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Community mental health care in the UK was established by two influential mental health acts (MHAs). The 1930 MHA legislated for voluntary admissions and outpatient clinics. The 1959 MHA required hospitals to provide local follow- up after discharge, required them to work closely with local social services and obliged social services to help with accommodation and support. An effect of this was to establish highly sectorized services for populations of about 50,000. These were served by multidisciplinary teams (generic CMHTs), which accepted all local referrals from family doctors. Sector CMHTs evolved a pragmatic approach with an emphasis on skill-sharing and outreach, depending heavily on community psychiatric nurses. The NHS is funded by central taxation, with no distortion of clinical practice by per-item service fees. It is highly centrally regulated, with a strong emphasis on evidence-based treatments. Since 2000, generic sector teams have gradually been replaced or enhanced by Crisis Resolution Home Treatment teams, Assertive Outreach Teams and Early Intervention Teams. Assertive Outreach Teams were resorbed into CMHTs, based on outcome evidence. The last decade has seen a major expansion in outpatient psychotherapy (Improving Access to Psychological Treatments (IAPT) services) and in specialist teams for personality disorders and perinatal psychiatry. The traditional continuity of care across the inpatient-outpatient divide has recently been broken. During the last decade of austerity, day care services have been decimated, and (along with the reduction in availability of beds) compulsory admission rates have risen sharply. Mental health care is still disadvantaged, receiving 11% of the NHS spend while accounting for 23% of the burden of disease.

IntroductionThe primary aim of the National Institute of Health Research-funded global health research group, Warwick-India-Canada (WIC), is to reduce the burden of psychotic disorders in India. India has a large pool of undetected and untreated patients with psychosis and a treatment gap exceeding 75%. Evidence-based packages of care have been piloted, but delivery of treatments still remains a challenge. Even when patients access treatment, there is minimal to no continuity of care. The overarching ambition of WIC programme is to improve patient outcomes through (1) developing culturally tailored clinical interventions, (2) early identification and timely treatment of individuals with mental illness and (3) improving access to care by exploiting the potential of digital technologies.Methods and analysisThis multicentre, multicomponent research programme, comprising five work packages and two cross-cutting themes, is being conducted at two sites in India: Schizophrenia Research Foundation, Chennai (South India) and All India Institute of Medical Sciences, New Delhi (North India). WIC will (1) develop and evaluate evidence-informed interventions for early and first-episode psychosis; (2) determine pathways of care for early psychosis; (3) investigate the efficacy and cost-effectiveness of community care models, including digital and mobile technologies; (4) develop strategies to reduce the burden of mental illnesses among youth; (5) assess the economic burden of psychosis on patients and their carers; and (6) determine the feasibility of an early intervention in psychosis programme in India.Ethics and disseminationThis study was approved by the University of Warwick’s Biomedical and Scientific Research Ethics Committee (reference: REGO-2018-2208), Coventry, UK and research ethics committees of all participating organisations. Research findings will be disseminated through peer-reviewed scientific publications, presentations at learnt societies and visual media.

The fundamental building blocks of modern mental health services (primary care provision, inpatient wards, and some form of multi-disciplinary community team) are broadly established in high-income countries. In low- and middle-income countries, the availability of each of these three components is highly variable and investment often reflects local traditions and practices. Planning rarely begins with a blank sheet, and while it should be informed by local needs assessment and epidemiology, it is likely to be an exercise in the possible. Strengthening primary care provision and establishing multi-disciplinary teams that can provide outreach to the most severely ill are key to success. Organizational simplicity and stability, coupled with effective liaison with social care, mark effective systems.

SummaryIn the wake of the deinstitutionalisation of mental health services, community treatment orders (CTOs) have been introduced in around 75 jurisdictions worldwide. They make it a legal requirement for patients to adhere to treatment plans outside of hospital. To date, about 60 CTO outcome studies have been conducted. All studies with a methodology strong enough to infer causality conclude that CTOs do not have the intended effect of preventing relapse and reducing hospital admissions. Despite this, CTOs are still debated, possibly reflecting different attitudes to the role of evidence-based practice in community psychiatry. There are clinical, ethical, legal, economic and professional reasons why the current use of CTOs should be reconsidered.Learning Objectives• Gain an overview of the development and use of CTOs in the UK and internationally• Get up-to-date information about the evidence base for CTO effectiveness and the relative contributions of different levels of evidence• Appreciate the nature of the current controversy around the use of CTOs and become familiar with the factors in the ongoing debate about their future

BACKGROUND: Most studies investigating the effectiveness of Community Treatment Orders (CTOs) use readmission to hospital as the primary outcome. Another aim of introducing CTOs was to improve continuity of care. Our study was a 3-year prospective follow-up which tested for associations between CTOs and continuity of care. METHODS: Our study sample included 333 patients recruited to the Oxford Community Treatment Order Trial (OCTET). We collected data on continuity of care using eight previously operationalized measures. We analysed the association between CTOs and continuity of care in two ways. First, we tested the association between continuity of care and OCTET randomisation arm (CTO versus voluntary care via Section 17 leave). Second, we analysed continuity of care and CTO exposure independent of randomisation; using any exposure to CTO, number of days on CTO, and proportion of outpatient days on CTO as outcomes. RESULTS: 197 (61%) patients were made subject to CTO during the 36-month follow-up. Randomisation to CTO arm was significantly associated with having a higher proportion of clinical documents copied to the user but no other measures of continuity. Having a higher proportion of outpatient days on CTO (irrespective of randomisation) was associated with fewer 60 day breaks without community contact. A sensitivity analysis found that any exposure to CTO and a higher proportion of outpatient days on CTO were associated with fewer days between community mental health team contacts and 60 day breaks without contact. CONCLUSION: We found some evidence of an association between CTO use and better engagement with the community team in terms of increased contact and fewer breaks in care. Those with CTO experience had a higher number of inpatient admissions which may have acted as a mediator of this association. We found limited evidence for an association between CTO use and other measures of continuity of care.

