ‘Outpatient Commitment’ (OPC) from the USA and reported that they identified little evidence that compulsory community treatment was effective 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 1.2);
  • Social functioning (2 RCTs, n = 416, RR for arrested at least once by 11-12 months 0.97 CI 0.62 to 1.52)
  • Quality of life (2 RCTs, n = 416, RR for homelessness 0.67 CI 0.39 to 1.15)
  • Satisfaction with care (2 RCTs, n = 416, RR for perceived coercion 1.36 CI 0.97 to 1.89)

One positive finding was that risk of victimisation may decrease with OPC (1 RCT, n = 264, RR 0.5 CI 0.31 to 0.8).

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 6 (CI 6 to 6.5).

The reviewers presented the following implications for practice:

1. For people with serious mental illnesses
Patients and carers should question the rationale for compulsory community treatment and advocate more effective treatments.

2. For clinicians
Clinicians and health service planners who wish to reduce hospital admissions should consider alternatives with stronger evidence for effectiveness such as Intensive Case Management (Dieterich 2010).

3. For policy makers
Based on results from this review, there is no strong evidence to support the claims made for compulsory community treatment that make it so attractive for legislators. It does not appear to reduce health service use or improve patients’ social functioning. It also does not significantly reduce perceived coercion. Lack of data made it impossible to assess its effect on costs, mental state, and other aspects of patient/carer satisfaction.

Legislation in this area may detract from the introduction of interventions that are of benefit to individuals with severe mental disorder such as Intensive Case Management (Dieterich 2010), but which are more expensive than legislative solutions to the problem. If governments continue to introduce this type of legislation, without further evidence for effectiveness, some evaluation of outcome should be included.

Links

Kisely SR, Campbell LA, Preston NJ. Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Cochrane Database of Systematic Reviews 2011, Issue 2. Art. No.: CD004408. DOI: 10.1002/14651858.CD004408.pub3.

Dieterich M, Irving CB, Park B, Marshall M. Intensive case management for severe mental illness. Cochrane Database of Systematic Reviews 2010, Issue 10. Art. No.: CD007906. DOI: 10.1002/14651858.CD007906.pub2.

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