Compulsory treatment in patients' homes in the Netherlands: what do mental health professionals think of this?

BACKGROUND: Compulsory treatment in patients' homes (CTH) will be introduced in the new Dutch mental health legislation. The aim of this study is to identify the opinions of mental health workers in the Netherlands on compulsory community treatment (CCT), and particularly on compulsory treatment in the patients' home. METHODS: This is a mixed methods study, comprising a semi-structured interview and a survey. Forty mental health workers took part in the semi-structured interview about CCT and 20 of them, working in outpatient services, also completed a questionnaire about CTH. Descriptive analyses were performed of indicated (dis) advantages and problems of CCT and of mean scores on the CTH questionnaire. RESULTS: Overall, the mental health workers seemed to have positive opinions on CCT. With respect to CTH, all mean scores were in the middle of the range, possibly indicating that clinicians were uncertain regarding safety issues and potential practical problems accompanying the use of CTH. CONCLUSIONS: The majority of the participating mental health workers in this study had a positive attitude towards CCT, but they seemed relative uncertain about potential possibilities and problems of working with CTH.

Community treatment orders: clinical and social outcomes, and a subgroup analysis from the OCTET RCT.

OBJECTIVE: Despite widespread use internationally, there is no convincing evidence that community treatment orders (CTO) (legal regimes making out-patient treatment compulsory), reduce readmission rates or have wider patient benefit. The primary and secondary outcomes of the Oxford Community Treatment Order Evaluation Trial (OCTET) (hospitalisation) showed no benefit. This article will, first, test the effect of community compulsion on wider clinical and social outcomes and on patients' experiences of services and the use of treatment pressure and second, explore differential effects in different groups of patients. METHOD: OCTET is a RCT of CTO effectiveness. Three hundred and thirty-six patients were randomised and data for the 333 eligible patients were collected from interviews and medical records at baseline, 6 and 12 months. RESULTS: There was no significant difference at 12 months between the two arms in any of the reported outcomes, except a small difference in patients' view of the effectiveness of treatment pressure, which is unlikely to be clinically meaningful. Two statistically significant interactions were found in the subgroup analysis: symptoms interacted with age and with education, but no pattern was demonstrated. CONCLUSION: CTOs do not have benefit on any of the tested outcomes, or for any subgroup of patients. Their continued use should be carefully reconsidered.

Lawfulness of a randomised trial of the new community treatment order regime for England and Wales.

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.

Anxious adults vs. cool children: children's views on smoking and addiction.

Tobacco addiction represents a major public health problem, and most addicted smokers take up the habit during adolescence. We need to know why. With the aim of gaining a better understanding of the meanings smoking and tobacco addiction hold for young people, 85 focused interviews were conducted with adolescent children from economically deprived areas of Northern Ireland. Through adopting a qualitative approach within the community rather than the school context, the adolescent children were given the opportunity to freely express their views in confidence. Children seem to differentiate conceptually between child smoking and adult smoking. Whereas adults smoke to cope with life and are thus perceived by children as lacking control over their consumption, child smoking is motivated by attempts to achieve the status of cool and hard, and to gain group membership. Adults have personal reasons for smoking, while child smoking is profoundly social. Adults are perceived as dependent on nicotine, and addiction is at the core of the children's understanding of adult smoking. Child smoking, on the other hand, is seen as oriented around social relations so that addiction is less relevant. These ideas leave young people vulnerable to nicotine addiction. It is clearly important that health promotion efforts seek to understand and take into account the actions of children within the context of their own world-view to secure their health.

Smoking and symbolism: children, communication and cigarettes.

Health promotion, with its concern with empowerment and autonomy, must recognize the agency of its target population. Based on 85 in-depth interviews with 10- to 11-year-old children throughout Northern Ireland, this paper argues that it is necessary to focus on the social relations of children if we are to understand and prevent childhood smoking. Addressing the complex issue of childhood agency, it is argued that regardless of various restrictions to their choices, children can act intentionally in constructing their identities. Instead of viewing the smoking children as communicating with the adult world, we focus on smoking as negotiation of status within the children's culture. Such negotiations utilize symbolism derived from and shared with the 'adult world'. It is important that those analyzing children's lives understand children's ideas and behaviour on their own terms. We must make sure that the very concepts in which the children's experiences are put are appropriate ones. It is suggested that the metaphor 'rite of passage' and terminology such as peer 'pressure' versus adult 'influence', commonly used to analyse the children's smoking behaviour, may actually conceal important aspects of childhood agency.