BackgroundCoercion comprisesformal coercionorcompulsion[treatment under a section of the Mental Health Act (MHA)] andinformal coercion(a range of treatment pressures, includingleverage). Community compulsion was introduced in England and Wales as community treatment orders (CTOs) in 2008, despite equivocal evidence of effectiveness. Little is known about the nature and operation of informal coercion.DesignThe programme comprised three studies, with associated substudies: Oxford Community Treatment Order Evaluation Trial (OCTET) – a study of CTOs comprising a randomised controlled trial comparing treatment on CTO to voluntary treatment via Section 17 Leave (leave of absence during treatment under section of the MHA), with 12-month follow-up, an economic evaluation, a qualitative study, an ethical analysis, the development of a new measure of capabilities and a detailed legal analysis of the trial design; OCTET Follow-up Study – a follow-up at 36 months; and Use of Leverage Tools to Improve Adherence in community Mental Health care (ULTIMA) – a study of informal coercion comprising a quantitative cross-sectional study of leverage, a qualitative study of patient and professional perceptions, and an ethical analysis.ParticipantsParticipants in the OCTET Study were 336 patients with psychosis diagnoses, currently admitted involuntarily and considered for ongoing community treatment under supervision. Participants in the ULTIMA Study were 417 patients from Assertive Outreach Teams, Community Mental Health Teams and substance misuse services.OutcomesThe OCTET Trial primary outcome was psychiatric readmission. Other outcomes included measures of hospitalisation, a range of clinical and social measures, and a newly developed measure of capabilities – the Oxford Capabilities Questionnaire – Mental Health. For the follow-up study, the primary outcome was the level of disengagement during the 36 months.ResultsCommunity treatment order use did not reduce the rate of readmission [(59 (36%) of 166 patients in the CTO group vs. 60 (36%) of 167 patients in the non-CTO group; adjusted relative risk 1.0 (95% CI 0.75 to 1.33)] or any other outcome. There were no differences for any subgroups. There was no evidence that it might be cost-effective. Qualitative work suggested that CTOs’ (perceived) focus on medication adherence may influence how they are experienced. No general ethical justification was found for the use of a CTO regime. At 36-month follow-up, only 19 patients (6% of 329 patients) were no longer in regular contact with services. Longer duration of compulsion was associated with longer time to disengagement (p = 0.023) and fewer periods of discontinuity (p ConclusionsCommunity Treatment Orders do not deliver clinical or social functioning benefits for patients. In the absence of further trials, moves should be made to restrict or stop their use. Informal coercion is widespread and takes different forms.Trial registrationCurrent Controlled Trials ISRCTN73110773.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

Community treatment orders are a legal mechanism to extend powers of compulsion into outpatient mental health settings in certain circumstances. Previous ethical analyses of these powers have explored a perceived tension between a duty to respect personal freedoms and autonomy and a duty to ensure that patients with the most complex needs are able to receive beneficial care and support that maximises their welfare in the longer-term. This empirical ethics paper presents an analysis of 75 interviews with psychiatrists, patients and family carers to show how these ethical considerations map onto the different ways that community treatment orders are used and experienced in practice. A complex and nuanced account of how the requirements to respect patients’ autonomy, to respect patients’ liberty and to act beneficently should be interpreted in order to make judgements about the ethics of community treatment orders is presented. The article argues that, due to such complexity, no general ethical justification for community treatment orders can be provided, but a justification on the basis of the promotion of patients’ autonomy could provide an ethical reason for community mental health practitioners to make use of a community treatment order in some limited circumstances.

Background: Continuity of care (COC) is central to the organization and delivery of mental health services. Traditional definitions have excluded service users, and this lack of involvement has been linked to poor conceptual clarity surrounding the term. Consequently, very little is known about the differences and similarities in the conceptualization of COC by mental health service users and professionals. Objective: To explore and compare mental health service users’ and professionals’ definitions of COC. Methods: Using an exploratory, qualitative design, five focus groups with 32 service users each met twice. Data were analysed thematically to generate a service user-defined model of COC. In a cross-sectional survey, health and social care professionals (n = 184) defined COC; responses were analysed thematically. Service user and professional definitions were conceptually mapped and compared to identify similarities and differences. Results: There was crossover between the service user and professional derived models of COC. Both contained temporal, quality, systemic, staff, hospital and needs-related elements of COC. Service users prioritized access, information, peer support and avoiding services; health professionals most frequently referred to staff, cross-sectional and temporal COC. Service users alone identified service avoidance, peer support and day centres as COC elements; professionals alone identified cross-sectional working. Conclusions: Important similarities and differences exist in service user and professional conceptualizations of COC. Further research is necessary to explore these differences, prior to integrating service user and professional perspectives in a validated COC framework which could enable the development and evaluation of interventions to improve COC, informing policy and practice.

