Compulsory community and involuntary outpatient treatment for people with severe mental disorders.

BACKGROUND: There is controversy as to whether compulsory community treatment 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. OBJECTIVES: To examine the clinical and cost effectiveness of compulsory community treatment for people with severe mental illness. SEARCH STRATEGY: We undertook searches of the Cochrane Schizophrenia Group Register 2003, 2008, and Science Citation Index. We obtained all references of identified studies and contacted authors of each included study. SELECTION CRITERIA: All relevant randomised controlled clinical trials of compulsory community treatment compared with standard care for people with severe mental illness. DATA COLLECTION AND ANALYSIS: We reliably selected and quality assessed studies and extracted data. For binary outcomes, we calculated a fixed effects risk ratio (RR), its 95% confidence interval (CI) and, where possible, the weighted number needed to treat/harm statistic (NNT/H). MAIN RESULTS: We identified two randomised clinical trials (total n = 416) of court-ordered 'Outpatient Commitment' (OPC) from the USA. We found 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); mental state; quality of life (2 RCTs, n = 416, RR for homelessness 0.67 CI 0.39 to 1.15) or satisfaction with care (2 RCTs, n = 416, RR for perceived coercion 1.36 CI 0.97 to 1.89). However, 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 six (CI 6 to 6.5). A new search for trials in 2008 did not find any new trials that were relevant to this review. AUTHORS' CONCLUSIONS: Compulsory community treatment results in no significant difference in service use, social functioning or quality of life compared with standard care. People receiving compulsory community treatment were, however, less likely to be victims of violent or non-violent crime. It is unclear whether this benefit is due to the intensity of treatment or its compulsory nature. Evaluation of a wide range of outcomes should be considered when this type of legislation is introduced.

Can epidemiological studies assist in the evaluation of community treatment orders? - The experience of Western Australia and Nova Scotia.

Epidemiological studies using administrative databases have several advantages over other methodologies in studying the effectiveness of compulsory community treatment such as community treatment orders (CTOs). We compared patients placed on CTOs in Western Australia with controls drawn from both within the jurisdiction and from another without this measure (Nova Scotia). Although in different countries, the mental health services in both jurisdictions share common characteristics. Notably, we were able to control for forensic history in our comparison within Western Australia. We analysed predictors of admission and number of bed-days using multiple, logistic or Cox regression as appropriate. Of the 274 subjects placed on a CTO, we were able to find controls for up to 96% (n=265). CTO placement was not associated with reduced admissions or mean bed-days, although there was a threshold effect with a reduced risk of inpatient stays exceeding 100 days. Outpatient contacts were significantly greater for the CTO group. However, we do not know whether the intensity of treatment, or its compulsory nature, effected outcome.

Gender differences in premorbid adjustment of patients with first episode psychosis.

Gender differences in premorbid adjustment, clinical presentation, and longitudinal course have been considered increasingly in explanatory models of psychotic disorders, such as the schizophrenias. Indeed, findings of a male propensity to poor premorbid adjustment, negative and non-affective symptoms, and poor outcome relative to their female counterparts, has led to suggestions that males are more prone to an early-onset dementia praecox type of schizophrenic disorder. The current study investigated a sample of 38 male and 20 female patients presenting with their first episode of psychosis (broadly defined, but excluding obvious drug-induced disorders) from a defined catchment area population, which had been systematically ascertained without prejudice to diagnostic subtype or illness duration. The study investigated gender, diagnosis and interaction of gender and diagnosis on differences within the three developmental age categories of childhood, early adolescence and late adolescence, to identify where, within these age categories, differences lie. The second part of the study was to investigate the relationship between premorbid adjustment, gender, and psychopathology as measured by the PANSS and SCL-90. General linear modelling revealed that males were reported to have had poorer premorbid adjustment in late adolescence when compared to females, notably in items examining school performance, adaptation to school, social interests and sociosexual development. Males were observed to have higher levels of negative symptoms but not for positive or general symptoms on the PANSS. This finding is independent from the effect of diagnosis or of the interaction effect between gender and diagnosis on premorbid adjustment. There were no gender effects for the self reported global indices on the SCL-90. The results suggest that in comparison with their female counterparts, males who develop a psychotic illness have significantly poorer premorbid adjustment at the late adolescent stage and that this may contribute to higher levels of negative symptoms.

Neck dissection for squamous cell carcinoma of the head and neck.

