Title: Coercion in mental health. Patterns and prevalence of coercion in mental health care and a trial of the effectiveness and costs of Supervised Community Treatment orders
Funder: Department of Health (England)

Abstract: Aims and objectives To obtain a detailed understanding of the coercion, both legal and informal, experienced by mental health service users and test the of the effectiveness of the Supervised Community Treatment Orders (SCTs) to be introduced in 2008. There are four overarching objectives: 1.Examine the experiences of coercion (‘leverage’) in four distinct cliinical populations. 2.Explore the ethical, practical and legal constraints on study methodologies to test the efficacy of SCTs. 3.Conduct the most rigorous study possible (see 2) of SCTs. 4. Develop and disseminate a training package for best practice in SCTs. Background Compulsion in MH is increasing (1), new service structures do not reduce it (2) and it extends beyond legal restrictions (3;4). Legislation will introduce SCTs in 2008 targeting ‘revolving door patients’, not as an alternative to good quality community care but a component of it (5). International research on SCTs (various terms are used) is inconclusive. The most influential study (6) found no overall differences but significant benefits for patients who received ‘adequate care’ (contact X1 per week) and were maintained on SCTs over 6 months. This group accurately reflects the current proposals for SCTs in E&W. Rates of use vary widely internationally and UK projections even more so(7). Research plans Leverages study (years 1-2) Four distinct samples (psychosis patients in Assertive Outreach (AO) Teams, psychosis and non-psychosis patients in Community Mental Health (CMHT) care and Substance Abuse patients) will be interviewed on experiences of 5 leverages (housing, finance, child care, criminal justice and MHA) in the preceding year. The MacArthur Leverage semi-structured interview (4) has been adapted and successfully piloted in Oxford. Types and degree of leverage will be tested for association with patient and treatment characteristics. Qualitative interviews with staff will explore attitudes to leverage and contribute to the SCT training programme outlined below. SCT study (years 1-5) Preparation comprises two work programmes: i) (Year 1) A series of meetings with clinicians, legal, policy and ethical groups by CM & TH to carry out a detailed investigation of ethical, legal and practical issues of methodologies to test the impact of SCTs. The aim is to obtain agreement and support on the strongest test of the intervention producing a detailed study brief. ii) (years 1 & 2) Developing and piloting a staff SCT training pack using senior clinicians in existing good practice networks. Potential SCT recipients will contribute both as participants and as trainers. It will produce a manual and a programme of workshops. The effectiveness trial (years 2-5). An RCT is proposed (dependent on phase one). 200 patients currently admitted under section 3 of the 1983 MHA will be randomised equally to ‘SCT’ or ‘non SCT’ care. Patients must be judged appropriate for SCT by their clinicians and not subject to other legal restrictions. Assessments are by independent research interview and examination of casenotes at baseline (randomisation) and 6 and 12 months. Outcomes include hospitalisation (including time to initial discharge), MHA use, recall, and patterns of care. Patient and treatment characteristics associated with successful outcomes will be sought. Qualitative interviews will explore experiences broadly and a detailed economic analysis will model the national costs of introducing SCTs. Research team Burns HSR and trials; Morgan coercion and ethnic minorities; Sinclair and Priebe HSR and qualitative methods; Gray health economics; Hope medical ethics; Firn assertive outreach and MH policy; Doll statistics; McLaughlin NHS management. The team is advised by John Dawson (Prof. of Law Otago, NZ) and John Monahan (director of the MacArthur Network, Virginia, USA). Research environment The Trust and University Department of Psychiatry aim to establish a Research and Training Resource centre to consolidate their extensive activities. This is included in the Foundation Trust Estate Strategy proposal and NIHR programme staff will be accommodated in this dedicated resource centre. Estimates of accommodation costs per person per year are based on these proposals. Anticipated outputs Detailed interim and final reports to the funders, publications in peer-review scientific and professional journals plus presentations at relevant conferences. Training materials (e.g. seminars, booklets, website) and best practice guidelines will be developed and extensively disseminated. Public involvement The preparation for the trial involves an extensive consultation with the public. User groups have been extensively involved in piloting the leverage interview and service users will be involved in the development and delivery of the training materials?


Research activity codes: 8.3 POLICY, ETHICS AND RESEARCH GOVERNANCE
Health categories: MENTAL HEALTH