Background Patient 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. Methods The 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 a sub-sample (N = 50) 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. Results The OxCAP-MH showed good internal consistency (Cronbach’s alpha 0.79) and test-retest reliability (ICC = 0.86). Convergent validity was evidenced by strong correlations with the EQ-5D (VAS 0.52, p

Purpose Community 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. Methods A sub-sample (n = 114) 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. Results No significant association was found between the duration of CTO intervention and social network size (IRR = 0.996, p = .63), objective social outcomes (B = -0.003, p = .77), health-related quality of life (B = 0.001, p = .77), and capabilities (B = 0.046, p = .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 (SD = 5.9) contacts in their social networks, 42% of whom were relatives. Conclusions CTO 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.

Background In 2008, the Mental Health Act (MHA) 2007 amendments to the MHA 1983 were implemented in England and Wales. The amendments were intended to remove perceived obstacles to the detention of high risk patients with personality disorders (PDs), sexual deviance and learning disabilities (LDs). The AMEND study aimed to test the hypothesis that the implementation of these changes would lead to an increase in numbers or proportions of patients with these conditions who would be assessed and detained under the MHA 2007. Method A prospective, quantitative study of MHA assessments undertaken between July–October 2008–11 at three English sites. Data were collected from local forms used for MHA assessment documentation and patient electronic databases. Results The total number of assessments in each four month period of data collection varied: 1034 in 2008, 1042 in 2009, 1242 in 2010 and 1010 in 2011 (n = 4415). Of the assessments 65.6% resulted in detention in 2008, 71.3% in 2009, 64.7% in 2010 and 63.5% in 2011. There was no significant change in the odds ratio of detention when comparing the 2008 assessments against the combined 2009, 2010 and 2011 data (OR = 1.025, Fisher‘s exact Χ2 p = 0.735). Only patients with LD and ‘any other disorder or disability of the mind’ were significantly more likely to be assessed under the MHA post implementation (Χ2 = 5.485, P = 0.018; Χ2 = 24.962, P > 0.001 respectively). There was no significant change post implementation in terms of the diagnostic category of detained patients. Conclusions In the first three years post implementation, the 2007 Act did not facilitate the compulsory care of patients with PDs, sexual deviance and LDs.

The emphasis on care in the community in current mental health policy poses challenges for community mental health professionals with responsibility for patients who do not wish to receive services. Previous studies report that professionals employ a range of behaviors to influence reluctant patients. We investigated professionals' own conceptualizations of such influencing behaviors through focus groups with community teams in England. Participants perceived that good, trusting relationships are a prerequisite to the negotiation of reciprocal agreements that, in turn, lead to patient-centred care. They described that although asserting professional authority sometimes is necessary, it can be a potential threat to relationships. Balancing potentially conflicting processes-one based on reciprocity and the other on authority-represents a challenge in clinical practice. By providing descriptive accounts of micro-level dynamics of clinical encounters, our analysis shows how the authoritative aspect of the professional role has the potential to undermine therapeutic interactions with reluctant patients. We argue that such micro-level analyses are necessary to enhance our understanding of how patient-centered mental health policy may be implemented through clinical practice.

AIMS AND METHODWe retrospectively investigated the association between the Jarman and Townsend indices of deprivation and referral rates to community mental health teams (CMHTs) and in-patient admissions rates, including the contribution of general practice factors to these rates. The samples consisted of all community/out-patient referrals and admissions to four CMHTs over 1 year.RESULTSLow positive correlation was found between community/out-patient referral rates for all diagnoses and psychosis with the Jarman index, and between both the indices and admission rates for all diagnoses and non-psychosis. Referrals from general practitioners (GPs) varied nearly 40-fold and were not related to either indices, fundholding status or having practice manager or practice nurse.CLINICAL IMPLICATIONSOverall, the Jarman index appears to be a more useful index for planning psychiatric service provision. However, because of the small correlation with referral and admission rates, deprivation indices in themselves would be of limited value, as there may be other relevant factors that require investigating. GP characteristics investigated did not predict referral rates.

BackgroundThere is growing concern about patient satisfaction with psychiatric in-patient provision. This paper measures satisfaction in psychiatric in-patients and its relationships with patient characteristics and ward experiences.AimsTo: (a) measure overall in-patient satisfaction; (b) examine its relationship to in-patient experiences; and (c) examine its relationship to patient factors.MethodFour hundred and thirty-three patients were interviewed. Satisfaction was assessed by a single question, the Client Satisfaction Questionnaire (CSQ) and by a semi-structured interview.ResultsOver three-quarters of the patients were satisfied, but two-thirds reported adverse events. Females, younger patients and those detained were more dissatisfied. No significant relationship was found for ethnic group. Results were similar in the mental hospital and district general hospital.ConclusionsThere remain problems with satisfaction scales. Qualitative approaches to examine patients' experiences in hospital and the causes of dissatisfaction are recommended.

BackgroundThere has been major concern about the ‘over-representation’ of Black and ethnic minority groups amongst people detained under the Mental Health Act (MHA). We explored the effect of patient ethnicity on detention following an MHA assessment, once confounding variables were controlled for.MethodProspective data were collected for all MHA assessments over 4-month periods in the years 2008, 2009, 2010 and 2011 each in three regions in England: Birmingham, West London and Oxfordshire. Logistic regression modelling was conducted to predict the outcome of MHA assessments – either resulting in ‘detention’ or ‘no detention’.ResultsOf the 4423 MHA assessments, 2841 (66%) resulted in a detention. A diagnosis of psychosis, the presence of risk, female gender, level of social support and London as the site of assessment predicted detention under the MHA. Ethnicity was not an independent predictor of detention.ConclusionsThere is no evidence for that amongst those assessed under the MHA, ethnicity has an independent effect on the odds of being detained.

