East Asian Arch Psychiatry 2023;33:37-43 | https://doi.org/10.12809/eaap2246
REVIEW ARTICLE
Abstract
Introduction: Community treatment orders (CTOs) enable patients to actively engage in mental health services while being supervised in the community outside the hospital setting. However, the efficacy of CTOs remains controversial in terms of mental health services usage or service contacts, emergency visits, and violence.
Methods: The databases PsychINFO, Embase, and Medline were searched on 11 March 2022 by 2 independent reviewers through the Covidence website (www.covidence.org). Randomised or non- randomised case-control studies and pre-post studies were included if they examine the effect of CTOs on service contacts, emergency visits, and violence in individuals with mental illnesses by comparing with control groups or pre-CTO conditions. Conflicts were resolved by consultation of the third independent reviewer.
Results: Sixteen studies provided sufficient data in the target outcome measures and were included in analysis. Variability in the risk of bias was high among studies. Meta-analyses were conducted separately for case-control studies and pre-post studies. For service contacts, a total of 11 studies with 66,192 patients reported changes in the number of service contacts under CTOs. In 6 case-control studies, a small non-significant increase in service contacts was observed in those under CTOs (Hedge’s g = 0.241, z = 1.535, p = 0.13). In 5 pre-post studies, a large and significant increase in service contacts was noted after CTOs (Hedge’s g = 0.830, z = 5.056, p < 0.001). For emergency visits, a total of 6 studies with 930 patients reported changes in the number of emergency visits under CTOs. In 2 case-control studies, a small non-significant increase in emergency visits was noted in those under CTOs (Hedge’s g = –0.196, z = –1.567, p = 0.117). In 4 pre-post studies, a small significant decrease in emergency visits was noted after CTOs (Hedge’s g = 0.553, z = 3.101, p = 0.002). For violence, a total of 2 pre-post studies reported a moderate significant reduction in violence after CTOs (Hedge’s g = 0.482, z = 5.173, p < 0.001).
Conclusion: Case-control studies showed inconclusive evidence, but pre-post studies showed significant effects of CTOs in promoting service contacts and reducing emergency visits and violence. Future studies on cost-effectiveness analysis and qualitative analysis for specific populations with various cultures and backgrounds are warranted.
Elson Ho Yin Lam, Department of Forensic Psychiatry, Castle Peak Hospital, Hong Kong SAR, China
Eric Shek Kin Lai, Department of Occupational Therapy, Castle Peak Hospital, Hong Kong SAR, China
Eric Chun Lun Lai, Department of Child and Adolescent Psychiatry, Castle Peak Hospital, Hong Kong SAR, China
Esther Lau, Department of Occupational Therapy, Castle Peak Hospital, Hong Kong SAR, China
Bonnie Wei Man Siu, Department of Forensic Psychiatry, Castle Peak Hospital, Hong Kong SAR, China
Dorothy Yuen Yee Tang, Department of Forensic Psychiatry, Castle Peak Hospital, Hong Kong SAR, China
Cycbie Ching Man Mok, Department of Occupational Therapy, Castle Peak Hospital, Hong Kong SAR, China
Ming Lam, Department of General Adult Psychiatry, Castle Peak Hospital, Hong Kong SAR, China
Address for correspondence: Dr Elson Ho Yin Lam, Department of Forensic Psychiatry, Castle Peak Hospital, 15 Tsing Chung Koon Road, Tuen Mun, New Territories, Hong Kong SAR, China. Email: lhy095@ha.org.hk
Submitted: 26 September 2022; Accepted: 29 March 2023
Introduction
Community treatment orders (CTOs) enable patients to actively engage in mental health services while being supervised in the community outside the hospital setting.1 Patients who meet specific criteria, such as a high risk of self-harm or violence to others if they are untreated or experience acute episodes, are required to follow the prescribed treatment under legal provision.2 Failure to comply with this can result in hospitalisation. CTOs were first introduced in the United States and Australia in the 1980s following deinstitutionalisation of mental health services.3 They have also been implemented in the United Kingdom, Canada, and various European countries. Different models of mandatory community treatments are available, and the execution of CTOs varies between countries.2 Compulsory community treatment, involuntary outpatient commitment, and CTO are similar terminologies.
For patients with major mental illnesses, CTOs serve as less restrictive legal requirements and offer an alternative to compulsory inpatient treatment by allowing more freedom for patients to undergo psychiatric care in the community while being closely monitored.1 In addition, CTOs improve adherence to treatment and medication and enable healthcare professionals to monitor a patient’s mental state.4 Patients with severe mental illness who have limited insight and a negative attitude towards treatment can benefit from CTOs.
