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Correspondence |
Leeds Mental Health Teaching Trust, Malham House, 25 Hyde Terrace, Leeds LS2 9LN, UK
We fully agree with Kisley et al (2004) that the patients receiving compulsory community treatment are often relatively young, male, single, Black or from a minority ethnic group, unemployed and with a history of schizophrenia, drug use, previous admissions and forensic contact. They obviously are more severely unwell and more liable to be readmitted than are those who are treated without compulsory treatment orders (CTOs). Therefore, it would have been more appropriate to compare the patients on CTOs with individuals whose applications for CTOs were not granted by the family courts (as in New Zealand), or who were discharged by the Mental Health Review Boards (as in Australia).
In our experience, a patient’s non-adherence with treatment is a common reason for the psychiatrist to consider compulsory treatment in the community. In this respect, the clinical experience of psychiatrists in New Zealand has been satisfactory as 69.2% reported that CTOs were a useful tool for promoting community treatment for people with mental illnesses (Currier, 1997). On the other hand, there is a paucity of conclusive findings and qualitative research into the experience of patients, carers and professionals regarding compulsory community treatment, with respect to how it may impact upon civil liberties and, in particular, future engagement with mental health services (Moncrieff & Smyth, 1999), which is of concern.
REFERENCES
Currier, G. W. (1997) A survey of New Zealand psychiatrists’ clinical experience with the Mental Health (Compulsory Assessment and Treatment) Act of 1992. New Zealand Medical Journal, 110, 6 -9.[Medline]
Kisley, S. R., Xiao, J. & Preston, N. J.
(2004) Impact of compulsory community treatment on admission
rates. Survival analysis using linked mental health and offender databases.
British Journal of Psychiatry,
184, 432
-438.
Moncrieff, J. & Smyth, M. (1999) Community
treatment orders – a bridge too far? Psychiatric
Bulletin, 23, 644
-646.
Department of Psychiatry, Dalhousie University, Abbie J. Lane Memorial Building, 5909 Veterans Memorial Lane, Suite 9211, Halifax, Nova Scotia B3H 2E2, Canada
As Robinson & Mahmood point out the crucial issue in our paper is the comparability of those patients who were on community treatment orders (CTOs) and those who were not. Although we controlled for sociodemographic variables, clinical features, case complexity and psychiatric history, we fully acknowledged in our paper that there may have been additional factors that we could not control for in the analysis. These might include social disability, aggression not resulting in a forensic history, medication type (including the use of depot preparations) and characteristics of the clinician, treating team or service. Inevitably, a study that took these factors into account would be restricted to one or two services with consequent loss of statistical power and the dangers of selection or referral bias. Furthermore, our study was able to adjust for more service use confounders than others that have shown positive effects of compulsory community treatment (Bindman, 2002).
However, we disagree that patients who had been discharged from a CTO by a Mental Health Review Board would be a more appropriate control group. Even with careful matching, there would be a reason why the intervention group remained on a CTO while the controls were discharged from their order. For instance, patients who remained on compulsory community treatment could have been less insightful about their illness or more likely to have a history of aggressive behaviour. Neither can we accept that surveys of psychiatrists’ views on CTOs have any place in an era of evidence-based practice. This would not be accepted as a reason to introduce any other psychiatric intervention. Why should CTOs with their attendant implications for the civil liberties of patients be treated differently?
REFERENCES
Bindman, J. (2002) Involuntary outpatient treatment in England and Wales. Current Opinion in Psychiatry, 15, 595 -598.[CrossRef]
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