The aims of this naturalistic non-interventional study were to quantify the level of stigma and discrimination in persons with schizophrenia and to test for potential associations between different types of stigma and adherence to antipsychotics. Antipsychotic medication use was electronically monitored with a Medication Event Monitoring System (MEMS®) for 12 months in 111 outpatients with schizophrenia and schizophrenia-like psychosis (DSM-IV). Stigma was assessed at endpoint using the Discrimination and Stigma Scale (DISC). Single DISC items that were most frequently reported included social relationships in making/keeping friends (71%) and in the neighborhood (69%). About half of the patients experienced discrimination by their families, in intimate relationships, regarding employment and by mental health staff. Most patients (88%) wanted to conceal their mental health problems from others; 70% stated that anticipated discrimination resulted in avoidance of close personal relationships. Non-adherence (MEMS® adherence≤0.80) was observed in 30 (27.3%). When DISC subscale scores (SD) were entered in separate regression models, neither experienced nor anticipated stigma was associated with adherence. Our data do not support an association between stigma and non-adherence. Further studies in other settings are needed as experiences of stigma and levels of adherence and their potential associations might vary by a healthcare system or cultural and sociodemographic contexts.

OBJECTIVE: Little research is conducted on service closures. We examined the social, clinical and service use impact of the closure of a partial hospitalisation service (day hospital) on its users. METHODS: Patients attending the closing day hospital were studied at closure and one year after, and compared to patients at an unchanged day hospital. RESULTS: The closure did not increase use of inpatient beds, primary care or emergency room. Overall clinical improvements were similar for both groups as were costs. Social networks of the discharged patients decreased. CONCLUSIONS: Closures of services need to be as carefully evaluated as new developments.

Considerable national debate exists about the need for some form of compulsory supervision or treatment for mentally disordered individuals in the community and a recent Government review has proposed a new power of Supervised Discharge. Prior to this, a survey was undertaken in the London area of psychiatrists, community psychiatric nurses and approved social workers (ASWs). Their knowledge of, and attitudes towards, various forms of proposal were obtained. There were clear professional differences in willingness to use such powers, with psychiatrists the most enthusiastic. The Royal College of Psychiatrists' proposal was the best understood and most favoured by all three groups. Only ASWs considered extension of guardianship order a viable alternative and they placed it third. The commonest reservations expressed were that compulsory supervision would scare patients off or be used as a substitute for properly resourced services. Psychiatrists were asked to indicate the number and diagnoses of patients they considered suitable for compulsory supervision. Over 70% of patients recommended suffered from schizophrenic disorders and 20% from affective psychoses. Their number ranged from 0-15 per team with an average of 2.38. The total adjusted figure for South West Thames was 195 patients, which would suggest just over three thousand patients in England and Wales. © 1995 Informa UK Ltd All rights reserved: reproduction in whole or part not permitted.

BackgroundSince de-institutionalisation, much has been written about the risk posed to the community by those with severe mental illness. However, violent victimisation of people with mental illnesses has received little attention.AimsTo establish the 1-year prevalence of violent victimisation in community-dwelling patients with psychosis and to identify the socio-demographic and clinical correlates of violent victimisation.MethodA total of 691 subjects with established psychotic disorders were interviewed. The past-year prevalence of violent victimisation was estimated and compared with general population figures. Those who reported being violently victimised were compared with those who did not on a range of social and clinical characteristics.ResultsSixteen per cent of patients reported being violently victimised. Victims of violence were significantly more likely to report severe psychopathological symptoms, homelessness, substance misuse and previous violent behaviour and were more likely to have a comorbid personality disorder.ConclusionsThose with psychosis are at considerable risk of violent victimisation in the community. Victimisation experience should be recorded in the standard psychiatric interview.

During March 1998 we had the privilege of visiting the mental health services in Kumasi, Ghana at the invitation of Dr Yaw Osei, Senior Lecturer at the Department of Behavioural Sciences, School of Medical Sciences, University of Science and Technology.

Continuity of care is considered by patients and clinicians as an essential feature of good quality care in long-term disorders, yet there is general agreement that it is a complex concept and the lack of clarity in its conceptualisation and operationalisation has been linked to a deficit of user involvement. In this paper we utilise the concept of the 'patient career' to frame patient accounts of their experiences of the mental health care system. We aimed to capture the experiences and views of users and carers focusing on the meanings associated with particular (dis)continuities and transitional episodes that occurred over their illness career. As part of a large longitudinal study of continuity of care in mental health a sub-sample of 31 users was selected together with 14 of their carers. Qualitative interviews framed around the service user's illness career explored general experiences of relationship with services, care, continuity and transition from both user and carer perspectives. Five key themes emerged: relational (dis)continuity; depersonalised transitions; invisibility and crisis; communicative gaps and social vulnerability. One of the important findings was the fragility of continuity and its relationship to levels of satisfaction. Supportive, long-term relationships could be quickly undermined by a range of factors and satisfaction levels were often closely related to moments of transition where these relationships were vulnerable. Examples of continuity and well managed transitions highlighted the importance of professionals personalising transitions and situating them in the context of the daily life of service users. Further research is required to identify how best to negotiate these key points of transition in the future.

