Dieuwertje Anna de Waardt1*
Anne Laura van Melle2
Guy Antoine Marie Widdershoven3
Wichor Matthijs Bramer4Franciscus Martinus Machiel Adrianus van der Heijden5
Jorun Rugkåsa6,7
Cornelis Lambert Mulder8,9- 1Department of Psychiatry, ETZ Hospital (Elisabeth-TweeSteden Ziekenhuis), Tilburg, Netherlands
- 2GGZ inGeest Mental Health Care, Amsterdam, Netherlands
- 3Department of Ethics, Law, and Humanities, Amsterdam University Medical Centers (Location VUmc), Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- 4Medical Library, Erasmus MC, Erasmus University Medical Center, Rotterdam, Netherlands
- 5Department Emergency Psychiatry, Vincent van Gogh for Psychiatry, Venray, Netherlands
- 6Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
- 7Centre for Care Research, University of South-Eastern Norway, Porsgrunn, Norway
- 8Parnassia Psychiatric Institute, Rotterdam, Netherlands
- 9Department of Psychiatry, Epidemiological and Social Psychiatric Research institute (ESPRi), Erasmus MC, Erasmus University Medical Center, Rotterdam, Netherlands
Background: Multiple studies have examined the effects of compulsory community treatment (CCT), amongst them there were three randomized controlled trials (RCT). Overall, they do not find that CCT affects clinical outcomes or reduces the number or duration of hospital admissions more than voluntary care does. Despite these negative findings, in many countries CCT is still used. One of the reasons may be that stakeholders favor a mental health system including CCT.
Aim: This integrative review investigated the opinions of stakeholders (patients, significant others, mental health workers, and policy makers) about the use of CCT.
Methods: We performed an integrative review; to include all qualitative and quantitative manuscripts on the views of patients, significant others, clinicians and policy makers regarding the use of CCT, we searched MEDLINE, EMBASE, PsycINFO, CINAHL, Web of Science Core Collection, Cochrane CENTRAL Register of Controlled Trials (via Wiley), and Google Scholar.
Results: We found 142 studies investigating the opinion of stakeholders (patients, significant others, and mental health workers) of which 55 were included. Of these 55 studies, 29 included opinions of patients, 14 included significant others, and 31 included mental health care workers. We found no studies that included policy makers. The majority in two of the three stakeholder groups (relatives and mental health workers) seemed to support a system that used CCT. Patients were more hesitant, but they generally preferred CCT over admission. All stakeholder groups expressed ambivalence. Their opinions did not differ clearly between those who did and did not have experience with CCT. Advantages mentioned most regarded accessibility of care and a way to remain in contact with patients, especially during times of crisis or deterioration. The most mentioned disadvantage by all stakeholder groups was that CCT restricted autonomy and was coercive. Other disadvantages mentioned were that CCT was stigmatizing and that it focused too much on medication.
Conclusion: Stakeholders had mixed opinions regarding CCT. While a majority seemed to support the use of CCT, they also had concerns, especially regarding the restrictions CCT imposed on patients’ freedom and autonomy, stigmatization, and the focus on medication.
Introduction
Compulsory Community Treatment (CCT) is available as a coercive outpatient treatment option in many countries, including the USA, Canada, Australia, New Zealand, Asia, UK, and the Netherlands (1, 2). It is also known as Outpatient Compulsory Treatment or Supervised Community Treatment. The intention of this court-ordered treatment is to offer a less restrictive alternative to involuntary admission and to prevent relapses and the readmissions that can result from problems such as non-compliance with treatment. Although patients remain in the community, they have to comply with certain conditions such as taking medication or keeping appointments. The consequence of not complying with these conditions is usually readmission to a psychiatric hospital (3). In several countries, including United Kingdom, the court order is called a community treatment order (CTO).
There is an ongoing debate about the evidence on the effectiveness of CCT. Reviews of randomized controlled trials (RCTs) and pre-post studies on the effects of CCT did not demonstrate that CCT was more effective than voluntary outpatient care, either in reducing the number or duration of hospital admissions or in improving clinical outcomes (4, 5). The last Cochrane review in 2014 summarized the RCTs as follows: “CCT results in no significant difference in service use, social functioning or quality of life compared with standard voluntary care. […] However, [these] conclusions are based on three relatively small trials, with high or unclear risk of blinding bias, and low- to moderate-quality evidence” (5).
