Effectiveness of community treatment orders for treatment of schizophrenia with oral or depot antipsychotic medication: changes in problem behaviours and social functioning.

OBJECTIVE: Involuntary outpatient commitment (IOC) has been in use in various countries for a number of years and has recently been implemented (in the form of supervised community treatment) in England and Wales. Several studies indicate that IOC reduces relapse and readmission rates and decreases length of stay on inpatient units in patients diagnosed with schizophrenia. The aim of the present study was to examine whether the use of IOC in the Australian context, in the form of community treatment orders (CTOs), may be associated with a reduction in problem behaviours and improved social functioning. METHOD: A naturalistic retrospective mirror image study of case notes, with each case serving as its own control, was used. Behavioural and social outcomes were examined: episodes of aggression and suicidal and self-harming behaviour, episodes of homelessness, frequency of contact with family members and overall quality of relationship between family and patient, and employment status. RESULTS: Ninety-four sets of case notes were identified as meeting the criteria for inclusion. The number of episodes of aggression was found to be halved from the year before the CTO to the subsequent year (p<0.0001). Significant reductions in the number of episodes of homelessness were experienced by patients (p<0.05) when the pre-CTO year was compared with the CTO year. CONCLUSION: A CTO may contribute to improved outcomes related to patient quality of life. This may be seen to mitigate concerns about infringement of civil rights.

Graduate mental health worker case management of depression in UK primary care: a pilot study.

BACKGROUND: Based on data from large multicentre US trials, the National Institute for Health and Clinical Excellence (NICE) is advocating a stepped-care model for the management of depression, with 'case management' or 'collaborative care' for selected patients in primary care. AIM: To conduct a pilot study examining the use of graduate mental health workers case managing depressed primary care NHS patients. DESIGN OF STUDY: A randomised controlled trial comparing usual GP care with or without case management over 16 weeks of acute antidepressant drug treatment. SETTING: Three primary care practices in the North East of England. METHOD: Patients with depression, aged 18-65 years, who had failed to adequately respond to antidepressant treatment, were randomised to the two treatments. Assessments were made at baseline, 12, and 24 weeks using a combination of observer and self ratings. RESULTS: Randomisation of 62 patients required screening of 1073 potential patients. There was little difference in outcome between the two treatment arms but a gradual improvement in symptoms over time was seen. Client satisfaction was assessed as high across both treatments. CONCLUSION: While this pilot study confirmed the integrity of the study protocol and the suitability of the outcome measures and randomisation procedure, it raises questions regarding the practicality of recruitment and feasibility of the intervention. It would be crucial to address these issues prior to the implementation of a large multi-centre randomised controlled trial.

Effectiveness of community treatment orders for treatment of schizophrenia with oral or depot antipsychotic medication: clinical outcomes.

OBJECTIVE: This study examined the effectiveness of community treatment orders (CTOs) used in the treatment of patients with schizophrenia. The hypotheses were that CTOs enhance outcome for patients whose mental health would otherwise be compromised by poor adherence with treatment and that CTOs would enable this when either oral or depot antipsychotic medication was prescribed. METHOD: This was a naturalistic study using a retrospective mirror-image design. The sample consisted of patients with schizophrenia (n = 94) who were treated on a CTO between November 1996 and October 1999. Two subgroups were defined: patients treated with oral antipsychotic medication (n = 31), and patients treated with depot medication (n = 63). Data were gathered via file review using a questionnaire. RESULTS: For the whole sample and both subgroups the findings included significant increased number of service contacts, decreased number of admissions and decreased length of inpatient stay. For the total sample numbers of crisis team referrals and other episodes of relapse were significantly decreased. For the subgroup on depot medication there was a non-significant trend towards fewer crisis team referrals and a significant decrease in other episodes of relapse. There were no significant differences for the oral subgroup in crisis team referrals or other episodes of relapse. CONCLUSIONS: This study provides further evidence that CTOs may be effective in improving the outcome for selected persons with schizophrenia and some evidence that they may enhance the outcome for selected patients with schizophrenia on oral antipsychotic medication.