Some minority ethnic groups in England and Wales have higher rates of admission for mental\ud illness and more adverse pathways to care. Are the resulting accusations of institutional racism\ud within psychiatry justified?

Aims and MethodA questionnaire survey of all general practices in one health authority plus an assessment of a random sample of referrals were used to evaluate the impact of counsellors in primary care on referrals to mental health services.ResultsA total of 91.1% of practices responded to the survey. A counsellor was present in 20.3% of these practices. A random sample of 180 referrals to community mental health teams was reviewed. There was a significantly higher referral rate from practices that employed a counsellor (P = 0.003). There was no evidence of a difference in rates of caseness of referrals between practices that employed a counsellor and those that did not.Clinical ImplicationsPractices employing counsellors had significantly higher referral rates to mental health services, with no difference in the level of caseness between the two groups of referrals.

SummaryUsing treatment as usual (TAU) in trials has obscured the repeated finding that assertive outreach has never reduced hospitalisation when compared with treatment by multidisciplinary teams (community mental health teams, CMHTs). Its use has delayed recognising that CMHTs are the more cost-effective, evidence-based approach. The term should be abandoned and trials should compare two equally well-defined services.

Treatment records of 94 patients treated in an experimental home-based psychiatric service and 78 control patients in standard care were collected over one year. There was a substantial reduction in in-patient care in the experimental group, both in terms of proportion admitted and duration of admissions, despite similar out-patient and general practice care. The total treatment costs were significantly larger (>50%) for standard care when controlled for by diagnostic grouping. Costs were further examined by including all specialist psychiatric care, and by excluding patients with primary diagnoses of brain damage or alcoholism. Sensitivity analysis explored the effects of increasing the cost of home visits. The relative cost effectiveness of the experimental service persisted. Clinical and social outcome was similar in control and experimental groups.

Making threats and offers to patients is a strategy used in community mental healthcare to increase treatment adherence. In this paper, an ethical analysis of these types of proposal is presented. It is argued (1) that the primary ethical consideration is to identify the professional duties of care held by those working in community mental health because the nature of these duties will enable a threat to be differentiated from an offer, (2) that threatening to act in a way that would equate with a failure to uphold the requirements of these duties is wrong, irrespective of the benefit accrued through treatment adherence and (3) that making offers to patients raises a number of secondary ethical considerations that need to be judged on their own merit in the context of individual patient care. The paper concludes by considering the implications of these arguments, setting out a pathway designed to assist community mental healthcare practitioners to determine whether making a specific proposal to a patient is right or wrong.

OBJECTIVE: Increasing patient autonomy and decreasing coercion are frequently cited goals in mental health care. Research suggests that the therapeutic relationship and patients' experiences of coercion may be associated. This study investigated the association between the therapeutic relationship and perceived coercion in psychiatric admissions. METHODS: Associations between perceived coercion and the therapeutic relationship and sociodemographic and clinical variables were examined by using data from structured interviews with 164 patients consecutively admitted to two psychiatric hospitals in Oxford, England. RESULTS: High levels of coercion were experienced by 48% of voluntarily and 89% of involuntarily admitted patients. A high perceived coercion score was significantly associated with involuntary admission and a poor rating of the therapeutic relationship. The therapeutic relationship confounded legal status as a predictor of perceived coercion. CONCLUSIONS: Similar factors may influence patients' experience of both coercion and the therapeutic relationship during psychiatric hospital admission. Hospitalization, even when voluntary, was viewed as more coercive when patients rated their relationship with the admitting clinician negatively. Interventions to improve the therapeutic relationship may reduce perceptions of coercion.

Background: 'Relapse' is a common outcome indicator in intervention studies in schizophrenia. In community studies it is froqucntly equated with hospitalisation and in psychopharmacological studies with predetermined symptom scores. Its clinical meaning, however, remains undefined. Method: Consensus on the defining features of 'relapse' in schizophrenia used by academic and clinical schizophrenia experts in the UK, was investigated using a four stage Delphi process. A two panel, four stage, Delphi based methodology was used to investigate the implicit meanings of 'relapse' in clinical practice. A multi disciplinary panel of twelve members each listed anonymously ten indicators of relapse. A second panel, of ten experienced psychiatrists, rated the 188 submitted indicators from essential-unimportant (1-5). This panel completed a one day workshop during the remaining Delphi rounds ending with a structured discussion of the results. Results: Very strong consensus was achieved on the relative importance of potential relapse indicators. There was complete agreement about some aspects of a definition of relapse (such as recurrence of positive symptoms) and a number of the complex issues underlying the concept were clearly articulated. Conclusions: This four stage Delphi process achieved consensus on core features of relapse. The elucidation of the "softer" features at the threshold between normal fluctuations in functioning and the start of relapse require continuing investigations.

