Perception of Coercion Among Patients With a Psychiatric Community Treatment Order: A Literature Review
Abstract
Objective:
Methods:
Results:
Conclusions:
Methods
Design
Search Methods and Eligibility Criteria
Data Synthesis
Results
Region | Studiesb | Term | Patient eligibility | Methods | Reach | Enforcement and review |
---|---|---|---|---|---|---|
New Zealand | Newton-Howes, 2013 (39); McKenna et al., 2006 (40); Gibbs et al., 2005 (44); Gibbs, 2010 (45); Gibbs et al., 2004 (49); Gibbs et al., 2006 (56) | CTO | Has a mental illness and poses a serious danger to the health or safety of that person or others, seriously diminished capacity for self-care, involuntary treatment necessary for recovery, adequate outpatient care available, and adequate patient social circumstances | Court ordered after a hearing or by a psychiatrist (or physician) substituting for an involuntary inpatient order; if eligible, CTO preferred over hospital care | Mandatory judicial reviews at 6 and 12 months; after 12 months may be placed on CTO indefinitely; attend and accept treatment and meet with workers; possible restrictions: specified residence, abstinence from substances, travel beyond set boundaries | Recalled to hospital or clinic if conditions breached; police may be involved. Not possible to forcibly medicate in community setting |
Victoria, Australia | Brophy and Ring, 2004 (51) | CTO | Presence of serious mental illness, treatment can be obtained through a CTO, untreated mental illness would result in deterioration or dangerousness, the person has refused treatment or is unable to consent to the necessary treatment, and no adequate treatment for the mental illness possible in less restrictive form | Within 8 weeks of initial order by psychiatrist, CTO reviewed by the Mental Health Review Board (MHRB), an external review tribunal of community, legal, and psychiatrist members | Judicially reviewed at least once every 12 months; may be renewed indefinitely; legislation does not outline treatment; psychiatrist, not board, determines treatment specificities | Reviewed by MHRB at least once a year; appeals may be made to MHRB at any time by patient; order may be revoked by psychiatrist and patient returned to inpatient unit |
New York | Link et al., 2008 (1); Steadman et al., 2001 (14); Rain et al., 2003 (47); Phelan et al., 2010 (50) | AOT | Current inpatient, 18 or older, at least 2 involuntary hospitalizations in the past 18 months due to noncompliance with treatment, unlikely or unable to access treatment voluntarily once discharged, involuntary treatment necessary for recovery, history indicates likely to benefit from treatment | Ordered by the court; individuals with mental illness and a history of multiple hospitalizations or violence toward self or others; petition initiated by treatment provider | Valid for up to 180 days with option to be renewed; attend and accept treatment and meet with outpatient treatment team | Treatment adherence can be enforced by the sheriff’s department “but in practice nonadherence alone does not justify a sheriff’s pickup” (1) |
North Carolina | Swartz et al., 1999 (24); Swartz et al., 2002 (38); Elbogen et al., 2003 (46); Scheidcook, 1993 (54); Swartz et al., 2003 (57) | OPC | Presence of serious mental illness, the capacity to survive in the community with available supports, untreated mental illness would predictably result in deterioration or dangerousness, unlikely to access treatment voluntarily once discharged, history indicates likely to benefit from treatment | Court ordered after a hearing | Valid for up to 90 days with option to be renewed | A noncompliant patient can be brought back to a hospital by the police for “hopeful persuasion” (38) to accept treatment or evaluation for involuntary inpatient commitment; forced medication in community not permitted |
Pennsylvania | Gjesfjeld and Kennedy, 2011 (52) | OPC | No Pennsylvania-specific information provided | Court ordered after a hearing | No length or renewal information provided; requires compliance with designated outpatient treatment plan | No information provided |
Ohio | Galon and Wineman, 2011 (41); Galon et al., 2012 (48) | OPC | No Ohio-specific information provided | Court ordered after a hearing | No information provided | No information provided |
Saskatchewan, Canada | O’Reilly et al., 2006 (43) | CTO | At least 3 involuntary admissions or over 60 days of hospitalization in 24 months, meets inpatient committal criteria | Two psychiatrists must agree about need for initial CTO | Valid for 90 days; renewed if there is agreement from 2 psychiatrists | Admitted to inpatient unit if fails to meet conditions |
England and Wales | Canvin et al., 2002 (42) | SDO | Inpatient approaching discharge | Client consents to be placed on order or guardianship | Valid for 6 months, renewable; compulsory attendance of appointments; mandated place of residence; providing access to the clinical team | Recalled to hospital if fails to meet conditions; no compulsory medication adherence |
Scotland | Ridley and Hunter, 2013 (37) | CTO | Eligibility criteria not described | Involves appearance at mental health tribunal and development of care plan with providers, patient, and substitute decision maker | Compliance with outpatient treatment program, particularly medication | No information provided |
