The benefits and harms of community treatment orders for people diagnosed with psychiatric illnesses: A rapid umbrella review of systematic reviews and meta-analyses.

AIMS: Community treatment orders have been introduced in many jurisdictions with increasing use over time. We conducted a rapid umbrella review to synthesise the quantitative and qualitative evidence from systematic reviews and/or meta-analyses of their potential harms and benefits. METHODS: A systematic search of Medline, PubMed, Embase and PsycINFO for relevant systematic reviews and/or meta-analyses. Where available, participants on community treatment orders were compared with controls receiving voluntary psychiatric treatment. This review is registered with PROSPERO (CRD42023398767) and the Open Science Framework (https://osf.io/zeq35). RESULTS: In all, 17 publications from 14 studies met the inclusion criteria. Quantitative synthesis of data from different systematic reviews was not possible. There were mixed findings on the effects of community treatment orders on health service use, and clinical, psychosocial or forensic outcomes. Whereas uncontrolled evidence suggested benefits, results were more equivocal from controlled studies and randomised controlled trials showed no effect. Any changes in health service use took several years to become apparent. There was evidence that better targeting of community treatment order use led to improved outcomes. Although there were other benefits, such as in mortality, findings were mostly rated as suggestive using predetermined and standardised criteria. Qualitative findings suggested that family members and clinicians were generally positive about the effect of community treatment orders but those subjected to them were more ambivalent. Any possible harms were under-researched, particularly in quantitative designs. CONCLUSIONS: The evidence for the benefits of community treatment orders remains inconclusive. At the very least, use should be better targeted to people most likely to benefit. More quantitative research on harms is indicated.

The ethics of sexual relationships between psychiatrists and trainee psychiatrists in the 'me too' era.

OBJECTIVE: Since 2017, the structural dynamics that entrench rape culture, sexual harassment and exploitation have gained increased attention across the globe, particularly in regards to workplaces. This paper aims to review the current RANZCP guidelines and other literature pertaining to the ethics of sexual relationships between psychiatrists and trainees. CONCLUSIONS: Such relationships involve significant power differentials, which may make them unethical on an individual level. A culture condoning such relationships may also disadvantage women in the workplace. The current RANZCP guidelines on relationships between supervisors and trainees may unfairly disadvantage trainees.

Is suicidal behaviour a stronger predictor of later suicide than suicidal ideation? A systematic review and meta-analysis.

OBJECTIVE: Suicidal ideation and suicidal behaviour are both regarded as important risk factors for suicide, but it is usually believed that suicidal ideation is less strongly linked to suicide than suicidal behaviours. In this study, we assessed and compared the strengths of the associations that suicidal ideation and suicidal behaviour have with later suicide using meta-analysis of primary studies reporting both these independent variables and the dependent variable of suicide. METHODS: A total of 51 English language publications describing cohort or controlled studies that reported on both the association between suicidal ideation and suicide and the association between suicidal behaviours and suicide were located using searches for titles in PubMed containing variants of the word suicide (suicid*). Suicides were considered to include reported suicides and open verdicts from mortality registers. The strengths of the two associations were examined in separate random effects meta-analyses and were then compared using mixed effects meta-regression. Subgroups were examined according to study characteristics including the definitions of suicidal ideation or behaviour used, setting (psychiatric or non-psychiatric), diagnostic mix of the study population, study design (cohort or control) and study quality. RESULTS: Suicidal ideation (odds ratio = 3.11, 95% confidence interval = 2.51, 3.86) and suicidal behaviours (odds ratio = 4.09, 95% confidence interval = 3.05, 5.49) were both significantly associated with suicide but there was no significant difference in the strengths of association (p = 0.14). Nor were there significant differences in the strengths of the two associations in multiple subgroup analyses. CONCLUSION: Suicidal ideation and suicidal behaviour are both moderately associated with suicide. Existing data cannot conclusively demonstrate that suicidal behaviours are more strongly associated with suicide than suicidal ideation. Clinicians should not strongly prioritise suicidal behaviour over suicidal ideation when considering suicide risk.

Factors associated with involuntary mental healthcare in New South Wales, Australia.

BACKGROUND: There is uncertainty about factors associated with involuntary in-patient psychiatric care. Understanding these factors would help in reducing coercion in psychiatry. AIMS: To explore variables associated with involuntary care in the largest database of involuntary admissions published. METHOD: We identified 166 102 public mental health hospital admissions over 5 years in New South Wales, Australia. Demographic, clinical and episode-of-care variables were examined in an exploratory, multivariable logistic regression. RESULTS: A total of 54% of eligible admissions included involuntary care. The strongest associations with involuntary care were referral from the legal system (odds ratio 4.98, 95% CI 4.61-5.38), and psychosis (odds ratio 4.48, 95% CI 4.31-4.64) or organic mental disorder (odds ratio 4.40, 95% CI 3.85-5.03). There were moderately strong associations between involuntary treatment and substance use disorder (odds ratio 2.68, 95% CI 2.56-2.81) or affective disorder (odds ratio 2.06, 95% CI 1.99-2.14); comorbid cannabis and amphetamine use disorders (odds ratio 1.65, 95% CI 1.57-1.74); unmarried status (odds ratio 1.62, 95% CI 1.49-1.76) and being born in Asia (odds ratio 1.42, 95% CI 1.35-1.50), Africa or the Middle East (odds ratio 1.32, 95% CI 1.24-1.40). Involuntary care was less likely for people aged >75 years (odds ratio 0.68, 95% CI 0.62-0.74), with comorbid personality disorder (odds ratio 0.90, 95% CI 0.87-0.94) or with private health insurance (odds ratio 0.89, 95% CI 0.86-0.93). CONCLUSIONS: This research strengthens the evidence linking diagnostic, socioeconomic and cultural factors to involuntary treatment. Targeted interventions are needed to reduce involuntary admissions in disadvantaged groups.

