We need to talk about depot: effect of Community Treatment Order on depot antipsychotic medication compliance

Suetani, Shuichi; Foo, Edward; Wilson, Douglas

doi:10.1177/1039856214539859

Cited by 7 publications

(9 citation statements)

References 22 publications

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“…One article reported secondary outcomes from an RCT. 31 The remaining 9 papers 32 –40 reported on a wide range of other outcomes (for example, medication, access to secondary services, and mortality), with mixed, but largely negative, results as to CTO benefit.…”

Section: Resultsmentioning

confidence: 99%

Effectiveness of Community Treatment Orders: The International Evidence

Rugkåsa

2016

Can J Psychiatry

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Objective: Community treatment orders (CTOs) exist in more than 75 jurisdictions worldwide. This review outlines findings from the international literature on CTO effectiveness. Method: The article draws on 2 comprehensive systematic reviews of the literature published before 2013, then uses the same search terms to identify studies published between 2013 and 2015. The focus is on what the literature as a whole tells us about CTO effectiveness, with particular emphasis on the strength and weaknesses of different methodologies. Results:The results from more than 50 nonrandomized studies show mixed results. Some show benefits from CTOs while others show none on the most frequently reported outcomes of readmission, time in hospital, and community service use. Results from the 3 existing randomized controlled trials (RCTs) show no effect of CTOs on a wider range of outcome measures except that patients on CTOs are less likely than controls to be a victim of crime. Patients on CTOs are, however, likely to have their liberty restricted for significantly longer periods of time. Meta-analyses pooling patient data from RCTs and high quality nonrandomized studies also find no evidence of patient benefit, and systematic reviews come to the same conclusion. Conclusion: There is no evidence of patient benefit from current CTO outcome studies. This casts doubt over the usefulness and ethics of CTOs. To remove uncertainty, future research must be designed as RCTs. Abré géObjective : Les ordonnances de traitement en milieu communautaire (OTMC) existent dans plus de 75 administrations du monde entier. Cette revue présente les résultats de la littérature internationale sur l'efficacité des OTMC. Mé thode : L'article puise à deux revues systématiques complètes de la littérature publiée avant 2013, puis utilise les mêmes termes de recherche pour identifier les études publiées entre 2013 et 2015. L'accent est mis sur ce que la littérature dans son ensemble nous dit sur l'efficacité des OTMC, en insistant particulièrement sur les forces et faiblesses des différentes méthodologies.Ré sultats : Les résultats de plus de 50 études non randomisées étaient partagés. Certains montrent les avantages des OTMC alors que d'autres ne présentent aucun des résultats les plus fréquemment observés concernant: la réhospitalisation, le séjour à l'hôpital, et l'utilisation des services communautaires. Les résultats des trois essais randomisés contrô lés (ERC) existants n'indiquent aucun effet des OTMC sur ces mesures des résultats (ou une gamme plus vaste de mesures), excepté que les patients des OTMC sont moins susceptibles d'être victimes de criminalité. Les patients des OTMC sont toutefois susceptibles de se voir restreindre leur liberté pour des périodes de temps significativement plus longues. Les méta-analyses regroupant les données des patients des ERC, et les études non randomisées de grande qualité n'offrent pas non plus de preuves des avantages pour les patients, et les revues systématiques en viennent à la même conclusion.

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Section: Resultsmentioning

confidence: 99%

Effectiveness of Community Treatment Orders: The International Evidence

Rugkåsa

2016

Can J Psychiatry

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“…This suggests that workers need to find a way to ‘reach through’ the psychotic beliefs, to engage the person meaningfully, to gain their trust, to reach past the threat and the authority that they represent as part of their role; processes described by Banks, Stroud and Doughty [ 63 ] as ‘personalisation’. Of relevance to this need, Suetani, Foo and Wilson’s [ 64 ] study involving 90 mental health patients found a trend for greater compliance to depot medication by those not on a CTO compared with those who were. They concluded that CTOs become a double-edged sword because, while forced cooperation might lead some patients to accept medication in the long-term, other patients might associate the experience with a loss of autonomy and develop negative attitudes to medication more generally.…”

