A treatment programme for people with mental illness that legally requires adherence.
Focus of the intervention
Compulsory community treatment (CCT) is a community-based approach that makes adherence to treatment a legal requirement for individuals with mental illness. This includes ensuring that participants adhere to their medication regime and undergo additional levels of therapy decided by a judicial court. CCT gives mental health professionals and judges the right to return a person to a hospital against their will if they do not comply with treatment.
This narrative is based on one systematic review, including a meta-analysis, covering three studies. The review primarily focuses on health outcomes, however, participants’ interaction with police was also measured in two studies. The two primary studies which had outcomes relating to police contact were conducted in the USA.
Effect – how effective is it?
There is no evidence to suggest that CCT has had a statistically significant impact on likelihood of being arrested.
A meta-analysis of the two primary studies – that had either arrest or involvement with police following violence against a person as an outcome measure – found compulsory community treatment had no statistically significant effect on being arrested.
Both studies found this effect within 11 to 12 months post-intervention compared to the control groups who received voluntary care.
Additional analysis from one primary study found that participants who received CCT compared to control groups who received voluntary care were statistically significantly less likely to have been the victim of either a violent or non-violent crime within 11 to 12 months post-intervention.
Mechanism – how does it work?
CCT is assumed to reduce contact with the police by:
- participants adhering to their medication regimes for enough time to allow sufficient stability to develop in their lives
- a person being more likely to agree to follow up with clinicians and taking the recommended treatment when these requirements are legally enforced
- clinical services feeling obliged to engage or prioritise people on CCT because of the legal order
However, information was not available from the primary studies to test whether these mechanisms were responsible for the outcome patterns observed.
Moderators – in which contexts does it work best?
The review noted that CCT programmes are likely to differ depending on the country or place of implementation. CCT is regulated by law and therefore certain judicial aspects, such as eligibility criteria, may differ by country or region.
For example, the majority of studies included in the review were based in the USA where the power to administer medication forcibly in a community setting differs between states. However, this difference was not tested within the review.
Implementation – what can be said about implementing this initiative?
The review gave no account of how the intervention was implemented, nor of any implementation challenges encountered by the primary studies.
Economic considerations – how much might it cost?
The review did not mention the costs or benefits of CCT, and no formal economic analysis was provided.
General considerations
- The majority of the evidence was based in the USA so caution should be taken when applying the information to the UK.
- The evidence is primarily based on a meta-analysis of the two primary studies that had police contact outcomes. One study measured one-time arrest and the second combined arrest or police involvement (which did not lead to an arrest) for violence against a person.
- People with a history of violence were explicitly excluded from the trials so the results do not necessarily apply to that group.
Summary
There is no evidence to suggest that CCT has had a statistically significant impact on likelihood of being arrested.
The review authors noted that people who received CCT were no more likely to be arrested than people who did not receive the intervention. They also noted that people allocated to CCT were no more likely to commit a violent act than people who were not allocated the intervention.
However, the review authors did note that participants who received CCT were significantly less likely to have been victimised (been a victim once or more of either violent or non-violent crime) than people who were not allocated the intervention. All of these changes were observed within 11 to 12 months post-intervention.
The evidence is drawn from a small sample size of two studies and should be interpreted with caution. Additional evidence is required to identify potential mechanisms that make CCT work, and the moderating influence of implementing the programme in different jurisdictions. Further studies are also needed to examine the implementation issues surrounding CCT and associated costs/benefits.
Reviews
Review one
Reference
Kisely, S.R., Campbell, L.A., O’Reilly, R. (2017). Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Cochrane Database of Systematic Reviews 2017, Issue 3.
Summary prepared by
This narrative was prepared by UCL Jill Dando Institute and the College of Policing and was co-funded by the College of Policing and the Economic and Social Research Council (ESRC). ESRC grant title: 'University Consortium for Evidence-Based Crime Reduction'. Grant reference: ES/L007223/1.