Jorun Rugkåsa

Responsibilities with conflicting priorities: a qualitative study of ACT providers’ experiences with community treatment orders

BackgroundPatients with severe mental illness may be subjected to Community Treatment Orders (CTOs) in order to secure that the patients adhere to treatment. Few studies have investigated the use of CTOs within an Assertive Community Treatment (ACT) setting, and little is known about how the tension between the patients’ autonomy and the clinicians’ responsibility to act in the patients’ best interest are resolved in practice. The aim of this study was to explore the service providers’ experiences with CTOs within an ACT setting.MethodsThe study was based on reviews of case files of 15 patients, eight individual qualitative in depth interviews and four focus group interviews with service providers involved in ACT and decisions related to CTOs. A modified grounded theory approach was used to analyze the data.ResultsThe main theme ‘responsibility with conflicting priorities’ emerged from data analysis (case file reviews, individual interviews and focus group interviews). The balance between coercive approaches and the emphasis on promoting patient autonomy was seen as problematic. The participants saw few alternatives to CTOs as long-term measures to secure ongoing treatment for some of the patients. However, participants perceived the ACT model’s comprehensive scope as an opportunity to build rapport with patients and thereby better meet their needs. The team approach, the ACT providers’ commitment to establish supportive relationships and the frequent meetings with patients in their home environment were highlighted. The ACT approach gave them insight into patients’ everyday lives and, in some cases a greater sense of security when considering whether to take patients off CTOs.ConclusionsMany of the participants viewed CTOs as helpful in securing long-term treatment for patients. CTO decision-making was described as challenging and complex and presented the providers with many dilemmas. The ACT approach was considered as helpful in that it afforded comprehensive, patient-centered support and opportunities to build rapport.

Community treatment orders and social outcomes for patients with psychosis: a 48-month follow-up study

PurposeCommunity treatment orders (CTOs) are widely used internationally despite a lack of evidence supporting their effectiveness. Most effectiveness studies are relatively short (12-months or less) and focus on clinical symptoms and service data, while a little attention is given to patients’ social outcomes and broader welfare. We tested the association between the duration of CTO intervention and patients’ long-term social outcomes.MethodsA sub-sample (nxa0=xa0114) of community-based patients from the Oxford Community Treatment Order Evaluation Trial (OCTET) were interviewed 48 months after randomisation. Multivariate regression models were used to examine the association between the duration of the CTO intervention and social outcomes as measured by the social network schedule, Objective Social Outcomes Index, Euro-Qol EQ-5D-3L (EQ-5D), and Oxford Capabilities Questionnaire for Mental Health.ResultsNo significant association was found between the duration of CTO intervention and social network size (IRRxa0=xa00.996, pxa0=xa0.63), objective social outcomes (Bxa0=xa0−0.003, pxa0=xa0.77), health-related quality of life (Bxa0=xa00.001, pxa0=xa0.77), and capabilities (Bxa0=xa00.046, pxa0=xa0.41). There were no between-group differences in social outcomes when outcomes were stratified by original arm of randomisation. Patients had a mean of 10.2 (SDxa0=xa05.9) contacts in their social networks, 42% of whom were relatives.ConclusionsCTO duration was not associated with improvements in patients’ social outcomes even over the long term. This study adds to growing concerns about CTO effectiveness and the justification for their continued use.

Psychometric validation of a multi-dimensional capability instrument for outcome measurement in mental health research (OxCAP-MH)

