title: How shortcomings in the mental health system affect the use of involuntary community treatment orders.
abstract: Objective The aim of the present study was to examine stakeholder perspectives on how the operation of the mental health system affects the use of involuntary community treatment orders (CTOs). Methods A qualitative study was performed, consisting of semi-structured interviews about CTO experiences with 38 purposively selected participants in New South Wales (NSW), Australia. Participants included mental health consumers (n=5), carers (n=6), clinicians (n=15) and members of the Mental Health Review Tribunal of NSW (n=12). Data were analysed using established qualitative methodologies. Results Analysis of participant accounts about CTOs and their role within the mental health system identified two key themes, namely that: (1) CTOs are used to increase access to services; and (2) CTOs cannot remedy non-existent or inadequate services. Conclusion The findings of the present study indicate that deficiencies in health service structures and resourcing are a significant factor in CTO use. This raises questions about policy accountability for mental health services (both voluntary and involuntary), as well as about the usefulness of CTOs, justifications for CTO use and the legal criteria regulating CTO implementation. What is known about this topic? Following the deinstitutionalisation of psychiatric services over recent decades, community settings are increasingly the focus for the delivery of mental health services to people living with severe and persistent mental illnesses. The rates of use of involuntary treatment in Australian community settings (under CTOs) vary between state and territory jurisdictions and are high by world standards; however, the reasons for variation in rates of CTO use are not well understood. What does this paper add? This paper provides an empirical basis for a link between the politics of mental health and the uptake and usefulness of CTOs. What are the implications for practitioners? This paper makes explicit the real-world demands on the mental health system and how service deficiencies are a significant determinant in the use of CTOs. Practitioners and policy makers need to be candid about system limitations and how they factor in clinical and legal justifications for using involuntary treatment. The results of the present study provide data to support advocacy to improve policy accountability and resourcing of community mental health services.
authors.affiliation: Centre for Values, Ethics and the Law in Medicine, Level 1, Medical Foundation Building (K25), University of Sydney, NSW 2006, Australia. Email:.
authors.forename: Edwina M
authors.initials: EM
authors.lastname: Light
authors.affiliation: Centre for Values, Ethics and the Law in Medicine, Level 1, Medical Foundation Building (K25), University of Sydney, NSW 2006, Australia. Email:.
authors.forename: Michael D
authors.initials: MD
authors.lastname: Robertson
authors.affiliation: Discipline of Psychiatry, Westmead Hospital (C24), PO Box 533, Wentworthville, NSW 2145, Australia. Email:.
authors.forename: Philip
authors.initials: P
authors.lastname: Boyce
authors.affiliation: Sydney Law School (F10), University of Sydney, NSW 2006, Australia. Email.
authors.forename: Terry
authors.initials: T
authors.lastname: Carney
authors.affiliation: Illawarra Institute of Mental Health (Bldg 22), University of Wollongong, NSW 2522, Australia.
authors.forename: Alan
authors.initials: A
authors.lastname: Rosen
authors.affiliation: School of Health Sciences, Faculty of Health, University of Tasmania (Rozelle Campus, Sydney), Locked Bag 5052, Alexandria NSW 2015, Australia. Email.
authors.forename: Michelle
authors.initials: M
authors.lastname: Cleary
authors.affiliation: Discipline of Psychiatry, Concord Hospital (C22), University of Sydney, NSW 2139, Australia. Email.
authors.forename: Glenn E
authors.initials: GE
authors.lastname: Hunt
authors.affiliation: North Shore Ryde Mental Health Service, 2C Herbert St, St Leonards, NSW 2065, Australia. Email.
authors.forename: Nick
authors.initials: N
authors.lastname: O'Connor
authors.affiliation: Centre for Values, Ethics and the Law in Medicine, Level 1, Medical Foundation Building (K25), University of Sydney, NSW 2006, Australia. Email:.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Ryan
authors.affiliation: Centre for Values, Ethics and the Law in Medicine, Level 1, Medical Foundation Building (K25), University of Sydney, NSW 2006, Australia. Email:.
authors.forename: Ian H
authors.initials: IH
authors.lastname: Kerridge
mesh_terms: D000328:Adult; D003156:Community Mental Health Services / Q000458:organization & administration*; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D007407:Interviews as Topic; D000074441:Involuntary Treatment; D008297:Male; D001523:Mental Disorders / Q000628:therapy*; D009517:New South Wales; D036301:Qualitative Research