Does compulsory or supervised community treatment reduce 'revolving door' care?: Legislation is inconsistent with recent  evidence

Supervised community treatment to address‘revolving door’care is part of the new Mental Health Act in England and Wales.Two recent epidemiological studies in Australia (n>118 000),as well as a systematic review of all previous literature usingappropriately matched or randomised controls (n=1108), suggestthatitisunlikely to help.

INTRODUCTION

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INTRODUCTION

Although many patients have benefited from the de-institutionalisationof mental healthcare, there have been concerns that some havenot received the care they require. Compulsory community treatmentmay help people stay in contact with services but remains controversial.Approaches include conditional discharge from hospital, communitytreatment orders for patients who are in the community, andcourt-ordered civil out-patient commitment.

One problem has been that much of the literature is based onopinion or uncontrolled studies. However, recent studies haveused matching, multivariate analyses or randomisation to comparepatients on compulsory community treatment with those not subjectto such interventions. In the past year there have been fourpapers from two large studies based on the Victorian PsychiatricCase Register in Australia (n>118 000) (Burgess et al, 2006; Segal & Burgess, 2006a) as well as a systematic reviewof all previous literature using appropriately matched or randomisedcontrols (n=1108) (Kisely et al, 2007). This is timely, asthe Department of Health in England and Wales has includedsupervised community treatment in the new Mental Health Act to address the issue of ‘revolving door’ care (Department of Health, 2006).

The clearest indicator of whether compulsory community treatmenthelps ‘revolving door’ patients would be the numberof bed-days rather than admissions. The intervention can onlybe the least restrictive alternative if individuals spend lesstime in hospital. In contrast, interpretation of the effecton admissions is less clear. Community treatment orders couldconceivably either reduce admission rates, so allowing individualsto remain in their communities during treatment, or increasethem, as a result of earlier identification of relapse.

DOES COMPULSORY COMMUNITY TREATMENT REDUCE ‘REVOLVING DOOR’ CARE?

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DOES COMPULSORY COMMUNITY...

The latest data give a mixed picture of whether compulsory community treatment would help. In Victoria, conditional discharge wasassociated with an overall mean increase of 15 bed-days, despitea reduction in the days per admission or care episode (Segal & Burgess, 2006a).The interpretation of this is unclear, but it could representan increase in ‘revolving door’ care whereby individualshave more admissions and spend greater time in hospital. Thiswould be consistent with another study using the same Victoriandatabase where the risk of readmission increased followinginitial placement on a community treatment order (Burgess et al, 2006).These findings also reflect a systematic review of the literaturepre-dating the two Victorian studies (Kisely et al, 2007). Five studies were included: two randomised controlled trials(RCTs) and one controlled before-and-after (CBA) study of out-patientcommitment in the USA (Geller et al, 1998; Swartz et al, 1999; Steadman et al, 2001), and two CBA studies of community treatmentorders in Western Australia (Preston et al, 2002; Kisely et al, 2005a).This failed to demonstrate a significant reduction in bed-daysbetween patients receiving compulsory community treatment andcontrols.

ARE THERE OUTCOMES ON WHICH COMPULSORY COMMUNITY TREATMENT MIGHT HAVE AN EFFECT?

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ARE THERE OUTCOMES ON...

There are several potentially significant areas where the interventionwas found to have an effect. Although community treatment ordersused on initial discharge from hospital were associated witha higher risk of readmission, orders following subsequent admissionswere associated with a lower risk (Burgess et al, 2006). However,we do not know the effect on bed-days, which may be the morecritical measure of health service use. It was also difficultto determine whether this was also affected by changes in theuse of compulsory community treatment over time, given thatthe number of orders increased from 919 in 1992 to 2260 in 2000(Burgess et al, 2006).

Compulsory community treatment may also be more effective inearly-episode cases when used within 30 days of initial admissionto specialist services (Segal & Burgess, 2006b). However,the use of community treatment orders in first-episode caseswould be impossible in most jurisdictions outside Australasia,where orders are limited to patients who have had substantial health service use in the year prior to the intervention. Anotherpositive finding is that compulsory community treatment mayreduce subsequent mortality (Segal & Burgess, 2006c).However, 10% of the patients in that study had dementia orother nervous system disease, which is not typical of populations elsewhere who are receiving compulsory community treatment,and patients with these diagnoses made up 29% of the totaldeaths.