OBJECTIVES: To investigate the successes and failures of 172 patients receiving neck dissections for squamous cell carcinoma (SCC) managed through a multidisciplinary head and neck clinic and to observe factors in predicting failure (death with head and neck cancer or local regional recurrence) or local regional recurrence alone. STUDY DESIGN: A retrospective, 14-year surgical audit. METHODS: The information from patient medical records was correlated with that of a database. Multivariate analysis was performed with the use of a logistic regression model. RESULTS: The most common site for head and neck SCC was the oral cavity (42%), with 17% of patients having tumors of unknown primary site. The disease-free survival probability was 76.7% at five years. Patients who were older at neck dissection, were nonsmokers, or who did not have radiotherapy to the primary site were more likely to die with head and neck cancer or to have local regional recurrence (P < 0.1). Patients with more radical neck dissections did not have better survival or recurrence outcomes. Lymphatic invasion appears to be the only important factor in predicting local regional recurrence alone (P = 0.1), of which 67% occurred within the first postoperative year. CONCLUSIONS: Patients with smoking-related SCC are likely to have a less aggressive disease. Adjuvant radiotherapy plays an important role in the treatment of patients with head and neck SCC. Follow-up, especially within the first postoperative year, is essential in managing head and neck SCC. Head and neck surgeons can confidently continue their practice away from more radical neck dissections.

Randomized and non-randomized evidence for the effect of compulsory community and involuntary out-patient treatment on health service use: systematic review and meta-analysis.

BACKGROUND: There is limited randomized controlled trial (RCT) evidence for compulsory community treatment. Other study methods may clarify their effectiveness. We reviewed RCT and non-RCT evidence for the effect of compulsory community treatment on hospital admissions, bed-days, compliance and out-patient contacts. METHOD: A systematic review of RCTs, controlled before-and-after (CBA) studies, and interrupted time series (ITS) analyses. Meta-analysis of RCTs. RESULTS: Eight papers covering five studies (two RCTs and three CBAs) met inclusion criteria (total n=1108). There was no statistical difference in 12-month admission rates between subjects on involuntary out-patient treatment and controls. Survival analyses of time to admission were equivocal. All five studies reported decreases in the number of bed-days following involuntary out-patient treatment but this only reached statistical significance in one situation; patients receiving the intervention were less likely to have admissions of over 100 days. There was no difference in treatment adherence between the intervention and control groups in either RCT or two of the CBA studies. However, the third CBA study reported a statistically significant increase of nearly five visits in the mean number of overall contacts in the involuntary out-patient treatment group. CONCLUSIONS: The evidence for involuntary out-patient treatment in reducing either admissions or bed-days is very limited. It therefore cannot be seen as a less restrictive alternative to admission. Other effects are uncertain. Evaluation of a wide range of outcomes should be included if this type of legislation is introduced.

A comparison of health service use in two jurisdictions with and without compulsory community treatment.

BACKGROUND: This study examines whether community treatment orders (CTOs) reduce psychiatric admission rates or bed-days for patients from Western Australia compared to control patients from a jurisdiction without this legislation (Nova Scotia). METHOD: A population-based record linkage analysis of an inception cohort using a two-stage design of matching and multivariate analyses to control for sociodemographics, clinical features and psychiatric history. All discharges from in-patient psychiatric services in Western Australia and Nova Scotia were included covering a population of 2.6 million people. Patients on CTOs in the first year of implementation in Western Australia were compared with controls from Nova Scotia matched on date of discharge from in-patient care, demographics, diagnosis and past in-patient psychiatric history. We analysed time to admission using Cox regression analyses and number of bed-days using logistic regression. RESULTS: We matched 196 CTO cases with an equal number of controls. On survival analyses, CTO cases had a significantly greater readmission rate. Co-morbid personality disorder and previous psychiatric history were also associated with readmission. However, on logistic regression, patients on CTOs spent less time in hospital in the following year, with reduced in-patient stays of over 100 days. CONCLUSIONS: Although compulsory community treatment does not reduce hospital admission rates, increased surveillance of patients on CTOs may lead to earlier intervention such as admission, so reducing length of hospital stay. However, we do not know if it is the intensity of treatment, or its compulsory nature, that effects outcome.

The brief symptom inventory and the positive and negative syndrome scale: discriminate validity between a self-reported and observational measure of psychopathology.