However, the effectiveness of CTOs remain controversial.5 Three randomised controlled trials that evaluated readmission rates, number of readmissions, and lengths of hospital stay reported inconsistent findings.6-8 One study suggested that CTOs could reduce hospital readmissions and total hospital days,6 whereas another found no difference in rehospitalisation rates.7 The third study reported no favourable outcomes in terms of hospital readmissions.8 A Cochrane systematic review also reported insignificant results in favour of CTOs.9
In a systematic review and meta-analysis of compulsory community treatment in 2018, there was no consistent evidence that CTOs reduce readmission or length of inpatient stay.10 Hospitalisation-related outcomes are measurable variables that reflect mental health service burden. Other aspects such as quality of life, compliance with treatment, and service usage are also important but are of limited availability. The effect of CTOs on patients before readmitted to hospital should also be considered. The main purpose of CTOs is to actively engage patients in the mental health services,1 and therefore the degree of service usage is of concern, as non-adherence to treatment is associated with increased use of emergency psychiatric services.11
CTOs have not yet been introduced in Hong Kong; conditional discharge is a comparable community treatment administered under the power of chapter 136 of the Mental Health Ordinance.12 This allows patients with a history of criminal violence or a potential to commit such violence who were compulsorily admitted to a psychiatric hospital to be discharged under specific conditions. Patients can be recalled for inpatient treatment if they breach any terms of the conditional discharge. Non-adherence to CTOs has been reported to be associated with violence behaviours.13 Therefore, the aim of this study was to review the literature on the effect of CTOs on hospitalisation-related outcomes, promotion of service contacts, reduction of emergency visits, and reduction of violence.
Materials and Methods
This systematic review and meta-analysis of the literature was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.14 The databases PsychINFO, Embase, and Medline were searched on March 11, 2022 by 2 independent reviewers through the Covidence website (www.covidence.org) using the following key words: mental illness, mental disorder, mentally ill, or psychiatr* AND community treatment order, outpatient commitment, civil commitment, involuntary commitment, involuntary treatment, involuntary outpatient, involuntary community, compulsory commitment, compulsory treatment, compulsory outpatient, compulsory community, mandatory commitment, mandatory treatment, mandatory outpatient, or mandatory community.
The PICO (population, intervention, comparison, outcome) framework was used to develop focused clinical questions. Randomised or non-randomised case-control studies and pre-post studies were included if they examine the effect of CTOs (intervention) on mental health service usage or service contacts, emergency visits, and violence (outcomes) in individuals with mental illnesses (population) by comparing with control groups or pre-CTO conditions (comparison). Studies were excluded if they were published in languages other than English, unpublished, or if the full text could not be retrieved. Conflicts were resolved by consultation of the third independent reviewer.
The effect of CTOs on mental health service usage was determined by the numbers of service contacts in community mental health service, community and outpatient contacts, and scheduled non-emergency outpatient psychiatric visits. The number of emergency visits in a specified period was collected, as was the reported episodes of violence in the community and arrest statistics for violent crimes.
Data on study design, sample size, country, follow- up duration, and outcomes were collected. The quality of studies was assessed using the revised Cochrane risk-of- bias tool15 and the Risk of Bias in Non-randomised Studies of Interventions (ROBINS-I) tool16 for randomised and non-randomised studies, respectively. The ROBINS-I included 7 domains that address issues before the start of the interventions, at interventions, and after the start of interventions. The risk of bias in each domain is categorised as low, moderate, serious, or critical.
Meta-analysis was conducted using the Comprehensive Meta-Analysis software. Effect sizes were extracted and converted to standardised mean differences for continuous measures. Hedge’s g was computed, as it is a less biased measure of effect size than Cohen’s d.17 Effect sizes were pooled separately for pre-post studies and case-control studies. A random effects model was used for all analyses because of the variability of effect sizes. The model assumed that the reviewed studies had a random sample of effect sizes, which enables generalisation of the overall results. Effect sizes of 0.2, 0.5, and 0.8 were defined as small, moderate, and large, respectively. Results were considered significant when the p value was < 0.05. Heterogeneity was assessed using the I2 statistic, with values of 25%, 50%, and 75% indicating small, moderate, and high proportions of heterogeneity, respectively.18 Sensitivity was analysed using the leave-one-out method. Publication bias was assessed by visual examination of funnel plots.