BackgroundPatient reported outcome measures (PROMs) are widely used in mental healthcare research for quality of life assessment but most fail to capture the breadth of health and non-health domains that can be impacted. We report the psychometric validation of a novel, multi-dimensional instrument based on Amartya Sen’s capability approach intended for use as an outcome measure in mental health research.MethodsThe Oxford Capabilities Questionnaire for Mental Health (OxCAP-MH) is a 16-item self-complete capability measure that covers multiple domains of functioning and welfare. Data for validation of the instrument were collected through a national randomised controlled trial of community treatment orders for patients with psychosis. Complete OxCAP-MH data were available for 172 participants. Internal consistency was established with Cronbach’s alpha; an interclass correlation coefficient was used to assess test-retest reliability in axa0sub-sample (Nu2009=u200950) tested one week apart. Construct validity was established by comparing OxCAP-MH total scores with established instruments of illness severity and functioning: EuroQol (EQ-5D), Brief Psychiatric Rating Scale (BPRS), Global Assessment of Functioning (GAF) and Objective Social Outcomes Index (SIX). Sensitivity was established by calculating standard error of measurement using distributional methods.ResultsThe OxCAP-MH showed good internal consistency (Cronbach’s alpha 0.79) and test-retest reliability (ICCu2009=u20090.86). Convergent validity was evidenced by strong correlations with the EQ-5D (VAS 0.52, pu2009<u2009.001) (Utility 0.45, pu2009<u2009.001), and divergent validity through more modest associations with the BPRS (−0.41, pu2009<u2009.001), GAF (0.24, pu2009<u2009.001) and SIX (0.12, pu2009=u2009ns). A change of 9.2 points on a 0–100 scale was found to be meaningful on statistical grounds.ConclusionsThe OxCAP-MH has demonstrable reliability and construct validity and represents a promising multi-dimensional alternative to existing patient-reported outcome measures for quality of life used in mental health research.

Mental health, coercion and family caregiving: issues from the international literature

This article summarises current knowledge about two aspects of family care for people with mental illness: potentially pressurising or coercive aspects of family life; and family carers’ experiences of being involved in coercive service interventions. There is a paucity of studies on these topics, especially outside Europe, North America and Australasia, and further research is recommended.

How clinicians make decisions about CTOs in ACT: a qualitative study

BackgroundThe first 12 Norwegian assertive community treatment (ACT) teams were piloted from 2009 to 2011. Of the 338 patients included during the teams’ first year of operation, 38% were subject to community treatment orders (CTOs). In Norway as in many other Western countries, the use of CTOs is relatively high despite lack of robust evidence for their effectiveness. The purpose of the present study was to explore how responsible clinicians reason and make decisions about thexa0continued use of CTOs, recall to hospital and thexa0discontinuation of CTOs within an ACT setting.MethodsSemi-structured interviews with eight responsible clinicians combined with patient case files and observations of treatment planning meetings. The data were analysed using a modified grounded theory approach.ResultsThe participants emphasized that being part of a multidisciplinary team with shared caseload responsibility that provides intensive services over long periods of time allowed for more nuanced assessments and more flexible treatment solutions on CTOs. The treatment criterion was typically used to justify the need for CTO. There was substantial variation in the responsible clinicians’ legal interpretation of dangerousness, and some clinicians applied the dangerousness criterion more than others.ConclusionsAccording to the clinicians, many patients subject to CTOs were referred from hospitals and high security facilities, and decisions regarding the continuation of CTOs typically involved multiple and interacting risk factors. While patients’ need for treatment was most often applied to justify the need for CTOs, in some cases thexa0use of CTOs was described as a tool to contain dangerousness and prevent harm.

A cross-sectional study of experienced coercion in adolescent mental health inpatients

BackgroundInvoluntary care and coercive measures are frequently present in mental healthcare for adolescents. The purpose of this study was to examine to what extent adolescents perceive or experience coercion during inpatient mental health care, and to examine predictors of experienced coercion.MethodsA cross-sectional sample of 96 adolescent inpatients from 10 Norwegian acute and combined (acute and sub-acute) psychiatric wards reported their experienced coercion on Coercion Ladder and the Experienced Coercion Scale in questionnaires. Staff reported use of formal coercion, diagnoses, and psychosocial functioning. We used two tailed t-tests and mixed effects models to analyze the impact from demographics, alliance with parents, use of formal coercion, diagnostic condition, and global psychosocial functioning.ResultsHigh experienced coercion was reported by a third of all patients. In a mixed effects model, being under formal coercion (involuntary admission and / or coercive measures); a worse relationship between patient and parent; and lower psychosocial functioning, significantly predicted higher experienced coercion. Twenty-eight percent of the total sample of patients reported a lack of confidence and trust both in parents and staff.ConclusionsRoughly one third of patients in the sample reported high experienced coercion. Being under formal coercion was the strongest predictor. The average scores of experienced coercion in subgroups are comparable with adult scores in similar care situations. There was one exception: Adolescents with psychosis reported low experienced coercion and almost all of them were under voluntary care.

