Community Treatment Order Outcomes in Quebec: A Unique Jurisdiction

Abstract

Objective: We study compulsory community treatment orders (CTOs) for patients with severe and persistent mental illness (SPMI). Focusing on a unique jurisdiction in Canada that allows for long duration CTOs with strict enforcement procedures, our objectives are to determine whether extended duration CTOs are effective and to determine whether associated hospitalization costs are reduced. Method: A mirror image, naturalistic design was employed using patients as their own controls to enhance external validity. No inclusive or exclusive criteria were employed for the 367 SPMI clinic patients who were studied over a 5-year period. Detailed documentation of the dates of all CTOs, long-acting antipsychotic injections (LAIs), emergency visits, hospitalizations, duration of hospitalizations, crimes and/or police involvement were collected. To study the relation between CTO and injection adherence, we use a mixed-effect linear regression model. To study the effect of injection adherence and hospitalization, we use survival analysis via Kaplan–Meier and Cox survival models. Results: CTO and non-CTO patients did not differ with respect to demographics, but CTO patients were significantly more severely ill. Following a CTO, adherence to LAIs increased over time ( P < 0.001). The average time the patients spent in the community, that is, outside the hospital, was significantly longer under a CTO, and the duration of hospitalizations was decreased. Conclusions: LAI adherence and outpatient office visits were enhanced by extended duration CTOs, as was time out of the hospital. The shorter duration of hospital stays implies cost savings. These must be weighed against their undesirable coercive nature.

Care Pathways, Health Service Use Patterns and Opportunities for Justice Involvement Prevention Among Forensic Mental Health Clients

“…Third, as discussed in the introduction, Québec is a unique jurisdiction in Canada when it comes to use of the NCRMD regime, but also in terms of the duration and criteria for community treatment order and involuntary hospitalization. 47 While this may limit the generalizability of the findings, it should be highlighted that the vast majority of people found NCRMD annually in Canada are in Québec, which First presenters consist of participants for whom the NCR offense was both the first evidence of criminal behavior and the first evidence of mental illness.…”

Gilles Deleuze's societies of control: Implications for mental health nursing and coercive community care

“…Legal regimes, such as the CTO, MHC and FACT, function according to the logic of disciplinary threat. If a person under a compulsory order refuses medication and instructions, or fails to attend clinical follow-ups, he or she could be rehospitalized immediately, usually with police intervention (Canadian Civil Liberties Association, 2015;Frank et al, 2020). The incentive to follow instructions (e.g., participate in therapeutic activities, take medication, not use drugs, etc.)…”

“…For example, in the United Kingdom, the average duration of a CTO is around 3 years, while in the province of Québec (Canada), it can be granted for a period varying from 3 to 5 years (Frank et al, 2020;Gray et al, 2016). This continuous duration is based on the 'therapeutic' nature of the CTO, which must continue over time to produce beneficial effects.…”

Use of compulsory community treatment in mental healthcare: An integrative review of stakeholders’ opinions

“…There is some evidence suggesting that longer CTO's are of greater benefit in improving outcome measures (6,8). Other recent naturalistic studies did find that CCT increased treatment adherence, could increase the time people spent outside hospital, could decrease suicide risk and mortality and could decrease the duration of admission to hospital (8)(9)(10)(11).…”