Concern within the literature has emerged from time to time arguing the poor validity of self-reported measures in psychopathology, namely, the reporting of psychotic experience. Although it is commonly believed that patients who have had a psychotic episode cannot accurately self-report their experience, very few studies have been conducted to measure the concordance between self-reported and observational measures of psychopathology using multivariate statistical techniques. Sixty-nine patients presenting their first psychotic episode were interviewed and assessed on the Positive and Negative Syndrome Scale (PANSS) and were asked to complete the Brief Symptom Inventory (BSI). By clustering symptom dimensions from the BSI into discriminate functions, the research demonstrated that these symptom dimensions could adequately classify high versus low scores on the PANSS subscales and total score. When the same clusters were entered into multivariate analysis of variance (MANOVA) models, they also demonstrated significant differences between high versus low observed symptomatology on the PANSS Positive and General Subscale Groups and Total Score Groups. The current findings shed some doubt on the supposition that those who experience psychosis are unable to report symptom dimensions that concord with those who observe the psychosis. It appears that models, operational definitions, and the language used in measuring psychopathology may differ significantly from those who experience the psychotic experience and those who observe it. Techniques such as multitrait multimethod are discussed as ways of overcoming these concerns.

Assessing the outcome of compulsory psychiatric treatment in the community: epidemiological study in Western Australia.

OBJECTIVE: To examine whether community treatment orders for psychiatric patients reduce subsequent use of health services in comparison with control patients not placed on an order. DESIGN: Epidemiological study with a before and after, two stage design of matching and multivariate analysis, controlling for sociodemographic variables, clinical features, and psychiatric history. SETTING: All community based and inpatient psychiatric services in Western Australia, covering a population of 1.7 million people. PARTICIPANTS: 228 subjects placed on a community treatment order, matched with an equal number of controls to give a total of 456 patients. MAIN OUTCOME MEASURES: Inpatient admissions, bed days, and outpatient contacts one year after subjects were placed on a community treatment order or the index date of matched controls. RESULTS: Both subjects and their matched controls had reduced inpatient admissions and bed days in hospital. Subjects had significantly more outpatient contacts. Multivariate analysis indicated that being placed on a community treatment order was associated with increased outpatient contacts in the subsequent year compared with the control group. Otherwise, orders did not affect subsequent use of health services. Other factors associated with increased use of health services were age and inpatient admissions, bed days, and outpatient contacts before the order or index date. No covariates were shown to be associated with changes in within pair differences in inpatient admissions or bed days. CONCLUSIONS: The introduction of compulsory treatment in the community does not lead to reduced use of health services.

The effect of recalling paracetamol on hospital admissions for poisoning in Western Australia.

OBJECTIVES: To assess the effect of two recalls of paracetamol products on rates of intentional and unintentional overdoses of paracetamol in all age groups, as well as any effect on poisoning by other agents. DESIGN: A before-and-after epidemiological study using data from the Western Australian Health Services Research Linked Database, which records all admissions to public and private hospitals throughout the State. MAIN OUTCOME MEASURES: Hospital admissions in Western Australia for poisonings with all agents, including paracetamol and other over-the-counter analgesics. RESULTS: There were 11 752 admissions for poisoning from 1996 to 2001. Paracetamol was the primary poisoning agent in 2266 (19.3%) admissions, aspirin in 120 (1%) and ibuprofen in 277 (2%). There was a significant decrease in the admission rate for paracetamol poisoning when sales were restricted in 2000 (rate ratio, 0.82; 95% CI, 0.68-0.99) compared with the same period in other years. There was no increase in poisoning with other agents at this time. However, admissions for paracetamol overdose also showed a large random variation that tended to obscure any effect. CONCLUSIONS: Our study highlights the need to control for random as well as seasonal fluctuations in admission rates, and for restrictions on paracetamol sales to last for several months across all retail outlets. Limiting access to paracetamol may reduce paracetamol poisonings without a coincident increase in the use of other agents

Impact of compulsory community treatment on admission rates: survival analysis using linked mental health and offender databases.

BACKGROUND: There is controversy as to whether compulsory community treatment for psychiatric patients reduces hospital admission rates. AIMS: To examine whether community treatment orders (CTOs) reduce admission rates, using a two-stage design of matching and multivariate analyses to take into account socio-demographic factors, clinical factors, case complexity and previous psychiatric and forensic history. METHOD: Survival analysis of CTO cases and controls from three linked Western Australian databases of health service use, involuntary treatment and forensic history. We used two control groups: one matched on demographic characteristics, diagnosis, past psychiatric history and treatment setting, and consecutive controls matched on date of discharge from in-patient care. RESULTS: We matched 265 CTO cases with 265 matched controls and 224 consecutive controls (total n=754). The CTO group had a significantly higher readmission rate: 72% v. 65% and 59% for the matched and consecutive controls (log-rank chi(2)=4.7, P=0.03). CTO placement, aboriginal ethnicity, younger age, personality disorder and previous health service use were associated with increased admission rates. CONCLUSIONS: Community treatment orders alone do not reduce admissions.

