Coercion and Compulsion in community mental healthcare

1
Coercion and Compulsion in community mental
healthcare

• Andrew Molodynski
• Department of Social Psychiatry, Oxford

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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

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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

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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

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Main changes

• Approved Mental health Practitioners (AMHPs)
• Responsible Clinicians (RCs)
• Detention criteria change slightly
• Community Treatment Orders (CTOs)

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CTOs

• Only for those already detained in hospital ( or
  on S25 at 1st)
• 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

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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)!!

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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 (57fewer 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)

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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?

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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

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Wider Context

• Its not that we dont 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

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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

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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

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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

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Our Preliminary results (n287)
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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

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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

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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

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Scenario 1

• GN is a 45 yr old man with schizophrenia who
  lives alone. He just about manages with support
  but often doesnt 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

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Scenario 2

• SD is a young man who lives alone. He cant
  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

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Scenario 3

• PR is a 45 year old lady with a long history of
  relapsing psychosis. She drinks a lot, cant
  really manage her affairs, and doesnt much like
  medication. She is reluctant to see people and
  has no family support.
• Shes 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

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Scenario 1-Depot

• Doesnt address whole person
• Minimally disruptive to routines of life
• Social care responsibility/reciprocity?
• Practicality

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Scenario 2-residence

• Similar to existing powers
• Reduces self determination
• No medication
• Practicality?
• Responsibility/reciprocity?

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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?

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• 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??

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Please do get in touch

• Jorun.rugkasa_at_psych.ox.ac.uk
• andrew.molodynski_at_obmh.nhs.uk