Exploring professionals’ understanding, interpretation and implementation of the ‘appropriate medical treatment test’ in the 2007 amendment of the Mental Health Act 1983

Background The appropriate medical treatment test (ATT), included in the Mental Health Act (MHA) (1983, as amended 2007), aims to ensure that detention only occurs when treatment with the purpose of alleviating a mental disorder is available. Aims As part of the Assessing the Impact of the Mental Health Act (AMEND) project, this qualitative study aimed to assess professionals’ understanding of the ATT, and its impact on clinical practice. Method Forty-one professionals from a variety of mental health subspecialties were interviewed. Interviews were coded related to project aims, and themes were generated in an inductive process. Results We found that clinicians are often wholly relied upon for the ATT. Considered treatment varied depending on the patient’s age rather than diagnosis. The ATT has had little impact on clinical practice. Conclusions Our findings suggest the need to review training and support for professionals involved in MHA assessments, with better-defined roles. This may enable professionals to implement the ATT as its designers intended. Declaration of interest None. Copyright and usage

Carer involvement in compulsory out-patient psychiatric care in England

BackgroundThere is an expectation in current heath care policy that family carers are involved in service delivery. This is also the case with compulsory outpatient mental health care, Community Treatment Orders (CTOs) that were introduced in England in 2008. No study has systematically investigated family involvement through the CTO process.MethodWe conducted qualitative interviews with 24 family carers to ascertain their views and experiences of involvement in CTOs. The transcripts were subjected to thematic analysis that incorporated both deductive and inductive elements.ResultsWe found significant variation in both the type and extent of family carer involvement throughout the CTO process (initiation, recall to hospital, renewal, tribunal hearings, discharge). Some were satisfied with their level of involvement while others felt (at least partly) excluded or that they wanted to be more involved. Some wanted less involvement than what they had. From the interviews we identified key factors shaping carers involvement. These included: perceptions of patient preference; concern over the relationship to the patient; carers’ knowledge of the CTO and of the potential for carer involvement; access to and relationships with health professionals; issues of patient confidentiality; opportunities for private discussions, and; health professionals limiting involvement. These factors show that health professionals have many opportunities to facilitate, or hinder, carer involvement. The various roles attributed to carers, such ‘proxy’ for patient decision, ‘gatekeeper’ to services, ‘mother’ or ‘expert carer’, however, conflict with one another and make the overall role unclear.ConclusionsThere is a need for clarification of the expectations of carers in individual care situations, for carers to be equipped with the information they need to in order to be involved, and for services to find flexible and innovative ways of ensuring continuous, open communication. The introduction of CTOs in England has not been successful in its ambition for carer involvement.

Likelihood and predictors of detention in patients with personality disorder compared with other mental disorders: A retrospective, quantitative study of Mental Health Act assessments

BACKGROUNDnThe UK guidelines on the treatment of personality disorder recommend avoiding compulsory treatment except in extreme situations. Little is known about how often patients with personality disorder are detained or how this compares with the treatment of other mental disorders.nnnOBJECTIVESnOur aim is to test the hypothesis that people with personality disorder are infrequently detained under the Mental Health Act (MHA) and that risk factors associated with detention are the same as those for people with other mental disorders.nnnMETHODnWe used a retrospective, quantitative study of MHA assessments.nnnRESULTSnOf the 2u2009087 assessments undertaken, 204 (9.8%) patients had a diagnosis of personality disorder; 40.7% of assessments in the personality disorder group resulted in detention, as did 69.7% of patients with other mental disorders. A higher proportion of people with personality disorder received no intervention following assessment compared with those with other mental disorders (20.6% vs. 4.7%, pu2009<u20090.001). Study centre and a history of admission were risk factors for detention in both groups. Risk was a predictor of detention in those with other mental disorders.nnnCONCLUSIONSnDetention rates in patients with personality disorder are lower than those for other disorders but are still substantial. Risk factors for detention in patients with personality disorder differ from those with other mental disorders. Copyright