title: Pressures to adhere to treatment ('leverage') in English mental healthcare.
abstract: BACKGROUND
  Coercion has usually been equated with legal detention. Non-statutory pressures to adhere to treatment, 'leverage', have been identified as widespread in US public mental healthcare. It is not clear if this is so outside the USA.
  
  
  OBJECTIVE
  To measure rates of different non-statutory pressures in distinct clinical populations in England, to test their associations with patient characteristics and compare them with US rates.
  
  
  METHODS
  Data were collected by a structured interview conducted by independent researchers supplemented by data extraction from case notes.
  
  
  RESULTS
  We recruited a sample of 417 participants from four differing clinical populations. Lifetime experience of leverage was reported in 35% of the sample, 63% in substance misusers, 33% and 30% in the psychosis samples and 15% in the non-psychosis sample. Leverage was associated with repeated hospitalisations, substance misuse diagnosis and lower insight as measured by the Insight and Treatment Attitudes Questionnaire. Housing leverage was the most frequent form (24%). Levels were markedly lower than those reported in the USA.
  
  
  CONCLUSIONS
  Non-statutory pressure to adhere to treatment (leverage) is common in English mental healthcare but has received little clinical or research attention. Urgent attention is needed to understand its variation and place in community practice.
authors.affiliation: Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK. tom.burns@psych.ox.ac.uk
authors.forename: Tom
authors.initials: T
authors.lastname: Burns
authors.forename: Ksenija
authors.initials: K
authors.lastname: Yeeles
authors.forename: Andrew
authors.initials: A
authors.lastname: Molodynski
authors.forename: Helen
authors.initials: H
authors.lastname: Nightingale
authors.forename: Maria
authors.initials: M
authors.lastname: Vazquez-Montes
authors.forename: Kathleen
authors.initials: K
authors.lastname: Sheehan
authors.forename: Louise
authors.initials: L
authors.lastname: Linsell
mesh_terms: D000328:Adult; D002648:Child; D003068:Coercion; D003156:Community Mental Health Services / Q000379:methods / Q000706:statistics & numerical data*; D003431:Cross-Cultural Comparison; D003430:Cross-Sectional Studies; D004739:England; D005260:Female; D006556:Heroin Dependence / Q000453:epidemiology / Q000523:psychology / Q000534:rehabilitation; D006798:Housing; D006801:Humans; D008297:Male; D001523:Mental Disorders / Q000453:epidemiology / Q000523:psychology / Q000628:therapy*; D010349:Patient Compliance; D011569:Psychiatric Status Rating Scales; D011618:Psychotic Disorders / Q000453:epidemiology / Q000523:psychology / Q000628:therapy; D013223:Statistics as Topic; D011795:Surveys and Questionnaires; D014481:United States