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| British Journal of Psychiatry | Advances in Psychiatric Treatment | All RCPsych Journals |
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Department of Clinical Psychology, University of Leeds, 15 Hyde Terrace, Leeds LS2 9JT
Institute of Psychiatry, De Crespigny Park, London SE5 8AF; tel.: 020 78480714; fax: 020 72771462
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Abstract |
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 Top Abstract IntroductionMethodResultsCommentsReferences |
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Supervised discharge orders (SDOs) enable a degree of compulsion to be exerted over patients in the community. We aimed to establish the level of, and reasons for, their use and consultants' perceptions of their effectiveness. All mental health provider NHS trusts in England were surveyed, and a random sample cohort of cases was identified. Community responsible medical officers (CRMOs) were surveyed using a semi-structured questionnaire.
RESULTS
We identified 596 cases subject to SDOs in 170 mental health provider trusts (100%) in England, involving 18% of consultant psychiatrists. Responses were obtained from the CRMOs of 185 patients (84%) from a sample of 221 cases. The SDO was described as helpful or very helpful in 77% of cases in which it had been in place for over 2 months. In 58% of cases the SDO was intended to improve medication compliance, and in 46% of these cases it was perceived to be effective in doing so.
CLINICAL IMPLICATIONS
SDOs are not widely used in England. However, for those patients who are made subject to supervised discharge, the order appears to be effective and may improve medication compliance, despite the absence of the legal power to enforce treatment.
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Introduction |
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TopAbstractIntroductionMethodResultsCommentsReferences |
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The experiences of clinicians using supervised discharge may provide a guide to the way in which they would use the proposed new powers. As part of a larger study of the use of supervised discharge and guardianship, we surveyed a representative sample of psychiatrists acting as community responsible medical officers (CRMOs) for patients on supervised discharge. We aimed to establish (a) why the CRMO used supervised discharge in each case, and (b) whether the CRMO felt that the SDO had been of benefit for the patient and for the clinical team.
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Method |
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A cohort of patients subject to SDOs was identified by taking a random sample of 80 of the 178 mental health trusts in England in 1998. The 1998 survey figures suggested that this number of trusts could be expected to yield 120 prevalent cases. Ethical and management approval was obtained at trusts with cases (n=56), Mental Health Act administrators were contacted and a total of 132 prevalent cases were identified. Telephone contact with each trust on a monthly basis (October 1998 to June 1999) identified 89 new cases, which were included in a total cohort of 221 cases under the care of 133 CRMOs. Each CRMO was sent a 10-item semi-structured questionnaire to provide data on why supervised discharge was chosen as a management option with each patient and the CRMO's perception of its effectiveness.
Basic content analysis (Weber, 1985) was carried out on qualitative responses from the CRMO questionnaires, using the themes identified by Pinfold et al (1999) as a basis for exploring the data. The data were coded by two members of the research team independently, and inconsistencies were discussed before the data were recoded using the final emergent schema (Mays & Pope, 1995). The coded data were exported into MicroSoft Excel for descriptive statistical analysis. Perceived effectiveness was analysed only on orders that had been in place for over 2 months (n=152).
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Results |
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TopAbstractIntroductionMethodResultsCommentsReferences |
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Why is supervised discharge used?
Of the 133 CRMOs responsible for patients in the cohort, 122 (92%) returned
questionnaires relating to 185 patients (108 prevalent and 77 incident cases).
Seventy-six of the respondents (62%) returned a questionnaire on a single case
subject to the order, 37 (30%) returned two, 5 (4%) returned three, 2 (2%)
returned four and 2 (2%) returned six.
Table 2 shows the results of
the thematic analysis of CRMOs' reasons for choosing to use SDOs.
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The reasons given for the use of supervised discharge relate closely to statutory criteria for using SDOs: the presence of a mental disorder, identified risk factors; and a belief on the part of the applicant that without the imposition of the order patients would not receive after-care. However, the stated reasons also indicate the desire to control aspects of patients' lives in the community. In 58% of cases, supervised discharge was used in an attempt to improve medication compliance, despite not having the statutory power to enforce medication compliance directly. A judgement about the patient's likely response to the order also contributes to the decision to use it: 10% of cases were placed on supervised discharge because the CRMO felt that the patient would respect the authority of the order. In one example (a patient with Asperger's syndrome and a psychotic illness) the CRMO recorded:
"He is consistently uncooperative with voluntary mental health care, but very compliant when on the order. The sheer fact of being on a legal order makes him comply."
Effectiveness of supervised discharge
Responses to the question "How helpful has the current SDO been in
managing this client?" were analysed only in respect to the 152 cases
that had been subject to the order for more than 2 months when the
questionnaire was completed because an impression of the effectiveness of the
order after a shorter time was felt to be of limited value. In 117 (77%) of
these cases the CRMO considered the SDO to have been a helpful or very helpful
measure in managing the patient. Fifteen (10%) felt it was not very helpful or
very unhelpful and the remaining 20 (13%) were unsure. Fifteen CRMOs who
described the order as helpful in an individual case were, however,
unsupportive of the measure more generally. For example, one stated:
"Generally, I remain of the opinion that the legislation is fundamentally flawed, being excessively bureaucratic and crucially lacking the power to impose treatment... It may well be true that there are small groups (of vulnerable dependent patients, perhaps) who may benefit from supervised discharge."
Effectiveness for improving medication compliance
The CRMOs were also asked to describe the ways in which supervised
discharge had been helpful. As shown in
Table 2, many reported that
they had used SDOs in the hope of improving patients' medication compliance.