WHAT ARE THE POLICY AND RESEARCH IMPLICATIONS?

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WHAT ARE THE POLICY...

None of the studies of compulsory community treatment is entirely satisfactory. The systematic review of the literature withappropriately matched or randomised controls that pre-datedthe studies from Victoria was limited by the small number ofstudies (two RCTs and three CBA studies) (Kisely et al, 2007). Both RCTs were of court-ordered out-patient commitment in theUSA, which may not be generalisable to other jurisdictionswhere compulsory community treatment is initiated by cliniciansand excludes patients with a history of violence (Swartz et al, 1999;Steadman et al, 2001). Of the three CBA papers, two were epidemiologicalstudies from Western Australia which compared patients givencommunity treatment orders with controls from within the samejurisdiction and internationally (n=652) (Preston et al, 2002;Kisely et al, 2005a). However, the two studies were restrictedto patients given treatment orders in the first year of thelegislation and may not reflect subsequent practice as cliniciansgained experience in the use of the Act.

The two studies using the Victorian register were considerablylarger and not subject to selection bias (Burgess et al, 2006;Segal & Burgess, 2006a). They also covered a decade’s experience of the legislation, and so may give a clearer pictureof the longer-term effects than studies restricted to the firstyear of operation. However, there were also significant limitations.The authors did not match for date of placement on conditionalrelease and so could not exclude the effect of other health-systemchanges that might have occurred between 1990 and 2000. Inone study, conditional release and the outcome of interest hadto occur in the same year (Burgess et al, 2006); in the other,the authors controlled for time of first contact with mentalhealth services and mean year (Segal & Burgess, 2006a).Neither of these is quite the same as matching for dischargedate. Controlling for time of first contact with mental health services could be affected by people arriving from other jurisdictionswith pre-existing illness not captured by the Victorian PsychiatricCase Register. More importantly, although Segal & Burgess (2006a) controlled for time at risk, there was no stipulationthat the event of interest (e.g. readmission or mortality)had to occur within a certain period of placement on conditionaldischarge. This means it could occur any time from 1 day to10 years after the index date, whether someone was still onconditional discharge or not. Most previous work in this areahas limited follow-up to 12 months after the order, as onehas to be very cautious of ascribing an effect beyond a yearfollowing initial placement (Preston et al, 2002; Kisely et al, 2007).

In the case of mortality, the authors did not control for confounderssuch as life-style, psychotropic medication, reduced accessto general medical care and the difficulties in recognisingphysical comorbidity in psychiatric patients with physicalcomplaints (Kisely et al, 2005b; Segal & Burgess, 2006c).Furthermore, 72% of the deaths in people with mental healthproblems occur in patients who had only ever been seen in primarycare (Kisely et al, 2005b). Conditional discharge could thereforeonly play a very small part in addressing the increased mortalityamong patients with mental health problems, even if such alink were to be established.

Irrespective of how epidemiological studies have controlledfor confounders, the selection of controls from the same jurisdictionas the community treatment order cases may be subject to confoundingfrom variables such as social disability or characteristicsof the treating team (Kisely et al, 2005a). These might explainwhy some patients and not others were given compulsory communitytreatment. Comparing jurisdictions with and without compulsorycommunity treatment partially addresses this concern but raisesthe issue of comparability of the two health systems, especially with international comparisons (Kisely et al, 2005a).

In conclusion, there is limited evidence that compulsory community treatment will address the issue of the ‘revolving door’,at least in the short term, even though this is the Departmentof Health’s main justification for supervised communitytreatment in England and Wales (Department of Health, 2006). This issue illustrates how health policy remains determinedby social or political factors as much as by evidence (Black, 2001).At the very least, researchers, funding bodies and policy makersshould collaborate in evaluating the effects of the proposedlegislation. Studies should ideally include a range of patient,family and health service outcomes using mixed methods, ratherthan focus on admission rates and lengths of stay. In the meantime,it might be more appropriate to acknowledge openly the limitsof our knowledge, rather than rely on the illusion that evidenceexists.

REFERENCES

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