Coercion in mental health. Patterns and prevalence of coercion in mental health care and a trial of the effectiveness and costs of Supervised Community Treatment orders
Around 200 patients admitted under the Mental Health Act will be randomly assigned to either a new Supervised Community Treatment Order (SCT) or standard care, to test whether compulsory outpatient treatment actually works. This matters because coercion in mental health care is increasing, yet the evidence for SCTs—set to be introduced in England and Wales in 2008—remains inconclusive. The most influential international study found benefits only for patients receiving “adequate care,” a condition that may not hold in routine practice. The researchers will also interview four distinct patient groups about five types of “leverage” (housing, finance, childcare, criminal justice, and the Mental Health Act itself) to map the full landscape of coercion, both legal and informal. If the trial shows SCTs reduce hospital readmissions and improve outcomes, it could reshape how the NHS manages “revolving door” patients—those repeatedly hospitalised with severe mental illness. A parallel economic analysis will model the national costs of rolling out SCTs, giving policymakers hard data on whether the intervention is worth the investment. The team will also produce a staff training package for best practice, ensuring any benefits are not lost in translation to real-world care.
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Aims and objectivesTo obtain a detailed understanding of the coercion, both legal and informal, experienced by mental health service users and test the of the effectiveness of the Supervised Community Treatment Orders (SCTs) to be introduced in 2008. There are four overarching objectives:1.Examine the experiences of coercion (‘leverage’) in four distinct cliinical populations.2.Explore the ethical, practical and legal constraints on study methodologies to test the efficacy of SCTs.3.Conduct the most rigorous study possible (see 2) of SCTs.4. Develop and disseminate a training package for best practice in SCTs.BackgroundCompulsion in MH is increasing (1), new service structures do not reduce it (2) and it extends beyond legal restrictions (3;4). Legislation will introduce SCTs in 2008 targeting ‘revolving door patients’, not as an alternative to good quality community care but a component of it (5). International research on SCTs (various terms are used) is inconclusive. The most influential study (6) found no overall differences but significant benefits for patients who received ‘adequate care’ (contact X1 per week) and were maintained on SCTs over 6 months. This group accurately reflects the current proposals for SCTs in E&W. Rates of use vary widely internationally and UK projections even more so(7). Research plansLeverages study (years 1-2)Four distinct samples (psychosis patients in Assertive Outreach (AO) Teams, psychosis and non-psychosis patients in Community Mental Health (CMHT) care and Substance Abuse patients) will be interviewed on experiences of 5 leverages (housing, finance, child care, criminal justice and MHA) in the preceding year. The MacArthur Leverage semi-structured interview (4) has been adapted and successfully piloted in Oxford. Types and degree of leverage will be tested for association with patient and treatment characteristics. Qualitative interviews with staff will explore attitudes to leverage and contribute to the SCT training programme outlined below.SCT study (years 1-5)Preparation comprises two work programmes:i) (Year 1) A series of meetings with clinicians, legal, policy and ethical groups by CM & TH to carry out a detailed investigation of ethical, legal and practical issues of methodologies to test the impact of SCTs. The aim is to obtain agreement and support on the strongest test of the intervention producing a detailed study brief. ii) (years 1 & 2) Developing and piloting a staff SCT training pack using senior clinicians in existing good practice networks. Potential SCT recipients will contribute both as participants and as trainers. It will produce a manual and a programme of workshops.The effectiveness trial (years 2-5). An RCT is proposed (dependent on phase one). 200 patients currently admitted under section 3 of the 1983 MHA will be randomised equally to ‘SCT’ or ‘non SCT’ care. Patients must be judged appropriate for SCT by their clinicians and not subject to other legal restrictions. Assessments are by independent research interview and examination of casenotes at baseline (randomisation) and 6 and 12 months. Outcomes include hospitalisation (including time to initial discharge), MHA use, recall, and patterns of care. Patient and treatment characteristics associated with successful outcomes will be sought. Qualitative interviews will explore experiences broadly and a detailed economic analysis will model the national costs of introducing SCTs. Research teamBurns HSR and trials; Morgan coercion and ethnic minorities; Sinclair and Priebe HSR and qualitative methods; Gray health economics; Hope medical ethics; Firn assertive outreach and MH policy; Doll statistics; McLaughlin NHS management. The team is advised by John Dawson (professor of Law Otago, NZ) and John Monahan (director of the MacArthur Network, Virginia, USA).Research environmentThe Trust and University Department of Psychiatry aim to establish a Research and Training Resource centre to consolidate their extensive acti
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