1. Coercion and Compulsion in community mental healthcare Andrew Molodynski Department of Social Psychiatry, Oxford

2. Context Continuing change in the locus of psychiatric care through deinstitutionalisation Began in the mid part of the last century and has continued apace Happening in most western countries, with varying speed and varying levels of community provision

3. Recent UK developments NSF modernisation teams( assertive outreach, early intervention, and crisis teams): Allow more intensive long and short term support in the community More palatable ‘in vivo’ treatment with minimal disruption Expensive Potentially allow for more coercive treatment as better resourced and more intensive

4. Mental health act amendments Have recognised this changing locus of care and coercion/compulsion Have helped to focus minds upon the debate regarding these crucial issues and professional accountability within services

5. Main changes Approved Mental health Practitioners (AMHPs) Responsible Clinicians (RCs) Detention criteria change ‘slightly’ Community Treatment Orders (CTOs)

6. CTOs Only for those already detained in hospital ( or on S25 at 1 st ) To be considered once patient having any significant leave ( 1 week) Renewable Rights of appeal Potentially wide ranging conditions: residence freedom of movement attendence for therapy sessions medication

7. Evidence Cohort studies and naturalistic data suggest an effect in terms of service use and clinical outcome Randomised trials and before and after analyses have shown no statistically significant results “ More research urgently needed” as current evidence suggests a number needed to treat of 85 to prevent 1 admission (Cochrane review 2007)!!

8. But…… Swartz et al 1999 Large US RCT of 250 patients Found no overall significant effects A subgroup of people kept on orders for up to a year and receiving weekly (at least) support had reduced readmission rates (57%fewer readmissions and 20 days less overall and 72% and 28 days if psychotic) Concluded that they may work, but only with high levels of support ( for US)

9. Questions Are they really much different to S17 leave? Are they any more useful than S25? Do they reduce symptoms and improve functioning? Are they palatable, and to whom? Will we use them?

10. The Oxford Community Treatment Order Evaluation Trial (OCTET) Randomised controlled trial 300 patients, half assigned to CTO and half assigned to current management (S17 etc) 1 year follow up Clinical outcomes, satisfaction, hospital use, adverse events, economics, carer perspectives

11. Wider Context It’s not that we don’t use coercion However, we struggle to acknowledge this at times It is being increasingly acknowledged and attempts are being made to measure it and look for correlates etc

12. Treatment pressures Persuasion-an ‘appeal to reason’ Leverage-use of interpersonal pressure Inducement-offers of help contingent upon remaining well Threat-withdrawal of support/help if uncooperative Compulsion-use of legislation (ie MHA) Szmukler & Appelbaum 2000

13. Monahan et al 2005 1000 US patients( in 5 places) Housing leverage 23-40% Criminal sanction leverage 15-40% Financial leverage 7-19% Outpatient commitment 12-20% Childcare leverage reported but not measured systematically

14. Monahan… Leverage ubiquitous in standard mental health care Actual nature depended on available methods, but overall rates similar Correlations: substance misuse younger high BPRS low GAF long term/intensive treatment

15. Our Preliminary results (n=287)

16. Tentative conclusions… Leverage is very commonly reported by patients It is often, but not always reported negatively Housing(26%) and criminal justice(28%) are the most common Childcare leverage is important and rarely discussed

17. Summary New community powers seem to form part of a continuum of pressure rather than ‘standing alone’ There is limited and often conflicting evidence about their effectiveness Where they are available they are used often

18. Scenarios We will think about 3 different scenarios in which CTOs might or might not be used: Good points Bad points Ethical issues Practical issues Any other issues

19. Scenario 1 GN is a 45 yr old man with schizophrenia who lives alone. He just about manages with support but often doesn’t take medication properly and at these times often becomes unwell and can relapse and become aggressive. Consider a CTO to just give a depot 2 weekly

20. Scenario 2 SD is a young man who lives alone. He can’t really look after his money, personal care, or shopping etc. he is psychotic much of the time despite medication and neglects himself much of the time. He is no risk to others. He is currently ready to leave the ward but is felt to need residential care of some sort, which he is reluctant to accept. Consider a CTO to insist on residence

21. Scenario 3 PR is a 45 year old lady with a long history of relapsing psychosis. She drinks a lot, can’t really manage her affairs, and doesn’t much like medication. She is reluctant to see people and has no family support. She’s just about to leave hospital after a lengthy admission after a serious collapse at home after XS alcohol. Her house has been condemned by environmental health! Consider a CTO for residence, medication, and attendence at day centre

22. Scenario 1-Depot Doesn’t address whole person Minimally disruptive to routines of life Social care responsibility/reciprocity? Practicality

23. Scenario 2-residence Similar to existing powers Reduces self determination No medication Practicality? Responsibility/reciprocity?

24. Scenario 3-medication, residence, activity Cuts across many areas of life Does address more of the person/less narrow Perhaps better in terms of reciprocity? Practical/enforceable?

25. Are these dilemmas and trade offs between self determination and treatment anything new? Or is it just the same old stuff dressed in different clothes??

26. Please do get in touch… Jorun.rugkasa@psych.ox.ac.uk andrew.molodynski@obmh.nhs.uk