Results
Of 7633 papers retrieved, 25 were potentially relevant and reviewed for eligibility (Figure). Sixteen studies provided sufficient data in the target outcome measures and were included in analysis (Table 1).
The quality of the 16 studies was evaluated using the revised Cochrane risk-of-bias tool and the ROBINS-I tool. Variability in the risk of bias was high among studies. For randomised controlled studies, the risk of bias was low for selection, attrition, and reporting, whereas the allocation concealment process was unclear and the risk of bias was high for performance, detection, and other potential biases, especially for the uncertainty regarding the insufficient control condition and high percentage of participants (around 20%) being ineligible or refusing to take part in the study. The most concerning risk of bias was from non-randomised pre-post studies, specifically the risk of confounding bias and selection bias. Overall, the risk of bias for the included studies was low to moderate.
Table 2 shows the forests plots for the effect of CTOs on service contacts, emergency visits, and violence. Meta-analyses were conducted separately for case-control studies and pre-post studies. Service contact was defined as the number of community treatment days,20,24 face-to-face and phone contacts with the community mental health service,29 community and outpatient contacts,21,22 and scheduled, non- emergency outpatient psychiatry visits.25,27,30,33 For service contacts, a total of 11 studies with 66,192 patients from England, Australia, the United States, and Canada reported changes in the number of service contacts. In 6 case-control studies, a small non-significant increase in service contacts was observed in those under CTOs (Hedge’s g = 0.241, 95% confidence interval [CI] = –0.067 to 0.550, z = 1.535, p = 0.13). In 5 pre-post studies, a large and significant increase in service contacts was noted after CTOs (Hedge’s g = 0.830, 95% CI = 0.508-1.151, z = 5.056, p < 0.001). For emergency visits, a total of 6 studies with 930 patients from Australia, the United States, and Spain reported changes in the number of emergency visits for those under CTOs.19,23,28-30,33 In 2 case-control studies, a small non-significant increase in emergency visits was noted in those under CTOs (Hedge’s g = –0.196, 95% CI = –0.441 to 0.049, z = –1.567, p = 0.117). In 4 pre-post studies, a small significant decrease in emergency visits was noted after CTOs (Hedge’s g = 0.553, 95% CI = 0.203-0.902, z = 3.101, p = 0.002). Violence was defined as monthly reported episodes of violence in the community and arrest statistics for violent crimes.26,32 Two pre-post studies reported a moderate significant reduction in violence after CTOs (Hedge’s g = 0.482, 95% CI = 0.299-0.664, z = 5.173, p < 0.001).
Heterogeneity was high for all outcomes except for emergency visits in case-control studies and violence in pre-post studies. Sensitivity analyses using the leave-one- out method were carried out for outcomes with significant results (all in pre-post studies); results remained significant if any of the studies were removed. The effect of publication bias could not be analysed, as none of the analyses consisted of results from ≥10 studies.
Discussion
Previous studies have extensively evaluated the effects of CTOs on hospital readmissions, which yielded unfavourable results.6-9 In the present study, case-control studies showed a small non-significant effect of CTOs, but pre-post studies showed significant effects of CTOs in promoting service contacts and reducing emergency visits and violence.
Our results were comparable to those of a previous meta-analysis that investigated the effect on readmission to hospital.10 Although case-control studies yielded insignificant results, pre-post studies favoured the use of CTOs in reducing readmission, probably because the pre- post study design that measures outcomes before and after implementation of the intervention.34 The pre-post design also shows the effect of an intervention on a patient across a given time period, which reduces individual variation; theoretically, it can examine the specific effect of CTO on a patient. However, heterogeneity was high for our outcomes, which could be due to the intrinsic variations in CTOs across different countries and in patients from various backgrounds, ethnicities, and cultures. The high heterogeneity may have contributed to the inconsistent results.
Implementation of CTOs always requires a balance between benefits and costs. The lack of consistent evidence may be a reason that CTOs have not yet been implemented in Hong Kong. The non-significant findings on readmission rates in patients under CTOs may dissuade policy makers from introducing CTOs to Hong Kong. Service contacts, emergency visits, and violence are important in care management. By promoting service contacts, patients can have easier and more frequent contact with the psychiatric care team. Support from outpatient clinics or phone contacts may enable timely management and thus minimise undesirable outcomes should a patient’s mental condition deteriorate. Ideally, the more service contacts patients have, the more support can be given. The number of emergency visits may reflect the severity of mental illness and the level of management outside the hospital. The risk of violence is of paramount importance; any evidence that supports the reduction of violence should be highlighted.