The most recent meta-analysis about the effects of CCT, states: “We found no consistent evidence that CCT reduces readmission or length of inpatient stay, although it might have some benefit in enforcing use of outpatient treatment or increasing service provision, or both” (4).
Kisely et al. performed a meta-analysis on outcomes of CCT in Australia and New Zealand. They did not find that CCT reduced the duration or number of admissions (6). Neither did the observational study of Weich et al. (7). 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 (8–11).
Despite discussions about its effectiveness, CCT is still used in many countries (4). This might be because in developing mental health laws, other views, factors, and experiences are taken into account. It may be that stakeholder groups (clinicians, patients, significant others, and policy makers) have positive views on the use CCT, despite a lack of scientific evidence of its effectiveness.
Corring et al. performed a constant comparative analysis of published qualitative research of three stakeholder groups (patients, relatives, and mental health workers) concerning CCT. They find that all three groups see benefits that outweigh the coercive nature of CCT, but also name limitations regarding the representativeness of people on the CTO group, which may bias the results (12).
With this integrative review we added to this knowledge by:
(1) Integrating both the qualitative as well as the quantitative results of studies on the views on CCT of these stakeholder groups, now also searching for the views of policy makers.
(2) Investigating whether their opinion was influenced by having experience with CCT.
Methods
Integrative reviews – the method we chose to analyse the existing literature – were described by Whittemore and Knafl as “the broadest type of research review methods allowing for the simultaneous inclusion of experimental and non-experimental research in order to more fully understand a phenomenon of concern. [They] may also combine data from the theoretical as well as empirical literature” (13). By allowing for the inclusion of different methodologies (e.g., both quantitative and qualitative) to represent the current knowledge on a subject (13), integrative reviews are therefore very suited to analyse the wide-ranging literature on stakeholders’ views and experiences, as any restrictions on the inclusion of the manuscripts based on methodology would lead to the loss of valuable inputs.
Whittemore and Knafl describe five steps in performing an integrative review: (1) Problem identification, (2) Literature search, (3) Data evaluation, (4) Data analysis, and (5) Presentation.
These steps were followed in the execution of this integrative review.
Problem identification
While there is no evidence from empirical studies (see “Introduction” section) that CCT is an effective way to reduce time spent in hospital, the number of admissions or to improve clinical outcomes, many countries still use this measure. Maybe this decision is based on opinions of stakeholders who have other arguments than scientific evidence to be in favor of a mental health system including CCT. Therefore, we would like to know: (1) the opinions of the various stakeholders (patients, significant others, mental health workers, and policy makers) on the use of CCT and whether their opinion was influenced by having experience with CCT; and (2) the advantages and disadvantages of CCT these stakeholders identified.
Literature search
The following electronic bibliographic databases were searched two times, on 24 September 2019 and 27 August 2021 (date last searched) for manuscripts published in English: MEDLINE (via Ovid), EMBASE (via embase.com), PsycINFO (via Ovid), CINAHL (via EBSCOhost), Web of Science Core Collection, Cochrane Central Register of Controlled Trials (via Wiley) and Google Scholar. Although we used no filters for dates, populations and study designs, conference abstracts were removed from the search. Using the method described by Bramer et al. (14), the search was developed by an experienced information specialist (WMB) in close collaboration with the first author (DW). It consisted of four elements that are searched as controlled terms (MeSH or Emtree terms) and free text terms in title and/or abstract:
(1) Compulsory or involuntary, (2) outpatient or community, (3) mental health care or psychiatric diseases, and (4) experiences or opinion. We limited the results to articles published in the English language. Appendix 1 lists the search terms for all databases. References were imported in EndNote and deduplicated according to the method described by Bramer et al. (15).
Data evaluation
AM and DW screened the title and, if the title indicated that the manuscript could be relevant, abstract of all the manuscripts in order to identify and include:
- All qualitative and quantitative studies on the views of patients, significant others (partner, family, and carers), clinicians and policy makers regarding the use of CCT.
In the selected manuscripts, we also checked all references for relevant studies. If there was no initial consensus on including the manuscript for full text reading, or if the title and abstract did not provide enough information to decide whether a manuscript should be included at this stage, the manuscript was selected for full-text reading.