OBJECTIVE: This review investigates the effectiveness of 'home treatment' for mental health problems in terms of hospitalisation and cost-effectiveness. For the purposes of this review, 'home treatment' is defined as a service that enables the patient to be treated outside hospital as far as possible and remain in their usual place of residence. METHODS - SYSTEMATIC LITERATURE SEARCH: 'Home treatment' excluded studies focused on day, residential and foster care. The review was based on Cochrane methodology, but non-randomised studies were included if they compared two services; these were only analysed if they provided evidence of the groups' baseline clinical comparability. METHODS - REVIEW OF ECONOMIC EVALUATIONS: Economic evaluations among the studies found were reviewed against established criteria. METHODS - IDENTIFICATION OF SERVICE COMPONENTS: A three-round Delphi exercise ascertained the degree of consensus among expert psychiatrists concerning the important components of community-based services that enable them to treat patients outside hospital. The identified components were used to construct the follow-up questionnaire. METHODS - FOLLOW-UP OF AUTHORS: As a supplement to the information available in the papers, authors of all the studies were followed up for data on service components, sustainability of programmes and service utilisation. METHODS - DATA ANALYSIS: The outcome measure was mean days in hospital per patient per month over the follow-up period. (1) Comparative analysis - compared experimental to control services. It analysed all studies with available data, divided into 'inpatient-control' and 'community-control' studies, and tested for associations between service components and difference in hospital days. (2) Experimental services analysis - analysed only experimental service data and tested for associations between service components and hospital days. RESULTS - SYSTEMATIC LITERATURE SEARCH: A total of 91 studies were found, conducted over a 30-year period. The majority (87) focused on people with psychotic disorders. RESULTS - REVIEW OF ECONOMIC EVALUATIONS: Only 22 studies included economic evaluations. They provided little conclusive evidence about cost-effectiveness because of problems with the heterogeneity of services, sample size, outcome measures and quality of analysis. RESULTS - DELPHI EXERCISE: In all, 16 items were rated as 'essential', falling into six categories: home environment; skill-mix; psychiatrist involvement; service management; caseload size; and health/social care integration. There was consensus that caseloads under 25 and flexible working hours over 7 days were important, but little support for caseloads under 15 or for 24-hour services, and consensus that home visiting was essential, but not on teams being 'explicitly dedicated' to home treatment. RESULTS - RESPONSE TO FOLLOW-UP: A total of 60% of authors responded, supplying data on service components and hospital days in most cases. Other service utilisation data were far less readily available. RESULTS - SERVICE CHARACTERISATION AND CLASSIFICATION: The services were homogeneous in terms of 'home treatment function' but fairly heterogeneous in terms of other components. There was some evidence for a group of services that were multidisciplinary, had psychiatrists as integrated team members, had smaller caseloads, visited patients at home regularly and took responsibility for both health and social care. This was not a cohesive group, however. RESULTS - SUSTAINABILITY OF SERVICES: The sustainability of home treatment services was modest: less than half the services whose authors responded were still identifiable. Services were more likely to be operational if the study had found them to reduce hospitalisation significantly. RESULTS - META-ANALYSIS: Meta-analysis with heterogeneous studies is problematic. The evidence base for the effectiveness of services identifiable as 'home treatment' was not strong. Within the 'inpatient-control' study group, the mean reduction in hospitalisation was 5 days per patient per month (for 1-year studies only). No statistical significance could be measured for this result. For 'community-control' studies, the reduction in hospitalisation was negligible. Moreover, the heterogeneity of control services, the wide range of outcome measures and the limited availability of data might have confounded the analysis. Regularly visiting at home and dual responsibility for health and social care were associated with reduced hospitalisation. Evidence for other components was inconclusive. Few conclusions could be drawn from the analysis of service utilisation data. RESULTS - LOCATION: Studies were predominately from the USA and UK, more of them being from the USA. North American studies found a reduction in hospitalisation of 1 day per patient per month more than European studies. North American and European services differed on some service components, but this was unlikely to account for this finding, particularly as no difference was found in their experimental service results. CONCLUSIONS - STATE OF RESEARCH: There is a clear need for further studies, particularly in the UK. The benefit of home treatment over admission in terms of days in hospital was clear, but over other community-based alternatives was inconclusive. CONCLUSIONS - NON-RANDOMISED STUDIES: Difficulties in systematically searching for non-randomised studies may have contributed to the smaller number of such studies found (35, compared with 56 randomised controlled trials). This imbalance was compounded by a relatively poor response rate from non-randomised controlled trial authors. Including them in the analysis had little effect. CONCLUSIONS - LIMITATIONS OF THIS REVIEW: A broad area was reviewed in order to avoid the problem of analysing by service label. While reviews of narrower areas may risk implying a homogeneity of the services that is unwarranted, the current strategy has the drawback that the studies cover a range of heterogeneous services. The poor definition of control services, however, is ubiquitous in this field, however reviewed areas are defined. Inclusion of mean data for which no standard deviations were available was problematic in that it prevented measuring the significance of the main findings. The lack of availability of this data, however, is an important finding, demonstrating the difficulty in seeking certainty in this area. Only days in hospital and cost-effectiveness were analysed here. The range and lack of uniformity of measures used in this field made meta-analysis of other outcomes impossible. It should be noted, however, that the findings pertain to these aspects alone. The Delphi exercise reported here was limited in being conducted only with psychiatrists, rather than a multidisciplinary panel. Its findings were used as a framework for the follow-up and analysis. Their possible bias should be borne in mind when considering them as findings in themselves. CONCLUSIONS - IMPLICATIONS FOR CLINICIANS: The evidence base for home treatment compared with other community-based services is not strong, although it does show that home treatment reduces days spent in hospital compared with inpatient treatment. There is evidence that visiting patients at home regularly and taking responsibility for both health and social care each reduce days in hospital. CONCLUSIONS - IMPLICATIONS FOR CONSUMERS: Services that visit patients at home regularly and those that take responsibility for both health and social care are likely to reduce time spent in hospital. Psychiatrists surveyed in this review also considered support for carers to be essential. The evidence from this review, however, was that few services currently have protocols for meeting carers' needs. CONCLUSIONS - RECOMMENDATIONS FOR RESEARCH AND COMMISSIONERS: A centrally coordinated research strategy, with attention to study design, is recommended. Studies should include economic evaluations that report health and social service utilisation. Service components should be collected and reported for both experimental and control services. Studies should be designed with adequate power and longer durations of follow-up and use comparable outcome measures to facilitate meta-analysis. Research protocols should be adhered to throughout the studies. It may be advisable that independent researchers conduct studies in future. It is no longer recommended that home treatment be tested against inpatient care, or that small, localised studies replicate existing, more highly powered studies.