When considering CTOs, the potential clinical benefits to patients should be weighed against the curtailment of liberty for this group of marginalised and stigmatised patients.35 The implementation of CTOs remains controversial because of the inconsistent evidence, their cost-effectiveness, ethical issues, cultural differences, and public attitude towards patients with severe mental illness. CTOs are a form of compulsory treatment for patients who have refused to comply with psychiatric treatment. CTOs inevitably compromise patient autonomy and interfere with patient decisions on treatment choices. CTOs impose variable levels of coercion to ensure that patients follow the instructions given by healthcare professionals. Public acceptance of CTOs may vary across different countries and cultures. There is a paucity of research on CTOs in Asia, particularly in Chinese populations. Although the present study provides evidence on some quantitative outcomes, the qualitative outcomes such as descriptive and stakeholder trials should not be neglected.
There were several limitations in our study. Randomised controlled trials are gold standard of clinical research, but no such trial that evaluated any of the 3 outcomes were included in analysis. The pre-post studies did not have control groups, and therefore other contributing factors may not have been identified. Therefore, the observed effectiveness of CTOs may not be fully attributable to CTOs. Only 2 pre-post studies were identified to have assessed change in violence after CTOs. In one study, violence was defined as the rate of violent episodes in a month, but what constituted a violent event was not specified. The causal relationship between patients with mental illness and records of being arrested for a violent crime could not be ascertained. Measuring violence is difficult and this is a known limitation for studies in forensic settings. Outcomes such as reduction of self-harm and suicide were not assessed, as there has been no meta-analysis exploring the effectiveness of CTOs on the reduction of self-harm and suicide.
Conclusion
Case-control studies showed inconclusive evidence, but pre-post studies showed significant effects of CTOs in promoting service contacts and reducing emergency visits and violence. Future studies can explore cost-effectiveness analysis and qualitative analysis for specific populations with various cultures and backgrounds.
Contributors
All authors designed the study, collected and analysed the data, drafted the manuscript, and critically revised the manuscript for important intellectual content. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.
Conflicts of Interest
As an editor of the journal, BWM Siu was not involved in the peer review process. Other authors have no conflicts of interest to disclose.
Funding
This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Data Availability
All data generated or analysed during the present study are available from the corresponding author on reasonable request.
Acknowledgements
The authors acknowledge the staff of the Castle Peak Hospital who had provided support for the study.
References
- Segal SP, Burgess PM. Conditional release: a less restrictive alternative to hospitalization? Psychiatr Serv 2006;57:1600-6. Crossref
- Rugkasa J, Burns T. Community treatment orders: are they useful? BJPsych Advances 2017;23:222-30. Crossref
- Churchill R, Owen G, Singh S, Hotopf M. International Experiences of Using Community Treatment Orders. London: Institute of Psychiatry; 2007. Crossref
- Maughan D, Molodynski A, Rugkåsa J, Burns T. A systematic review of the effect of community treatment orders on service use. Soc Psychiatry Psychiatr Epidemiol 2014;49:651-63. Crossref
- Rugkasa J. Effectiveness of community treatment orders: the international evidence. Can J Psychiatry 2016;61:15-24. Crossref
- Swartz MS, Swanson JW, Wagner HR, Burns BJ, Hiday VA, Borum R. Can involuntary outpatient commitment reduce hospital recidivism? Findings from a randomized trial with severely mentally ill individuals. Am J Psychiatry 1999;156:1968-75. Crossref
- Steadman HJ, Gounis K, Dennis D, et al. Assessing the New York City involuntary outpatient commitment pilot program. Psychiatr Serv 2001;52:330-6. Crossref
- Burns T, Rugkasa J, Molodynski A, et al. Community treatment orders for patients with psychosis (OCTET): a randomised controlled trial. Lancet 2013;381:1627-33. Crossref
- Kisely SR, Campbell LA, O’Reilly R. Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Cochrane Database Syst Rev 2017;3:CD004408. Crossref
- Barnett P, Matthews H, Lloyd-Evans B, Mackay E, Pilling S, Johnson S. Compulsory community treatment to reduce readmission to hospital and increase engagement with community care in people with mental illness: a systematic review and meta-analysis. Lancet Psychiatry 2018;5:1013-22. Crossref
- Higashi K, Medic G, Littlewood KJ, Diez T, Granström O, De Hert M. Medication adherence in schizophrenia: factors influencing adherence and consequences of nonadherence, a systematic literature review. Ther Adv Psychopharmacol 2013;3:200-18. Crossref
- Mental Health (Amendment) Ordinance. Chapter 136, Laws of Hong Kong. Hong Kong Government; 1997.