DW and AM separately reviewed the manuscripts selected. Each manuscript was thoroughly read by both DW and LM separately to see if the authors described the opinion of the participants concerning whether or not they supported the use of CCT.
Table 1 describes the inclusion and exclusion criteria.
Table 1. Inclusion and exclusion criteria in the full text reading phase.
Then from the selected manuscripts the following data was extracted using a data extraction table:
- Which stakeholder groups.
- Whether the study used qualitative or quantitative methods.
- Country the study was performed in.
- In which way data was collected.
- Number of stakeholders.
- Whether or not participants had experience with CCT.
- For quantitative manuscripts: the percentages of stakeholders that were either for or against CCT.
- For qualitative manuscripts: terms in the studies that described the stakeholders’ majority view, such as “generally preferred…”, “supported”, “were opposed to”, “rejected” or “favored”. When possible, in the results of this review the literal phrases in the manuscripts are used to describe the results.
Discrepancies between DW and AM regarding the conclusion in qualitative manuscripts that the majority of the participants were in favor, were mixed or against the use of CCT, were discussed until consensus could be reached.
Quantitative results and qualitative results were summarized in a single table.
When the different stakeholder groups mentioned specific advantages or disadvantages of CCT, these were extracted and included in a separate table, being ranked from most to least mentioned by stakeholders in the different manuscripts.
No separate quality assessment of manuscripts was conducted. To ensure the quality of the manuscripts we only included manuscripts that had been published in journals with peer review.
Results
The search in the different databases identified 5,300 manuscripts, from which 2,711 unique articles remained after deduplication. On the basis of their title and in some cases abstract, 2,569 of the identified manuscripts were excluded, as they did not meet our inclusion criteria.
Finally, after full text screening, 55 manuscripts were included in the analysis (see Figure 1).
Figure 1. Literature selection process.
Table 2 lists the stakeholders’ opinions on the use of CCT. Quantitative outcomes are reported as percentages. The outcomes of qualitative studies are reported as they were reported in the manuscript. The number of participants named in the table for these quantitative studies, is, as far as it could be traced back, the number of participants answering the question about CCT.
Table 2. Outcomes of the studies that investigated the views of patients, significant others and mental health workers on the use of compulsory community treatment (CCT).
Appendix 2 lists participants characteristics, the kind of service participants were recruited from and the available information about methods of recruitment.
Data analysis and presentation
Patients
We found 29 manuscripts that reported on the views of patients, 22 of which were qualitative and seven of which were quantitative. Participants in 24 of the 29 studies had experience with CCT.
The studies were performed in eight different countries, being; Canada (n = 7), England (n = 7), Australia (n = 5), USA (n = 3), Norway (n = 3), New Zealand (n = 2), Scotland (n = 1), and Ireland (n = 1).
Of these 29 manuscripts, 14 found that the general opinion of patients was in favor of the use of CCT, eight found ambivalent views and seven found that the general opinion was against the use of CCT.
Significant others
In total, 14 manuscripts reported on the views of significant others (12 qualitative studies and 2 quantitative studies), 12 of them found that significant others supported the use of CCT, one found mixed feelings and one found that they were against the use of CCT.
In 11 of the 12 manuscripts in favor of CCT, the relatives had experience with CCT. So did the participants in the manuscript that reported mixed feelings. The participants in the manuscripts that found a negative attitude toward CCT did not have experience with CCT.
These manuscripts originated from six countries; England (n = 4), Canada (n = 3), New Zealand (n = 2), USA (n = 2), Australia (n = 2), and Norway (n = 1).
Mental health workers
Of the 31 manuscripts that reported the views of mental health workers (15 qualitative and 16 quantitative studies), 24 found that the majority of mental health workers supported the use of CCT, 4 found their participants to have mixed feelings and 3 found that their participants were mainly against the use of CCT. Two out of three studies in this last group were carried out in Scotland around the time CCT was implemented; the participants in these studies did not have experience with CCT.
These studies were performed in 13 different regions/countries: England (n = 7), Canada (n = 5), USA (n = 4), Norway (n = 3), New Zealand (n = 2), Australia (n = 2), Scotland (n = 2), United Kingdom (n = 2), Taiwan (n = 1), the Netherlands (n = 1), England and Wales (n = 1), and Spain (n = 1).
