1. Supervised Community Treatment Compulsory treatment in the community

2. What is supervised community treatment? Supervised community treatment (SCT) refers to mental health law which allows for the compulsory community-based treatment of people with mental health difficulties. It is also called ‘Outpatient commitment’, or a ‘Community Treatment Order’.

3. Context The first discussions of SCT began during a period of deinstitutionalisation and the establishment of more robust community- based treatment in many high income group (HIG) countries. Many patients in the community end up having multiple admissions; SCT was a proposed method to help prevent this cycle.

4. Use of SCT around the world Australia New Zealand USA (most states) Canada Europe, e.g., Sweden, Scotland, England & Wales, Norway, Israel, some Swiss Cantons Legal regimes allowing compulsory community supervision exist in around 70 jurisditions.

5. What does having an SCT mean? The exact definition of SCT differs between countries, and reflects the individual legislation of those countries. Broadly speaking, SCT enables a treating clinician to: Impose a set of regulations under which the patient must comply to whilst in the community. – This could include engaging with the community team and attending regular appointments, taking prescribed medication, residing at a specific residence, and having regular drug tests. Allow a clinician to rapidly recall a patient to hospital if those conditions are not met. It does not allow clinicians to involuntarily medicate patients in the community.

6. How is SCT meant to work? SCT is designed to encourage treatment compliance. Treatment compliance means that a patient will regularly take some medication and see their community mental health team. This in turn it is suggested should keep patients well enough to gain insight in to their illness and voluntarily engage with services.

7. Evidence for the effectiveness of SCT For such a wide-spread and controversial intervention there have been relatively few studies in to the effectiveness of SCT. There are a number of non-experimental trials with mixed findings “There is very little evidence to suggest that CTOs are associated with any positive outcomes” (Review of 72 published articles by Churchill et al., 2007). There have been 3 Random Controlled Trials New York (USA) North Carolina (USA) OCTET (UK)

8. Participants who were leaving involuntary care were randomised to either SCT (n=78) or to be released (n=64) and followed for 11 months. Results showed that at 11 months there were no statistical difference in the number of patients readmitted, or the number of days spent in hospital. New York Steadman et al. (1999)

9. North Carolina Swartz et al. 2001 Participants who were leaving involuntary care were randomised to either SCT (n=129) or to be released (n=135) and followed for 1 year. Results showed that at 1 year there were no statistical difference in the number of patients readmitted, or the number of days spent in hospital.

10. OCTET Burns et al. (2013) Participants who were leaving involuntary care were randomised to either SCT (n=167) or to S17 leave (n=169) and followed for 1 year. Results showed that at 1 year there were no statistical difference in the number of patients readmitted, or the number of days spent in hospital.

11. All three RCT found no evidence to suggest that SCTs make a difference to patients risk of being hospitalised. “In well functioning mental health services CTOs do not reduce the readmission rate, time to readmission or time in hospital for psychosis patients in the 12 months from discharge.” (Burns et al., 2013). RCT Conclusions

12. Summary Evidence from randomised trials concurs that there is no apparent treatment effect. Evidence from other types of studies are complex, with some suggesting a positive effect upon outcome and others not. Community compulsion is increasingly used

13. Burns, T., Rugkåsa, J., Molodynski, A., Dawson, J., Yeeles, K., Vazquez- Montes, M.,... & Priebe, S. (2013). Community treatment orders for patients with psychosis (OCTET): a randomised controlled trial. The Lancet. Churchill, R., Owen, G., Hotopf, M., Singh, S. (2007). International experiences of using community treatment orders. London: Department of Health and Institute of Psychiatry, King’s College London. Steadman, H., Gounis, K., Dennis, D., Hopper, K., Roche, B., Swartz, M., Robbins, R. C. (2001). Assessing the New York City Involuntary Outpatient Commitment Pilot Programme. Psychiatric Services, 52(3), 330-336. Swartz, M. S., Swanson, J.W., Wagner, H. R., Burns, B. J., Hiday, V. A., Borum, R. (1999). Can involuntary outpatient commitment reduce hospital recidivism?: Findings from a randomized trial with severely mentally ill individuals. American Journal of Psychiatry, 156 (12), 1968-1975. References