Systematic review finds no good evidence to restrict the freedom of people with mental health problems

Compulsory community treatment (CCT) is a method used in many industrialized nations, including the UK and Australia, that allows clinicians to legally oblige those with severe mental illness to comply with treatment in the community and can allow clinicians to recall them to hospital merely because they are not compliant with an aspect of treatment (as opposed to being demonstrably unwell). What’s the significance? There is questionable evidence that CCT actually does any good, whether in terms of keeping people well, keeping them out of hospital, or reducing the risk of self harm or harm to others. However CCT restricts the rights and freedoms of those with severe mental illness. This recent review sought to bring together evidence from the last decade pertaining specifically to service use.

As a previous study (Churchill et al, 2007) had reviewed evidence up until and including 2005, the subject of this review was to investigate similar evidence pertaining to papers published after this. The reviewers looked at service use outcomes; hospital admission/readmission rates, inpatient days, community service use and medication compliance. This review included all relevant studies (according to their criterion) whatever the quality. One author worked out if studies should be included or not. It is not clear if one person, or two people recorded the data from these studies.

18 relevant studies were identified in this search which reported results from 11 data-sources.

The identified studies were; 1 large trial, nine before and after controlled studies, six uncontrolled before and after studies and two reported epidemiological studies.
The review found one large RCT (the OCTET trial) which was

The reviewers found one large RCT (the OCTET trial) which was carried out by the final author of the review

The large trial (known as OCTET – see the Mental Elf blog here) compared CCT with section 17 leave and was a multi centre trial within the UK (Burns et al, 2013). Community Treatment Orders were compared with Section 17 leave. Section 17 leave occurs when a patient is effectively an inpatient under inpatient compulsory care but is given variable lengths of leave until such a time as it is deemed that voluntary outpatient care can be commenced. Although the study effectively compared two different types of compulsion, the period under compulsion under section 17 leave was considerably shorter than in CCT.

Many of the other papers were derived from two other data sets. Five studies reported on data from Victoria, Australia, and three studies reported on data from New York State, USA.

Admission rates

12 studies reported on admission rates
    The best quality evidence, the trial, demonstrated no significant difference between CCT and section 17 leave in terms of readmission rates
    7 studies suggested a reduction in admission rates with CCT, of these four studies suggested that this reduction is more marked if the supervision lasts for more than 6 months
    4 studies suggested an increase in admission rates with CCT

Inpatient days

This outcome was reported in 13 studies
    7 studies suggest a reduction in inpatient days with CCT
    2 studies suggest an increase in inpatient days with CCT
    3 studies including the best quality evidence, the trial, suggest no difference

Outpatient service use
This review found no good evidence that compulsory community treatment has a positive effect

This review found no good evidence that compulsory community treatment has a positive effect

This outcome was reported in ten studies
    4 of which reported that CCT was associated with greater use
    2 that it was associated with reduced use
    4 studies, comprising three from the Victoria dataset and the trial, found no significant difference


3 studies investigated compliance all of which were from the New York Dataset
    All of which reported increased medication compliance on CCT
    Although interestingly one showed that after discharge of the CCT, compliance rates fell below those who had never been subject to CCT. Compliance rates were not measured directly but by using a proxy measure


There is no good evidence that CCT has a positive effect
The best quality evidence, the trial, demonstrates that there is no positive outcome from the use of supervised community treatment
The evidence from other types of study appears to be equivocal

Limitations of review and summary follows.