What Clinicians Say About the Experience of Working With Individuals on Community Treatment Orders.

OBJECTIVE: Community treatment orders (CTOs) refer to a variety of legal schemes that require a person with a serious mental illness to follow a plan of treatment and supervision while living in the community. Use of CTOs has been controversial, and they have been the subject of a considerable amount of quantitative and qualitative research. This article reports the results of a systematic review of qualitative studies focused on understanding the views and experiences of clinicians who work with individuals on CTOs. METHODS: Relevant databases and gray literature were searched for articles that used a qualitative methodology for data collection and analysis to examine clinicians' perspectives. CTOs were defined as various legal schemes, including court-ordered outpatient commitment and renewable conditional-leave provisions initiated while a person is an inpatient in a psychiatric unit. Mandatory treatment and supervision required after a person has been charged with or convicted of committing a criminal offense was not considered. RESULTS: Fourteen articles met inclusion criteria. They represented the views of more than 700 clinicians from six international jurisdictions. Three themes were identified: endorsement of the benefits of CTOs despite tensions both within and between clinicians concerning several aspects of CTOs; belief that medication compliance is a central aspect of CTOs; and acknowledgment that there is room for improvement in CTO implementation, monitoring, and administration. Strategies for reducing tensions and improving administration of CTOs are discussed. CONCLUSIONS: Clinicians view CTOs as providing benefits to their clients but struggle with the coercive nature of these tools.

A systematic review of the views and experiences of subjects of community treatment orders.

OBJECTIVE: CTOS have been the subject of many qualitative and quantitative research studies. Both research approaches add value to our understanding of CTOs. Qualitative studies provide an understanding of CTOs and the experience of being on a CTO that quantitative studies cannot provide. Many qualitative studies that have examined the views of subjects of CTOs have been published. However, authors of these studies continue to note that views and experiences of the subjects of these orders are not well known. This paper provides the results of a systematic review of qualitative studies focused on understanding the experiences of individuals who have been the subjects of CTOs. METHOD: Relevant databases and grey literature were searched. To be included, a study had to have used a qualitative methodology for data collection and analysis, and focus on examining stakeholder perspectives on the lived experience of CTOs. RESULTS: After a rigorous review of the abstracts, we identified 22 papers that met the criteria. These papers were analysed in detail in order to examine the existence of common themes. The 22 papers represented the views of 581 participants from 7 countries around the world. Ten themes were found to be common among the research findings of the 22 papers. Three themes in particular were highlighted: feelings of coercion and control, medication seen as the main reason for a CTO and that the perception of CTOs as a safety net. Findings also highlight the ambivalence that subjects of CTOs experience, the importance of the therapeutic relationship for successful engagement of the subject of the CTO and the complex role of coercion. RECOMMENDATIONS: We have made a number of recommendations about how clinicians might use the views of the subjects of CTOs achieve a more positive experience of a CTO.

Obsessive-compulsive disorder in the postpartum period: diagnosis, differential diagnosis and management.

Childbirth can trigger or exacerbate a variety of psychiatric disorders but the extant literature has focused primarily on mood disorders. Obsessive-compulsive disorder (OCD) after childbirth can occur alone or in combination with other psychiatric disorders such as major depressive disorder. Due to the general lack of awareness of the relationship between childbirth and OCD among clinicians as well as patients, the disorder may be underdiagnosed or misdiagnosed as major depressive disorder. This article describes the prevalence, clinical features, common psychiatric comorbidities, differential diagnosis and potential consequences of underdiagnosis or misdiagnosis. Using case vignettes strategies for its detection and clinical management are suggested. Finally, areas in need of further research are proposed.

Aripiprazole augmentation of antidepressants for postpartum depression: a preliminary report.

We describe the results of an open-label study designed to assess the effectiveness and tolerability of aripiprazole addition to an antidepressant in patients with major depressive disorder with postpartum onset who had not experienced significant clinical improvement following an adequate trial of an antidepressant. Eight of ten women completed the trial with augmentation of aripiprazole (2-10 mg) to their existing antidepressant treatment. Our results suggest a possible therapeutic role for aripiprazole when added to an antidepressant in non-breastfeeding women with postpartum depression. Aripiprazole addition appeared effective and safe with no serious adverse events reported.

Pharmacotherapy of bipolar II disorder during and after pregnancy.

OBJECTIVES: The objective of this study was to evaluate the pharmacotherapy of bipolar II disorder during pregnancy and the postpartum period. METHODS: The use of psychotropic drugs and recurrence risk during and after pregnancy was studied in a prospective, observational study of 37 women with bipolar II disorder. RESULTS: During pregnancy the majority of participants (54.0%) were not on any psychotropic medication, approximately one third (32%) received monotherapy, and the rest were on combination therapy. In comparison, during the postpartum period only 14% of participants were not on any psychotropic medication, approximately 35% received monotherapy, and over 50% were on combination therapy. While only 13.5% of participants were on 3 or more psychotropic drugs during pregnancy, 21.6% required 3 or more psychotropic drugs after childbirth in order to manage their symptoms. During pregnancy, 51 % of women had a mood episode compared to a recurrence rate of 70% in the postpartum period. LIMITATIONS: Small sample size, lack of a control group, and absence of random treatment assignment. CONCLUSIONS: The findings of this prospective, observational study indicate that the recurrence risk is much higher after childbirth than during pregnancy in spite of higher utilization of psychotropic drugs in the postpartum period.

Post-abortion mania.

We describe case histories of three women with post-abortion mania, including two women who underwent a change in diagnosis from bipolar II to bipolar I disorder and another woman who had no prior history of psychiatric disturbance. It is argued that the study of post-abortion mania should provide an opportunity to better understand the aetiology of puerperal mania.

Are antidepressants effective in the treatment of postpartum depression? A systematic review.

OBJECTIVE: In spite of the paucity of randomized controlled trials of antidepressants in postpartum depression, these drugs are the most commonly used agents in the pharmacologic treatment of postpartum depression. This article reviews the literature on the efficacy of antidepressants in randomized controlled trials of postpartum depression. DATA SOURCES: Four electronic databases, MEDLINE/PubMed (1966-2013), PsycINFO (1806-2013), EMBASE (1980-2013), and the Cochrane Database of Systematic Reviews, were searched using a combination of the keywords antidepressive agents/therapeutic use, antidepressant drugs, antidepressant agent/drug therapy, depression, postpartum/drug therapy, postpartum depression, and puerperal depression/drug therapy. STUDY SELECTION: The reference lists of articles identified were also searched. All relevant articles published in English were included. A total of 124 articles were identified. The efficacy of antidepressants has been studied in 6 randomized controlled trials, of which 3 were placebo-controlled studies. RESULTS: Placebo-controlled randomized data do not support the notion that antidepressants are efficacious in postpartum depression. However, the methodological flaws of studies have to be kept in mind while interpreting the results of these studies. CONCLUSIONS: Due to the paucity of controlled data and methodological limitations of studies, the question about the efficacy of antidepressants in postpartum depression cannot be answered unequivocally.