Section: Discussionmentioning

confidence: 99%

Examining the use of metaphors to understand the experience of community treatment orders for patients and mental health workers

et al. 2016

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BackgroundCommunity Treatment Orders (CTOs) are often complex because of the ethical tensions created by an intervention that aims at promoting the patient’s good through an inherently coercive process. There is limited research that examines the complexity of CTOs and how patients on CTOs and workers administering CTOs make sense of their experiences.MethodsThe study involved in-depth interviews with 8 patients on CTOs and 10 community mental health workers in South Australia, to explore how they constructed their experiences of CTOs. Critical discourse analysis (CDA) was used to analyse the data, supported by NVIVO software.ResultsAnalysis of the interviews revealed that patients and workers experienced the CTO process as multi-dimensional, including some positive as well as more negative constructions. The positive metaphor of CTOs as a safety net is described, followed by a more detailed description of the metaphors of power and control as the dominant themes, with five sub-themes of the CTO as control, wake-up, punishment, surveillance, and tranquiliser.DiscussionMetaphors are a way that mental health patients and mental health workers articulate the nature of CTOs. The language used to construct these metaphors was quite different, with patients overwhelmingly experiencing and perceiving CTOs as coercive (that is, punishing, controlling and scrutinizing), whereas workers tended to perceive them as necessary, beneficial and supportive, despite their coerciveness.ConclusionsBy acknowledging the role of metaphors in these patients’ lives, workers could enhance opportunities to engage these patients in more meaningful dialogue about their personal experiences as an alternative to practice predominantly focused on risk. Such a dialogue could enhance workers’ reflection on their work and promote recovery-based practice. More understanding of how to promote autonomy, capacity and supported decision-making, and how to address the impacts of coercion within care, is needed.

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“…Of note, one of our worker participants argued for more first episode psychosis patients to be put on CTOs so that they would receive earlier, more assertive treatment and avoid the long-term negative consequences of untreated mental illness. What such a view fails to appreciate is the damage to trust, worker-patient relationships and engagement with healthcare providers that such a path can bring, as described by many of our patient participants, and noted in other studies [ 9 , 11 – 14 , 35 , 36 ]. O’Hagan refers to coercion as the ‘elephant in the recovery room’ [ 52 ] and that, to make progress, we need to have more open dialogue about paternalism and coercion and their association with the moral framings that both workers and patients use to describe their experience of CTOs.…”

Section: Discussionmentioning

confidence: 81%

“…Most research has shown that CTOs do not reduce readmission rates or duration, or increase time to readmission or treatment adherence [ 17 , 32 – 34 ]. A study of 90 patients by Suetani et al [ 35 ] found a trend for greater compliance to intra-muscular depot medication by those not on a CTO compared with those who were. They concluded that CTOs become a double-edged sword because, while forced cooperation might lead some patients to accept medication in the long-term, other patients might associate the experience with the loss of autonomy and develop negative attitudes to medication, help-seeking from mental health services and indeed the medical profession, more generally.…”

Section: Introductionmentioning

confidence: 99%

A qualitative study examining the presence and consequences of moral framings in patients’ and mental health workers’ experiences of community treatment orders

et al. 2015

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BackgroundMental health recovery involves acknowledging the importance of building the person’s capacity for agency. This might be particularly important for patients on community treatment orders (CTOs - which involve enforced treatment for their mental illness), given limited international evidence for their effectiveness and underlying concerns about the use of coercion by workers and systems of care towards this population of people with mental illness.MethodsThis study sought to understand how the meaning of CTOs is constructed and experienced, from the perspective of patients on CTOs and workers directly administering CTOs. Qualitative interviews were conducted with South Australian community mental health patients (n = 8) and mental health workers (n = 10) in 2013–14. During thematic analysis of data, assisted by NVIVO software, the researchers were struck by the language used by both groups of participants and so undertook an examination of the moral framings apparent within the data.ResultsMoral framing was apparent in participants’ constructions and evaluations of the CTO experience as positive, negative or justifiable. Most patient participants appeared to use moral framing to: try to understand why they were placed on a CTO; make sense of the experience of being on a CTO; and convey the lessons they have learnt. Worker participants appeared to use moral framing to justify the imposition of care. Empathy was part of this, as was patients’ positive right to services and treatment, which they believed would only occur for these patients via a CTO. Workers positioned themselves as trying to put themselves in the patients’ shoes as a way of acting virtuously towards them, softening the coercive stick approach. Four themes were identified: explicit moral framing; best interests of the patient; lessons learned by the patient; and, empathy.ConclusionsExperiences of CTOs are multi-layered, and depend critically upon empathy and reflection on the relationship between what is done and how it is done. This includes explicit examination of the moral framing present in everyday interactions between mental health workers and their patients in order to overcome the paradox of the moral grey zone between caring and controlling. It suggests a need for workers to receive ongoing empathy training.

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We need to talk about depot: effect of Community Treatment Order on depot antipsychotic medication compliance

Cited by 7 publications

References 22 publications

Effectiveness of Community Treatment Orders: The International Evidence

Effectiveness of Community Treatment Orders: The International Evidence

Examining the use of metaphors to understand the experience of community treatment orders for patients and mental health workers

A qualitative study examining the presence and consequences of moral framings in patients’ and mental health workers’ experiences of community treatment orders

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