Israel | Greenberg et al., 2005 (53) | IOC | Presence of mental illness, presence of danger to self or others, and refusal to accept voluntary care | Issued by a district psychiatrist on the recommendation of the patient’s psychiatrist | Valid for 6 months; must continue to attend appointments and receive treatment in the community | Recalled to hospital if fails to attend appointments |
Studya | Location | Description | Relationship of PC and CTOs | Additional factors and findings |
---|---|---|---|---|
Quantitative | ||||
Steadman et al., 2001 (14); Rain et al., 2003 (47) | New York | Randomized controlled trial (RCT): 142 patients recruited from Bellevue Hospital at discharge; pilot study of CTO. Pilot group, N=78; control group (enhanced services only), N=64. Chart review and structured interviews at baseline and 1, 5, and 11 months posthospital discharge (57%–68% follow-up rates) | No significant correlation between greater PC and CTOs; majority of participants at baseline scored >3 on an adapted MacArthur PC Scale (range 1–5) (72% CTO, 63% control group) | No significant differences in main outcome measurements; some correlation between greater PC and adherence to injected medication at first follow-up (r=.524) but not significant at second or third follow-ups; no pick-up orders issued by police for enforcement of the CTO during pilot study |
Link et al., 2008 (1); Phelan et al., 2010 (50) | New York | Longitudinal comparative study: 184 outpatients recruited from clinics in New York City. CTO group, N=76; voluntary outpatient group, N=108. Interviews at baseline and 3, 6, 9, and 12 months (62%–84% follow-up rates) | No significant correlation between greater PC and CTOs; mean scores on adapted MacArthur PC Scale (possible range 0–3) of 1.45 for CTO participants and 1.33 for control group. CTO patients marginally less likely to have greater PC (p<.10) during follow-up period | Some correlation between a greater number of past involuntary hospitalizations and increased PC (r=.331, p<.001) |
Swartz et al., 1999 (24); Swartz et al., 2002 (38); Swartz et al., 2003 (57) | North Carolina | RCT: 258 patients at hospital discharge. CTO group, N=100; voluntary outpatient group, N=113; nonrandomized CTO patients with violent history, N=45. Chart review and structured interviews at baseline and 4, 8, 12, and 16 months; interviews with family member or collateral informant and case manager | Significant difference in PC between CTO patients (median=5.51) and control groups (median=3.80) (p=.002) on the adapted 15-item MacArthur Admissions Experience Survey measuring coercion, negative pressures, and process exclusion (possible range 1–15; logistical regression completed after dichotomizing participants as higher or lower than median, as scores were skewed to the low end of the scale) | Higher PC significantly associated with African-American patients (p≤.05), more severe psychiatric symptoms (p≤.05), mood disorder (p≤.05), problems related to substance use (p≤.01), increased days on CTOs (p≤.05), increased case managers’ reminders and warnings of consequences of nonadherence to treatment (p≤.05), patients whose orders were enforced due to nonadherence (p≤.05). Lower PC significantly associated with greater levels of insight (p≤.05), being married or cohabiting (p≤.01). Patients who experienced greater PC unlikely to endorse benefits of CTOs unless they experienced positive treatment outcomes (p<.05) |
Elbogen et al., 2003 (46) | North Carolina | RCT (secondary analysis of North Carolina RCT) (24,36,38) using 12-month follow-up data. Patients reorganized in 4 nonrandomized subgroups: neither CTO nor financial guardianship (N=65, (25%), financial guardianship only (N=46, 18%), CTO only (N=62, 24%), both CTO and financial guardianship (N=62, 24%) | Significantly higher rates of PC for patients with both financial guardianship and CTO compared with neither (p=.004). No significant difference in PC between patients with a CTO or financial guardianship alone compared with neither | Significant effect of number of types of leverage on increased PC for medication-nonadherent patients (p=.023), but not for adherent patients |
Galon and Wineman, 2011 (41); Galon et al., 2012 (48) | Ohio | Quasi-experimental comparative study: 154 outpatients recruited from 2 clinics. Four comparison groups: assertive community treatment (ACT) and CTO (N=31), ACT and no CTO (N=45), usual care and CTO (N=34), and usual care only (N=45); did not reach the sample sizes necessary for strong analysis | CTO groups nearly 3 times more likely to have higher PC scores compared with those without a CTO (p<.001); overall PC scores lower than for other CTO studies (1.73±1.88, CTO; .67 [SD not reported], non-CTO) based on an adapted MacArthur PC Scale, range 0–5) | Strong inverse correlation between procedural justice and PC (r=–.51, p<.001), accounted for 25.8% of variance in PC scores; less strong with African-American patients (accounted for 8.9% of variance, with CTO status accounting for 2%). College graduates (2.57±1.98) had higher PC, compared with non–high school graduates (.70±1.20, p=.004), and lower perceived procedural justice (2.29±2.36, p=.012), compared with non–high school graduates (4.37±1.91, p=1.91) and high school graduates (4.16±2.01, p=.20). No additive effect of CTO and ACT on PC |