What determines compulsory community treatment? A logistic regression analysis using linked mental health and offender databases.

OBJECTIVE: Western Australia has one of the highest published rates of the use of compulsory treatment orders in the English-speaking world. Differences in patient characteristics, legislation and service setting may explain variations in the reported efficacy of compulsory community treatment. Our objective is to investigate predictors of Community Treatment Orders (CTO) placement in the first year of implementation in Western Australia and see if there were any differences in the type of patients placed on these orders compared to other studies. METHOD: A population-based record linkage study of Mental Health and Offender Databases comparing 265 patients on CTOs with a consecutive control group (CCG) of equal number matched on date of discharge from inpatient care or CTO placement. RESULTS: Previous health service use, after-care placement, mental disorder history including schizophrenic history, a positive forensic history of violence to others as well as patient's marital status were the significant predictors of CTO placement. CONCLUSIONS: Studies of compulsory community treatment appear to be of similar populations. In spite of the comparatively high rate of use, psychiatrists in Western Australia do not appear to be applying community treatment orders to different types of patient compared to elsewhere. We need further research to establish the relative contribution of patient characteristics, legislation and service setting toward the use and outcome of compulsory community treatment.

Correlates of dysmorphic concern in people seeking cosmetic enhancement.

OBJECTIVE: To determine the clinical correlates of dysmorphic concern in persons seeking cosmetic enhancement from cosmetic physicians. METHOD: A questionnaire survey of 137 patients attending the practices of two cosmetic physicians. RESULTS: Four subjects (2.9%; 95% CI = 0.8%-7.3%) had a diagnosis of body dysmorphic disorder (BDD), but many more expressed overconcern with physical appearance ('dysmorphic concern'). Dysmorphic concern accounted for a substantial amount of the variance for mood, social anxiety, and impairment in work and social functioning, while concerns related to how self or others perceive the putative flaw in appearance, impacted significantly on work and leisure activities, but did not apparently influence mood and social anxiety to any significant degree. CONCLUSIONS: Dysmorphic concern is a broad dimensional construct that is related to both inter- and intrapsychic distress and disablement associated with people seeking cosmetic enhancement

A statewide evaluation system for early psychosis.

OBJECTIVE: We describe a system of outcome evaluation for early psychosis programmes and present preliminary data. The Early Psychosis Outcome Evaluation System (EPOES) was designed for use in a naturalistic, prospective study of a cohort of early-episode psychosis patients. We describe patients in terms of symptoms, substance use, social functioning and family burden, and examine the effectiveness of treatment programmes. METHOD: Four sites in Perth, Western Australia, participated. Outcome was evaluated from three sources: case manager (CM), patient (P) and family member (FM). Seven clinical outcome measures were used: the Brief Psychiatric Rating Scale (CM), Brief Symptom Inventory (P), Substance Use (CM); Social Functioning Scale (P); Global Assessment Scale (CM); Burden Assessment Scale (FM), and the General Health Questionnaire-12 (FM). Measures were collected at intake (baseline) into a specialist early psychosis service and thereafter every 6 months until discharge from the service. RESULTS: After the first year of data capture, 84 baseline assessments have been completed, and 23 patients have been followed up at 6 months. Clinicians and patients reported significantly less psychopathology at 6 months. Sixty per cent of patients reported marijuana use within 3 months of baseline assessment, and 30% amphetamine, ecstasy or cocaine use. Increased levels of psychopathology were recorded for substance-using patients. Family members (59%) reported psychological distress at baseline; this was reduced at 6 months. Patient social functioning and family burden did not improve measurably. CONCLUSIONS: The EPOES is an effective system that provides feedback on the clinical status of early-episode psychosis patients. Both observed and self-rated psycho-pathology and family psychological distress, is improved after 6 months of intervention. Family burden and patient social functioning did not demonstrate improvement. Patient social functioning is an important area for treatment. Substance use is associated with poorer psychopathology. EPOES provides a feasible system of measuring outcome in early psychosis intervention.