In 84 such cases, where the patient had been on the order for more than 2
months, the CRMO perceived that it had been instrumental in improving
compliance in 40 (46%) individuals. In an additional 22 cases, where
medication compliance was not given as a reason for use, it was described as a
way in which the order had been helpful. In a total of 62 (41%) cases,
medication compliance was described as having been positively influenced by
the use of supervised discharge.
Effectiveness for improving engagement with services
The CRMOs reported that they had used supervised discharge in the hope of
improving engagement with services in 54 (29%) cases (see
Table 2). In 35 of these cases,
where the patient had been on the order for more than 2 months, the CRMO
reported that 18 (51%) did indeed show better engagement. In an additional 78
(42%) cases where improved engagement was not given as a reason for use, it
was described as a way in which the order had been helpful. In a total of 96
(63%) cases engagement was described as having been positively influenced by
the use of supervised discharge.
Effectiveness of monitoring patients in the community
Forty patients (22%) were placed on SDOs in an effort to ensure that their
health and social functioning were regularly monitored
(Table 2). In 36 of these
cases, where the patient had been on the order for longer than 2 months, the
monitoring function of supervised discharge had been effective for 17
(47%).
In an additional 29 (19%) cases, where monitoring of the patient was not stated as a reason for use, the order did improve the clinical team's monitoring of the patient. In a total of 46 (30%) cases, improvement in accessing the patient was observed.
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Comments |
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TopAbstractIntroductionMethodResultsCommentsReferences |
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Limitations
The study had high response rates, and the views of CRMOs were obtained on
a representative sample of almost one-third of all patients subject to SDOs in
England. The principal limitation of the study is that the sample is biased
towards cases that remained on SDOs long enough to be identified by the study;
cases that were of short duration, owing to the order's apparent
ineffectiveness or to readmission to hospital, may not have been identified.
The study is also limited by its use of professional opinion as a proxy for a
measure of effectiveness. Trauer and Sacks
(1998) report high levels of
concordance between mental health professionals in ratings of medication
compliance of patients, but levels between clinicians and clients were
significantly lower, and CRMOs' reports of supervised discharge being
effective in helping compliance with medication may only be partly
reliable.
Relationship with other studies
Evaluation of regional studies on supervised discharge have focused on
rates of use and initial experiences of CRMOs since its introduction in 1996
(Knight et al, 1998;
Davies et al, 1999).
Although descriptions of patients subject to the order, and attitudes of
consultants in particular areas, have been reported, this is the first
national study to seek views on perceived effectiveness of the SDO in the care
of individual patients. The use of supervised discharge by CRMOs to improve
medication compliance, despite this not being part of the statutory criteria
for use of the order, has been noted previously by Knight et al
(1998). They have suggested
that CRMOs could be using the SDO much as a compulsory treatment order,
despite the limited powers of compulsion that the SDO allows.
Policy implications
Although it is clear that supervised discharge can be of value in the care
of some individuals, they are a select group, who may be identified by their
willingness to comply with treatment when it is offered within a legal
framework and to accept treatments despite the inability of the law to compel
them to do so. Supervised discharge was introduced in response to political
priorities (Eastman, 1995), and
this may have contributed to the failure of the majority of consultant
psychiatrists to make use of it and to a level of use far less than the 3000
cases originally anticipated (Department of
Health, 1993). Professional opinion on whether further legislation
to compel acceptance of community treatment is necessary remains divided
(Burns, 1999;
Moncrieff & Smyth, 1999). If future legislation lacks credibility with clinicians, it may not be widely
used.
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Acknowledgments |
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References |
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TopAbstractIntroductionMethodResultsCommentsReferences |
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DAVIES, S., BRUCE, J. & FALLOWS, S. (1999) Section 25 Aftercare under supervision: the first eighteen months' experience. Medicine, Science and the Law, 39, 214-218.
DEPARTMENT OF HEALTH (1993) Legal Powers on the Care of Mentally Ill People in the Community. Report of the Internal Review. London: Department of Health.
DEPARTMENT OF HEALTH (1999) Reform of the Mental Health Act 1983: Proposals for Consultation. Cm 4480. London: Stationery Office.
EASTMAN, N. (1995) Anti-therapeutic community mental
health law. British Medical Journal,
310,
1081-1082.
KNIGHT, A., MUMFORD, D. & NICHOL, B. (1998)
Supervised discharge order: the first year in the South and West Region.
Psychiatric Bulletin,
22,
418-420.
MAYS, N. & POPE, C. (1995) Rigour and qualitative
research. British Medical Journal,
311,
109-112.
MONCRIEFF, J. & SMYTH, M. (1999) Community
treatment orders: a bridge too far? Psychiatric
Bulletin, 23,
644-646.
PINFOLD, V., BINDMAN, J., FRIEDLI, K., et al (1999) Supervised discharge orders in England: compulsory care in the community. Psychiatric Bulletin, 23, 199-203.
TRAUER, T. & SACKS, T. (1998) Medication compliance: a comparison of the views of severely mentally ill clients in the community, their doctors and their case managers. Journal of Mental Health, 7, 621-629.[CrossRef]
WEBER, R. P. (1985) Basic Content Analysis: Quantitative Applications in the Social Sciences (no. 49). London: Sage Publications.
This article has been cited by other articles:
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S. Davies Compulsory treatment in the community: current legal powers Advan. Psychiatr. Treat., May 1, 2002; 8(3): 180 - 188. [Full Text] [PDF]
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 T. Burns Supervised discharge orders Psychiatr. Bull., November 1, 2000; 24(11): 401 - 402. [Full Text]
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| British Journal of Psychiatry | Advances in Psychiatric Treatment | All RCPsych Journals |
See pp. 401-402, this issue. 