Case management was originally a specific, tightly defined, role developed for the care of de-institutionalised psychiatric patients in the US. The term rapidly caught on and, as a consequence of its success, is now widely used throughout mental health care (and beyond). Predictably it is now surrounded by ambiguity and controversy. This paper explores its history - from the age of innocence, through that of controversy, to consolidation. It attempts to identify what, if anything, is unique to the approach by examining the reported features of its most developed form (Assertive Community Treatment). It goes on to speculate on whether such a 'generic' role will survive the increasing range of evidence based mental health interventions that are in use.

Introduction Limitations of mental health services research Components of mental health services for schizophrenia Multidisciplinary community teams Specialized teams Specialist teams or specialist functions? Controversies and ethics in schizophrenia care Conclusions References © 2011 Blackwell Publishing Ltd.

Background: Leverage is a particular type of treatment pressure that is used within community mental health services to increase patients’ adherence to treatment. Because leverage involves practitioners making proposals that attempt to influence patients’ behaviours and choices, the use of leverage raises ethical issues. Aim: To provide guidance that can assist practitioners in making judgements about whether it is ethically acceptable to use leverage in a particular clinical context. Method: Methods of ethical analysis. Results: Four ethical duties relevant to making such judgements are outlined. These four duties are (1) benefitting the individual patient, (2) benefitting other individuals, (3) treating patients fairly and (4) respecting patients’ autonomy. The practical requirements that follow from each of these duties are considered in detail. It is argued that practitioners should determine whether the use of leverage will mean that care is provided in ways that are consistent with the requirements of these four duties, regardless of whether the patient accepts or rejects the terms of the proposal made. Conclusion: Particular attention must be paid to determine how the requirements of the four duties should be applied in each specific treatment scenario, and in making careful judgements when these duties pull in opposing directions.

The NHS Plan ([Department of Health, 2000][1]) is a programme for major reform in the UK health services. The mental health component draws on the National Service Framework (NSF; [Department of Health, 1999][2]), which proposes radical changes based, wherever possible, on evidence. This emphasis on

‘Shared care in mental health is now a policy imperative in England and Wales, yet its meaning … [is] … still open to debate’. Dr Lester's opening line says it all (Lester, 2005, this issue). We're all in favour of it, but none of us is exactly sure what it is. Ambiguity is considered a failing in academic publications and, under pressure from editors, we usually excise the unnecessary and unclear. Politicians, however, often deliberately insert ambiguity, as it allows scope for interpretation. By a simple shift in emphasis, either shared care's achievement can be claimed as a manifesto success or slow progress towards it can be cited to justify further targets.

Background: In 2008, the Swiss Civil Code was amended. From 1 January 2013, each Swiss canton may propose specific provisions for involuntary outpatient treatment (community treatment orders (CTOs)) for individuals with mental disorders. Aim: This review catalogues the legal provisions of the various Swiss cantons for CTOs and outlines the differences between them. It sets this in the context of variations in clinical provisions between the cantons. Methods: Databases were searched to obtain relevant publications about CTOs in Switzerland. The Swiss Medical Association, Swiss Federal Statistical Office, Swiss Health Observatory and all the 26 Cantonal medical officers were contacted to complete the information. Conférence des cantons en matière de protection des mineurs et des adultes (COPMA), the authority which monitors guardianship legislation, and Pro Mente Sana, a patients’ right association, were also approached. Results: Three articles about CTOs in Switzerland were identified. Psychiatric provisions vary considerably between cantons and only a few could provide complete or even partial figures for rates of compulsion in previous years. Prior to 2013, only 6 of the 20 cantons, for which information was returned, had any provision for CTOs. Now, every canton has some form of legal basis but the level of detail is often limited. In eight cantons, the powers of the measure are not specified (for example, use of medication). In 12 cantons, the maximum duration of the CTO is not specified. German speaking cantons and rural cantons are more likely to specify the details of CTOs. Conclusion: Highly variable Swiss provision for CTOs is being introduced despite the absence of convincing international evidence for their effectiveness or good quality data on current coercive practice. Careful monitoring and assessment of these new cantonal provisions are essential.

Assertive community treatment is one of the most researched and clinically replicated of all community mental health teams. It is clearly defined with established scales to measure its model fidelity. In the last decade its earlier claims to substantially reduce hospitalization have not been replicated in research studies. This inconsistency has generated considerable controversy. A careful systematic review and meta-regression analysis was conducted of 64 trials including 7,819 patients. The review included measures of model fidelity and hospitalization outcomes. Variation in reduced hospitalization was found to be mainly due to variation in control service practice but model fidelity to team organization principles was also associated with reduced hospitalization. Low caseloads and specified ACT staffing, however, had no effect at all on outcome. 'Ordinary CMHTs' share most of the organizational aspects of ACT and appear to deliver equal outcomes with much reduced resources. The value of investing in high fidelity ACT teams must, therefore, be in doubt.