Association between suicidal ideation and suicide: meta-analyses of odds ratios, sensitivity, specificity and positive predictive value.

BACKGROUND: The expression of suicidal ideation is considered to be an important warning sign for suicide. However, the predictive properties of suicidal ideation as a test of later suicide are unclear.AimsTo assess the strength of the association between suicidal ideation and later suicide measured by odds ratio (OR), sensitivity, specificity and positive predictive value (PPV). METHOD: We located English-language studies indexed in PubMed that reported the expression or non-expression of suicidal ideation among people who later died by suicide or did not. A random effects meta-analysis was used to assess the pooled OR, sensitivity, specificity and PPV of suicidal ideation for later suicide among groups of people from psychiatric and non-psychiatric settings. RESULTS: There was a moderately strong but highly heterogeneous association between suicidal ideation and later suicide (n = 71, OR = 3.41, 95% CI 2.59-4.49, 95% prediction interval 0.42-28.1, I2 = 89.4, Q-value = 661, d.f.(Q) = 70, P ≤0.001). Studies conducted in primary care and other non-psychiatric settings had similar pooled odds to studies of current and former psychiatric patients (OR = 3.86 v. OR = 3.23, P = 0.7). The pooled sensitivity of suicidal ideation for later suicide was 41% (95% CI 35-48) and the pooled specificity was 86% (95% CI 76-92), with high between-study heterogeneity. Studies of suicidal ideation expressed by current and former psychiatric patients had a significantly higher pooled sensitivity (46% v. 22%) and lower pooled specificity (81% v. 96%) than studies conducted in non-psychiatric settings. The PPV among non-psychiatric cohorts (0.3%, 95% CI 0.1%-0.5%) was significantly lower (Q-value = 35.6, P < 0.001) than among psychiatric samples (3.9%, 95% CI 2.2-6.6). CONCLUSIONS: Estimates of the extent of the association between suicidal ideation and later suicide are limited by unexplained between-study heterogeneity. The utility of suicidal ideation as a test for later suicide is limited by a modest sensitivity and low PPV.Declaration interestM.M.L. and C.J.R. have provided expert evidence in civil, criminal and coronial matters. I.B.H. has been a Commissioner in Australia's National Mental Health Commission since 2012. He is the Co-Director, Health and Policy at the Brain and Mind Centre (BMC) University of Sydney. The BMC operates an early-intervention youth services at Camperdown under contract to Headspace. I.B.H. has previously led community-based and pharmaceutical industry-supported (Wyeth, Eli Lily, Servier, Pfizer, AstraZeneca) projects focused on the identification and better management of anxiety and depression. He is a Board Member of Psychosis Australia Trust and a member of Veterans Mental Health Clinical Reference group. He was a member of the Medical Advisory Panel for Medibank Private until October 2017. He is the Chief Scientific Advisor to, and an equity shareholder in, InnoWell. InnoWell has been formed by the University of Sydney and PricewaterhouseCoopers to administer the $30 M Australian Government Funded Project Synergy. Project Synergy is a 3-year programme for the transformation of mental health services through the use of innovative technologies.

Impulsivity in the self-harm and suicidal behavior of young people: A systematic review and meta-analysis.

BACKGROUND: Impulsivity is considered a possible phenotype underlying the expression of self-harm and suicidal behaviors. Yet impulsivity is a not a unitary construct and there is evidence that different facets of impulsivity follow different neurodevelopmental trajectories and that some facets may be more strongly associated with such behaviors than others. Moreover, it is unclear whether impulsivity is a useful predictor of self-harm or suicidal behavior in young people, a population already considered to display heightened impulsive behavior. METHODS: A systematic review and meta-analysis of studies published in Medline, PubMed, PsychInfo or Embase between 1970 and 2017 that used a neurocognitive measure to assess the independent variable of impulsivity and the dependent variable of self-harm and/or suicidal behavior among young people (mean age < 30 years old). RESULTS: 6183 titles were identified, 141 full texts were reviewed, and 18 studies were included, with 902 young people with a self-harm or suicidal behavior and 1591 controls without a history of these behaviors. Deficits in inhibitory control (13 studies, SMD 0.21, p-value = 0.002, 95% confidence interval (CI) (0.08-0.34), prediction interval (PI) = 0.06-0.35) and impulsive decision-making (14 studies, SMD 0.17, p-value = 0.008, 95% CI (0.045-0.3), PI = 0.03-0.31) were associated with self-harm or suicidal behavior. There were no significant differences between measures of different facets of impulsivity (ie. delay discounting, risky decision-making, cognitive or response inhibition) and self-harm or suicidal behavior. CONCLUSION: Multiple facets of impulsivity are associated with suicidal behavior in young people. Future suicide research should be designed to capture impulsive states and investigate the impact on different subtypes of impulsivity.