Richard Mullen

How patients in New Zealand view community treatment orders

Background: New Zealand operates a well-embedded community treatment order scheme for patients with serious mental disorders. A similar scheme may be enacted for England and Wales. Aim: To explore the views of patients with recent experience of community treatment orders. Method: All patients in one region under an order in the last 2 years, not readmitted to hospital for at least 6 months, were included, subject to their capacity and consent. Forty-two patients out of 84 potential participants were interviewed. Results: The majority of patients were generally supportive of the community treatment order, especially if the alternative was hospital. Many valued the access to services and sense of security obtained, and attributed improvements in their health to treatment under the order. They also experienced reduced choice about medication and restrictions on residence and travel. For a minority this meant they were strongly opposed to the order, but for most the restrictions did not unduly hinder them. The majority of patients viewed the order as a helpful step towards community stability. Conclusions: The usefulness of community treatment orders is accepted by most patients under them in NZ, as well as by most psychiatrists. Critical factors include the quality of therapeutic relationships and the structure provided for community mental health care.

Maori Experience of Community Treatment Orders in Otago, New Zealand

Objective: To consider the impact of community treatment orders (CommTOs) on Maori patients and their whanau (extended family) and the associated views of mental health professionals. Method: As a distinct aspect of a larger study of CommTOs, eight Maori patients under compulsory community care were interviewed and, where possible, members of their whanau. Associated interviews were held with their psychiatrists, key workers and other carers: 39 interviews in total. Results: Both benefits and drawbacks of CommTOs for Maori were identified by patients and whanau. CommTOs were considered helpful in increasing patient safety and whanau security and in promoting access to services. They were favoured over hospital care, forensic care and homelessness. The drawbacks included the sense of external control imposed on both Maori patients and staff, particularly concerning medication and restrictions on choices. Conclusions: This was a small study of a limited number of Maori patients under CommTOs. Their views may not be fully representative. There was a general consensus among those interviewed that the timely use of CommTOs can enhance the mental wellbeing and social relationships of Maori patients. Continuing efforts are needed by health professionals to communicate effectively with whanau and to understand the conflicts experienced by Maori in reconciling their traditional beliefs with the medical model of mental illness.

Family perspective on community treatment orders: a New Zealand study.

Background: People with serious mental disorders typically live with family members. Despite increasing interest in compulsory community treatment for such patients, the experience and views of their family members have been little studied. Material: Qualitative interviews with 27 family members, whose relatives have been subject to compulsory community treatment. Discussion and conclusions: Family members are generally in favour of the use of compulsory community treatment orders. They perceive a positive influence on their relative, on themselves, on family relationships, and on relations with the clinical team. Family members are aware of the ethical and other dilemmas that attend the use of compulsory community care.

Delusions: the continuum versus category debate

Objective: In this paper I critically review the recently developed idea that delusions are best considered as part of a continuum along with more ordinary human beliefs. Method: A literature review of the area was guided by a Medline search, and supplemented with material already known to the author. Claims that recent research supports the continuum hypothesis is critiqued. Results: The argument and evidence advanced for the continuum approach to delusions depends largely on: (i) inadequacies of prevailing definitions of delusion, particularly in the light of evidence that delusional conviction is often not absolute; and (ii) the high prevalence of unusual beliefs in community populations. To the extent that the delusion construct contains much in addition to conviction and unusual or false belief content, the continuity approach is weak. The category of delusions continues to have some validity. Conclusion: Both categorical and continuous approaches to delusions have validity that depends at any time on our immediate clinical or scientific needs. No definitive resolution of the category versus continuum debate is likely to emerge.

Koro : the delusion of penile retraction

Koro is a psychiatric syndrome in which the patient is convinced his penis is retracting. A case of koro is described. The literature and proper approach to such patients are briefly summarized.

Thoughts of suicide and stage of recovery in patients with schizophrenia in community mental health care

Objective: Suicidality among patients with schizophrenia remains a major concern. The consumer-oriented concept of recovery has been recognised as important in recent years. We aimed to assess whether there was any relationship between stages of recovery and suicidality among people with schizophrenia in community care. Method: In a community mental health service, 85 patients with schizophrenia consented to an interview during which their stages of recovery were assessed using the Stages of Recovery Instrument. They were asked about suicidality and screened for depression using the Revised Clinical Interview Schedule. Insight was assessed via the Insight and Treatment Attitudes Questionnaire. Data analysis involved logistic regression. Results: In the past year 14% of the patients reported having wanted to die and 13% had considered suicide. Scores indicating the highest stage of recovery were associated with lower odds of suicidal thoughts. In contrast, suicidality was not significantly associated with depression or stage of insight. Conclusion: The link found between suicidality and stages of recovery has practical implications for suicide prevention among those with schizophrenia in community care. Approaches that facilitate the recovery process may reduce suicidal thoughts in this population.

Guidelines, process and ethics with the New Zealand Mental Health (compulsory assessment and treatment) Act: striking a balance

The New Zealand Mental Health (compulsory assessmentand treatment) act [1] was amended to mandate the con-sultation of family and care-givers in every stage of civilcommittal. Although the use of committal has been seenby clinicians as an impediment to care [2] and clinicianscontinue to have concerns about the timing of dischargefrom the act [3], many people with serious mental illnesshave experienced the act as beneficial [4]. A recent reviewof the regulations has increased the length and detail ofthe reports clinicians have to provide to the court. This,combined with a clear directive that an advocate who isnot part of the clinical care process must be present duringthe clinical interview to commence committal, may becausing a conflict between the provision of care in a timelymanner when patients are at risk and complying with therequirements of the court.