East Asian Arch Psychiatry 2023;33:35-6 | https://doi.org/10.12809/eaap2332
Editorial
Are Community Treatment Orders Needed to Improve Community Mental Healthcare for People with Mental Illnesses?
The Global Burden of Disease Study examining data from 204 countries and territories from 1990 to 2019 found that the proportion of global disability-adjusted life years attributed to mental disorders increased from 3.1% to 4.9% during this period.1 Since the start of the COVID-19 pandemic in 2020, numerous studies have emphasised the increased mental health needs in society because of the direct impact of the pandemic, lockdowns and/or other restrictions,2 and the associated economic concerns.3 Therefore, provision of mental health services that fit the changing needs of a population is of paramount importance.
Since the deinstitutionalisation movement in the 1950s, there have been significant developments in community mental health services both internationally and locally. One example is the implementation of Integrated Community Centres for Mental Wellness (ICCMWs) in Hong Kong in 2010 to strengthen community support for people with mental illnesses. The funding for ICCMWs increased from HK$135 million in 2010 to HK$303 million in 2016-2017, which indicates increased government expenditure on the services.4 A recent study evaluating the effect of ICCMWs on emergency psychiatric admissions using population-based data covering a 20-year period found that ICCMWs reduced hospital admissions in females, younger populations (age 18-44 years), and people with neurosis, but not in males, older populations, and people with schizophrenia or bipolar affective disorders.5 This highlights the need for improvement in the existing community mental healthcare provision for particular populations. This includes the enhancement of case management programmes for patients with severe mental health disorders and the introduction of community treatment orders (CTOs), either in tandem with or in place of the existing conditional discharge regime. The conditional discharge regime is a form of mandatory outpatient treatment that is currently used in Hong Kong. Its scope is limited to individuals with a medical history of criminal violence or a disposition to commit such violence who can be safely discharged from compulsory treatment in hospital subject to specified conditions (see section 42B of the Mental Health Ordinance, Cap 136). Because of controversies associated with implementing CTOs in Hong Kong (including the possibility of increasing the stigma of mental illness, potential far-reaching implications for civil liberties, and inconsistent results in terms of their effectiveness in reducing psychiatric admissions and readmissions), the Review Committee of the Hong Kong Mental Health Review Report, published in 2017, was unable to conclude that the benefits of introducing CTOs would sufficiently outweigh the curtailment of civil liberties, or that the occurrence of tragic incidents involving patients with mental illness would be reduced as a result.4
In this issue of the East Asian Archives of Psychiatry, Lam et al6 conducted a systematic review and meta-analysis of the effectiveness of CTOs on mental health service usage, emergency service visits, and episodes of violence. They reviewed 16 case-control or pre-post studies. The meta- analysis of the case-control studies found no significant effect of CTOs on the amount of contact with service providers and the number of emergency visits. However, meta-analysis of the pre-post studies found significant beneficial effects of CTOs in reducing the amount of contact with service providers, the number of emergency visits, and episodes of violence. The study provides preliminary evidence of the more comprehensive clinical benefits of CTOs. However, it should be noted that only two pre-post studies were included in the meta-analysis of results on violence reduction. Furthermore, the pre-post studies had small sample sizes and high heterogeneity. The pre-post design has a limitation, in which effects found at the post-intervention timepoint cannot be necessarily attributed to the intervention itself, as there are no controls to rule out other confounding factors. Additionally, it is difficult to conclude that the beneficial effects observed require the coercion that characterises CTOs, and instead may be simply due to the additional contact with service providers received because of the CTO, which could be achieved via other means without coercion. The follow-up periods of the included studies were generally short, most in the region of 1 year. Thus, it is difficult to determine the long-term effects of CTOs based on these studies. Finally, the outcome measures of CTOs in existing studies mostly focus on clinical benefits, rather than the potential negative impacts of increased stigma related to mental illnesses and difficulties associated with restrictions of liberty.7 Therefore, further studies and evidence on the comprehensive effects of CTOs are needed to facilitate discussions among service providers, policymakers, and service users.
Contributors
Both authors drafted the manuscript, approved the final version for publication, and take responsibility for its accuracy and integrity.
Conflicts of Interest
Both authors have disclosed no conflicts of interest.
Sherry Kit Wa Chan
Department of Psychiatry, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
Daisy Cheung
Centre for Medical Ethics and Law, The University of Hong Kong, Hong Kong SAR, China
Address for correspondence: Dr Sherry Kit Wa Chan, Department of Psychiatry, The University of Hong, Hong Kong SAR, China. Email: kwsherry@hku.hk
References
- GBD 2019 Mental Disorders Collaborators. Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Psychiatry 2022;9:137-50. Crossref
- Cheung D, Ip EC. COVID-19 lockdowns: a public mental health ethics perspective. Asian Bioeth Rev 2020;12:503-10. Crossref
- Wu T, Jia X, Shi H, et al. Prevalence of mental health problems during the COVID-19 pandemic: a systematic review and meta-analysis. J Affect Disord 2021;281:91-8. Crossref
- Food and Health Bureau, Hong Kong SAR Government. Mental Health Review Report. Available from: https://www.healthbureau.gov.hk/download/press_and_publications/otherinfo/180500_mhr/e_mhr_full_report.pdf.
- Ma CF, Luo H, Leung SF, et al. Impact of community mental health services on the adult psychiatric admission through the emergency unit: a 20-year population-based study. Lancet Reg Health West Pac 2023;100814. Crossref
- Lam EHY, Lai ESK, Lai ECL, et al. Effect of community treatment order on mental health service usage, emergency visits, and violence: a systematic review and meta-analysis. East Asian Arch Psychiatry 2023;33:37-43. Crossref
- Cheung D. Control in the community: a qualitative analysis of the experience of persons on conditional discharge in Hong Kong. Int J Law Psychiatry 2022;82:101791. Crossref