Mental health provision in most of the industrialised world seems to be in a state of continual revolution. In the UK the National Health Service (NHS) Plan ([Department of Health, 2000][1]) has mandated a fundamental reorganisation of care, with the establishment of 260 assertive outreach teams

Aims and MethodMental health day centres have been little researched. We carried out a 1-week census at the four day centres run by a London borough.ResultsThe centres catered for a g roup with long-standing mental health problems, mostly under community mental health team care. A surprising number were suffering from physical ill health. They attended the centres primarily for social reasons or to participate in creative groups such as music and art.Very few were concurrently attending day hospitals.Clinical ImplicationsFurther work is essential to understand the distinction between NHS day hospitals and Social Services day centres in terms of utilisation and client group.This client group's needs, particularly for physical health care, require urgent attention.

If you are working in mental health, you get used to being inspected and commented upon – the Mental Health Act Commission, Audit Commission, Social Services Inspectorate, Health Advisory Service (HAS, as was) and public inquiries into patient homicides. Working in multidisciplinary teams has made us used to operating with a variety of perspectives and for most of us this is a necessary and welcome part of the job. Few psychiatrists, however, are so sanguine about the former HAS or about homicide inquiries. The repeated complaint has been their inconsistency. Their quality and tone (potentially as damaging as their findings) have varied to quite an indefensible degree.

BackgroundIt is perceived that North American home treatment studies reveal greater success in reducing days in hospital than do European studies. There are difficulties in extrapolating findings internationally.AimsWe aimed to determine whether North American studies find greater reductions in days in hospital and whether experimental service patients in North American studies spend less time in hospital.MethodThe results of a systematic review were analysed with respect to study location. Service components ascertained through follow-up were utilised to interpret the meta-analyses conducted.ResultsMost of the 91 studies found were from the USA and UK. North American studies found a difference of one hospital day (per patient per month) more than European studies but there was no difference in experimental data between the two locations.ConclusionsNorth American studies demonstrate greater differences in days in hospital but patients in their experimental services seem to spend no fewer days in hospital, implying a disparity in control services.

SummaryKeown et al's paper highlights the complex nature of social determinants of hospital admission and compulsory care. We review here how research into compulsion in mental health has progressed beyond epidemiological studies of rates of admission. There is now a wider recognition of the range of compulsory and coercive processes used and how they are experienced by patients. The results of recent studies have confirmed the importance of confronting the complexity that Keown et al have presented. They have also produced unexpected and intriguing findings that set the direction for future research.

Background: Service users with non-psychotic disorders are rarely studied. How continuity of care functions for this group is unknown. Aims: To compare users of community mental health teams with non-psychotic disorders to those with psychotic disorders in terms of demographic and illness characteristics, continuity of care and clinical and social functioning. Methods: Service users with non-psychotic disorders ( N = 98) were followed up for one year and compared to 180 service users with psychotic disorders. Continuity of care factors were tested for association with user, illness and service variables. Results: Service users with non-psychotic disorders experienced more care transitions, but there were no differences in team practices in relation to these two different groups. Conclusion: The underlying concepts of continuity of care derived from users with psychotic disorders appear to be meaningful for users with non-psychotic disorders. Their greater likelihood of experiencing disruptive and distressing care transitions needs to be addressed.

Measuring change resulting from healthcare interventions is critical to evaluating their usefulness. The choice of outcome measure is an important part of such evaluations and is driven by assumptions about what is likely to change and how best to capture this. Despite its importance, forensic mental health has paid little attention to determining which are the best measures of outcome. This study used a panel of relevant professionals to (i) assess the relative importance of different areas of potential outcome measurement and (ii) evaluate specific instruments used currently as outcome measures in forensic mental health research. Although a wide range of potential outcomes were endorsed as appropriate, few corresponding instruments have been used consistently. Only three psychiatric instruments deemed by our panel as feasible, relevant and psychometrically adequate have been used in five or more studies (the Beck Depression Inventory; the Brief Psychiatric Rating Scale, and the Symptom Checklist-90-Revised). Significant measurement gaps were noted in areas such as social and emotional functioning. Although instruments exist that could capture most areas, none were sufficiently developed for routine use as outcomes. Further research to develop robust, sensitive and diverse outcome measures is needed. This is an essential precursor to extending the evidence base for forensic mental health interventions. © 2011 Taylor and Francis.

This article debates and defends the lawfulness of a randomised controlled trial of compulsory outpatient treatment under the mental health legislation for England and Wales. The trial is designed to compare the outcomes for patients of their treatment under the new Community Treatment Order (CTO) regime with their treatment under the older leave scheme - the two main forms of compulsory care in the community now authorised by the revised Mental Health Act 1983. The methods for the trial involve the random allocation of some patients between the two schemes, when they are considered by their Responsible Clinicians to be eligible for some form of compulsory outpatient care. The main question we consider is the lawfulness of that aspect of the methods. Can a carefully selected group of patients be allocated at random between the two regimes to permit an evaluation to proceed? Or would that involve some departure from the decision-making criteria specified by law? We argue that a group of patients can be identified who meet - simultaneously - the tests for treatment under both the CTO and the leave schemes. Those patients could then be allocated lawfully to treatment under either scheme. This opens the door, we argue, to their random allocation between the two schemes for the purposes of the research. In reaching this conclusion, we explain the methods and aims of the trial and closely compare the respective features of the leave and CTO regimes.