There was a wide range of different mental health workers who participated in the studies, amongst them were psychiatrists, psychologists, nurses, social workers, and occupational therapist. Appendix 2 lists the specific occupations for each study, as far as they were reported.
We found no manuscripts that reported the views of policy makers; we did find one study on the views of judges and commitment investigators, the majority of whom supported the use of CCT.
Overall, there are more studies that reported that patients were against the use of CCT (7 out of 29 studies), compared to relatives (1 out of 14 studies) and mental health workers (3 out of 31 studies).
But all stakeholder groups report ambivalence toward CCT.
Since most studies concerned stakeholders with experience, no conclusion can be drawn for all stakeholder groups regarding the influence of experience with CCT on the opinion on CCT.
The majority of these studies (67%) obtained qualitative data and only 18 (33%) studies obtained quantitative data. The 18 quantitative studies used different outcome measures, such as preferring to work in a system using CCT, or stating that CCT helps patients with complex needs.
Table 3 lists the advantages and disadvantages of CCT mentioned by stakeholders in the various studies. These are ranked from mentioned in most manuscripts to mentioned in least.
Table 3. The five advantages/disadvantages reported most often in studies of experience and views of compulsory community treatment (CCT).
The advantage mentioned most often for all stakeholder groups was that CCT facilitated access to care. Furthermore, patients mentioned that they experienced increased support in case of CCT versus not having CCT. Significant others expressed that CCT facilitated earlier admission as an important advantage. And for mental health workers a great advantage was also that it could enhance compliance with treatment.
The most mentioned disadvantage by all stakeholder groups was that CCT restricted autonomy and was coercive. Patients mentioned as second most often that it was stigmatizing. For significant others the second most often mentioned disadvantage was that it focused too much on medication and for mental health workers the second most often mentioned disadvantage was that CCT sometimes interfered with the therapeutic relationship.
Discussion
Despite the lack of scientific evidence for the effects of CCT, this integrative review showed that in half of the studies patients, and in the majority of the studies significant others and mental health workers favored a mental health system that included CCT. Nonetheless, nearly all studies indicated that stakeholders expressed ambivalences about CCT. Patients were more critical regarding the use of CCT than the other stakeholders. The question remains why, despite the ambivalence it raised and in the absence of empirical evidence of its effectiveness, CCT is implemented in so many countries.
It can be helpful to look at the advantages as well as the disadvantages of CCT mentioned by stakeholders more in detail.
The advantage of CCT mostly indicated by patients and significant others was that it facilitates access to care. The rationale for this may be that, if a patient’s situation deteriorated (when being on CCT) he or she would always have someone to contact who could provide the necessary (inpatient) care. The most valued advantage of CCT for mental health workers was that it provided a way to monitor a patient’s health and stay in touch with the patient. This improved access to care is supported in some uncontrolled studies that found that CCT increased the number of outpatient contacts (6).
Another advantage frequently mentioned, was that it provides a safety net and a sense of security.
Research findings also suggest that CCT could provide more safety, since there are studies that find that people on a CTO have a lower mortality rate (10), have lower suicide numbers (11) and were more likely to receive acute medical care for a physical illness (72).
The fact that these advantages seem to be so important for the stakeholders, is an interesting finding, as these advantages also could be achieved without CCT, as long as there is adequate access to care and continuity of care. – as in Italy, where outpatient care is easily accessible (73).
However, it has been argued that just the availability and accessibility of mental health care services alone is not enough to engage all groups of patients into mental health care (30).
The disadvantages mentioned mostly by all stakeholders were that CCT is a coercive measure that it constrains autonomy, and also that it is stigmatizing. Some authors argue on the other hand that CCT can help patients regain their autonomy - and reduces stigma when their stability improves (2). Another disadvantage all stakeholder groups mentioned, is the excessive focus on taking medication. Studies into the main reasons for deciding on using a CTO for mental health workers show that adherence to treatment is the most important reason for deciding to use a CTO (63, 65). Maybe this is because medication is something that mental health workers can easily provide (in contrast to proper housing or daytime activities) and it has proven to be effective in improving certain symptoms of mental health disorders. However, in a study on the opinions of mental health workers, mental health workers stressed that treatment not only involves medication, but other factors were also essential, such as a good therapeutic relationship, proper housing and access to jobs or daytime activities (69).