- Torrey EF, Zdanowicz M. Outpatient commitment: what, why, and for whom. Psychiatr Serv 2001;52:337-41. Crossref
- Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Int J Surg 2021;88:105906. Crossref
- Sterne JA, Savović J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 2019;366:l4898. Crossref
- Sterne JA, Hernán MA, Reeves BC, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 2016;355:i4919. Crossref
- Borenstein M. Effect sizes for continuous data. In: Cooper H, Hedges L, Valentine J, editors. The Handbook of Research Synthesis and Meta- Analysis. Russell Sage Foundation; 2009; 221-35.
- Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ 2003;327:557-60. Crossref
- Castells-Aulet L, Hernández-Viadel M, Jiménez-Martos J, et al. Impact of involuntary out-patient commitment on reducing hospital services: 2-year follow-up. BJPsych Bull 2015;39:196-9. Crossref
- Harris A, Chen W, Jones S, Hulme M, Burgess P, Sara G. Community treatment orders increase community care and delay readmission while in force: results from a large population-based study. Aust N Z J Psychiatry 2019;53:228-35. Crossref
- Kisely S, Preston N, Xiao J, et al. An eleven-year evaluation of the effect of community treatment orders on changes in mental health service use. J Psychiatr Res 2013;47:650-6. Crossref
- Kisely S, Moss K, Boyd M, Siskind D. Efficacy of compulsory community treatment and use in minority ethnic populations: a statewide cohort study. Aust N Z J Psychiatry 2020;54:76-88. Crossref
- Parker S, Arnautovska U, McKeon G, Kisely S. The association between discontinuation of community treatment orders and outcomes in the 12-months following discharge from residential mental health rehabilitation. Int J Law Psychiatry 2021;74:101664. Crossref
- Segal SP, Hayes SL, Rimes L. The utility of outpatient commitment: I. A need for treatment and a least restrictive alternative to psychiatric hospitalization. Psychiatr Serv 2017;68:1247-54. Crossref
- Vaughan K, McConaghy N, Wolf C, Myhr C, Black T. Community treatment orders: relationship to clinical care, medication compliance, behavioural disturbance and readmission. Aust N Z J Psychiatry 2000;34:801-8. Crossref
- Erickson SK. A retrospective examination of outpatient commitment in New York. Behav Sci Law 2005;23:627-45. Crossref
- Frank D, Fan E, Georghiou A, Verter V. Community treatment order outcomes in Quebec: a unique jurisdiction. Can J Psychiatry 2020;65:484-91. Crossref
- Lera-Calatayud G, Hernandez-Viadel M, Bellido-Rodriguez C, et al. Involuntary outpatient treatment in patients with severe mental illness: a one-year follow-up study. Int J Law Psychiatry 2014;37:267-71. Crossref
- Muirhead D, Harvey C, Ingram G. Effectiveness of community treatment orders for treatment of schizophrenia with oral or depot antipsychotic medication: clinical outcomes. Aust N Z J Psychiatry 2006;40:596-605. Crossref
- Munetz MR, Grande T, Kleist J, Peterson GA. The effectiveness of outpatient civil commitment. Psychiatr Serv 1996;47:1251-3. Crossref
- O’Brien AM, Farrell SJ, Faulkner S. Community treatment orders: beyond hospital utilization rates examining the association of community treatment orders with community engagement and supportive housing. Community Ment Health J 2009;45:415-9. Crossref
- O’Keefe C, Potenza DP, Mueser KT. Treatment outcomes for severely mentally ill patients on conditional discharge to community-based treatment. J Nerv Ment Dis 1997;185:409-11. Crossref
- Rohland BM, Rohrer JE, Richards CC. The long-term effect of outpatient commitment on service use. Adm Policy Ment Health 2000;27:383-94. Crossref
- Thiese MS. Observational and interventional study design types; an overview. Biochem Med (Zagreb) 2014;24:199-210. Crossref
- Burns T. Community treatment orders: state of the evidence. East Asian Arch Psychiatry 2013;23:35-6.