McKenna et al., 2006 (40) | Auckland, New Zealand | Comparative study: 138 outpatients, 2 comparison groups (CTO, N=69; voluntary outpatients, N=69). One-time interview; overall response rate of those able to be contacted or able to be involved in informed consent of 86% | Significant difference in PC between CTO and control groups (p<.001); overall levels of perceived coercion low in both cohorts | Both cohorts showed an overall high level of procedural justice. In bivariate analysis, greater insight into illness significantly associated with lower PC (p=.003); previous hospital admission (p=.004) or involuntary hospitalization (p≤.001) associated with higher PC; weak inverse correlation between PC and procedural justice (rs=–.286, p≤.001); correlation between lower PC and having a partner (p=.001) |
Newton-Howes, 2013 (39) | Otago, New Zealand | Self-administered survey: 79 outpatients; one-time survey of patients with a current or recent CTO | CTO status accounted for 41% of variance in client’s interpersonal problems, encompassing difficulties with mental health services and the legal system | Some patients identified benefits in treatment due to a perceived increase in availability of support services |
Qualitative | ||||
Scheidcook, 1993 (54) | North Carolina | Interviews and participant observation over 2 years with outpatients with a CTO (N=68) and clinicians (N=123) in rural community mental health care centers | Patients felt forced to take medication, found CTOs less coercive than hospitalization | Patients’ lack of knowledge of legislation |
Gjesfjeld and Kennedy, 2011 (52) | Pennsylvania | 1-time individual interviews with outpatients with current or recent (within 2 years) CTO (N=9) and client-nominated service providers (N=8) | Patients expressed lack of control in decision making | Patients’ lack of knowledge of legislation; patients identified benefits in treatment due to increase in availability of support services; positive relationship with mental health providers associated with reduced coercion and increased benefits of CTO |
O’Reilly et al., 2006 (43) | Saskatchewan, Canada | 8 stakeholder focus groups with CTO-experienced family members (N=14) and mental health care providers (N=50); individual interviews with outpatients with a CTO (N=14) | Patients expressed perception of coercion in treatment; found CTOs less coercive than hospitalization | More acceptance of CTO after time because of increase in safety and security provided by structure. Patients had awareness of their rights on CTOs but exercising those rights felt futile |
Gibbs et al., 2005 (44); Gibbs, 2010 (45); Gibbs et al., 2004 (49); Gibbs et al., 2006 (56) | Otago, New Zealand | 1-time individual interviews with outpatients with a current or recent (within 2 years) CTO (N=42), patient-nominated family members (N=27), and mental health providers (N=90); additional subanalyses of female clients (N=10) and Maori clients (N=8) and their families | Minority of patients perceived coercion related to medication adherence; travel and residence restrictions; control over treatment decisions by providers, particularly psychiatrists | Patients identified benefits in treatment due to increase in availability of support services; positive relationship with mental health providers reduced coercion and increased benefits of CTO; important to account for unique needs and concerns of women and Maori patients with a CTO |
Brophy and Ring, 2004 (51) | Victoria, Australia | 1-time focus groups with outpatients with a CTO (N=30) and patient-nominated service providers (N=18). Some Likert scales used with providers | Patients felt under threat of sanctions; disliked forced treatment, particularly intramuscular medication injections | Patients identified benefits in treatment due to increase in availability of support services; patients felt disempowered because of process and order |
Ridley and Hunter, 2013 (37) | Scotland | Baseline and 12-month individual interviews with outpatients with a CTO (N=49) from across the country | Patients found compulsion overall negative, but saw some benefits | Patients’ lack of knowledge of legislation; some patients identified benefits in treatment due to a perceived increase in availability of support services |
Canvin et al., 2002 (42) | South East England | 1-time interviews with outpatients with a CTO (N=20) | Patients disliked lifestyle restrictions; some expressed resistance to the order; CTO found less coercive than hospitalization | Patients’ lack of knowledge of legislation and patient rights; patients who successfully appealed their CTO were not included in this study due to recruitment methodology |
Greenberg et al., 2005 (53) | North Jerusalem | 1-time interviews with outpatients with a CTO (N=13) and psychiatrists (N=17); patient chart review (N=26) | Patients saw practice as coercive | Lack of knowledge of patient rights and ability to appeal; orders did not seem to have a great impact on relationship between patients and psychiatrists |
Patient Characteristics
Clinical history and characteristics.
Demographic factors.
Perceived Coercion and CTOs
Procedural Justice and CTO Enactment
Service Involvement
Discussion
Implications for Practice and Research
Limitations
Conclusions
Acknowledgments
Supplementary Material
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