Overall we find that the majority of the stakeholders prefer a system with CCT and apparently puts the emphasis on the advantages, accepting the disadvantages. Corring et al. (12) come to a similar conclusion in their comparative analysis.
When interpreting studies about the opinions of stakeholders on CCT, it should be kept in mind that there is a difference between comparing CCT with involuntary admission and comparing it with voluntary care in the community. A patient could prefer CCT to hospitalization, but if there was the choice between voluntary care in the community or CCT, this person might choose voluntary care. They thus seem to support CCT, but only if the alternative were hospitalization. In many of the studies in which patients reported that they supported CCT, they meant that they preferred it to admission to hospital.
We think patients’ preference should be taken into account when deciding on compulsory care. This practice is already in place in the Netherlands in the new Dutch mental health legislation in which patients make a care plan which entails that patients have the opportunity to state their preferences regarding compulsory care.
O’Reilly et al. describe a general consensus that “the use of CTO”s is justifiable for certain individuals, but only if it can be shown that CTOs confer significant benefits on those individuals’ (74) which leaves room for patients and their mental health care workers to decide to use CCT if they think it helps the patient.
Strengths
The main strength of this integrative review is that it included quantitative as well as qualitative studies. Another strength is that in the literature search we did not focus on specific stakeholder groups but were open for views of all relevant groups.
Limitations
The review protocol was not prospectively registered, however, no protocol changes have been made during the process, also no separate study quality appraisal has been performed for all the studies included.
Many of the studies included in this review were qualitative studies that were not designed to report representative views, but rather to provide the breadth and nuance of experiences in this field. Views on CCT are all very complex and almost always ambivalent, this makes it difficult to state whether participants are “pro or con” CCT. For that reason we also explicitly investigated the advantages and disadvantages reported in these studies.
Also there might be a form of selection bias, since most of the patient participants were recruited through their mental health workers or they signed up for the study themselves. This could mean that the patients who were doing well or were more satisfied with their treatment, were more likely to participate in the studies.
Implications for future research
First, it remains important to investigate further why stakeholders would support CCT. If accessibility and continuity of care is one of the main reasons, countries should invest in accessible voluntary care and further studies should be done to see how we can engage patients more easily in voluntary care rather than relying on coercive legal structures. Second, it would be good to include policymakers and other stakeholders, like judges or general practitioners in this research, in order to investigate the grounds on which mental health laws on CCT are developed and implemented.
Conclusion
While the majority of all stakeholders appears to support the use of CCT, many have reservations. Stakeholders considered the most important advantages of CCT to be access to care and a way to remain in contact with patients and monitor their health, especially during times of crisis or deterioration. Stakeholders mention as the most serious disadvantage the restrictions CCT imposes on patients’ freedom and autonomy, stigmatization, and the focus on the use of medication.
Author contributions
DW wrote the research plan, performed the literature analysis, and wrote the first version and later versions of the manuscript. AM performed the literature analysis and contributed to the manuscript. WB developed the literature search, wrote part of the methodology section, and contributed to the manuscript. FH worked on the initial research plan and contributed to the manuscript. JR worked on the analysis of the data and contributed to the manuscript. GW and CM worked on the research plan, the analysis of the data, and took part in writing the manuscript. All authors contributed to the article and approved the submitted version.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher’s note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
Supplementary material
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2022.1011961/full#supplementary-material
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Keywords: involuntary treatment, attitude of health personnel, personal satisfaction, family, personal autonomy, outpatient compulsory treatment, supervised community treatment, community treatment order
Citation: de Waardt DA, van Melle AL, Widdershoven GAM, Bramer WM, van der Heijden FMMA, Rugkåsa J and Mulder CL (2022) Use of compulsory community treatment in mental healthcare: An integrative review of stakeholders’ opinions. Front. Psychiatry 13:1011961. doi: 10.3389/fpsyt.2022.1011961
Received: 04 August 2022; Accepted: 18 October 2022;
Published: 03 November 2022.
Edited by:
Julian Schwarz, Brandenburg Medical School Theodor Fontane, GermanyReviewed by:
Brynmor Lloyd-Evans, University College London, United KingdomTeresa Scheid, University of North Carolina at Charlotte, United States
Copyright © 2022 de Waardt, van Melle, Widdershoven, Bramer, van der Heijden, Rugkåsa and Mulder. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Dieuwertje Anna de Waardt, ddewaardt_research@outlook.com