Introduction

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Enforcing psychiatric treatment in the community has become a feature in Australia, New Zealand, the United Kingdom, and the United States.^1-3 In the United States more than half the states have some form of compulsory community treatment,² and in Australasia similar provisions exist in Victoria, Western Australia, New South Wales, and New Zealand.^3-5 Initiatives in the United Kingdom have included extended leave for patients leaving hospital and the supervision register. ^{6 7} The recent white paper Reforming the Mental Health Act contains provisions for compulsory treatment in the community.⁸ Studies indicating limited but improved outcomes in terms of readmission to hospital, length of stay, and adherence to treatment have often not controlled for selection bias, variations in treatment, and differing criteria for compulsory treatment in the community.³

The new Mental Health Act of Western Australia, implemented in 1997, includes the provision of involuntary treatment in the community through the introduction of a community treatment order. The aim of our study was to compare the rate of inpatient admissions, bed days, and outpatient contacts of patients one year before and one year after placement on a community treatment order.

	Methods

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We compared data for subjects placed on a community treatment order with those for a matched control group and then entered them into a multiple regression equation to examine variables predicting the use of health services after placement on an order. The purpose was to identify similar patients not placed on an order as matched controls and examine whether keeping patient characteristics constant could contribute to similar outcomes for inpatient admissions, bed days, and outpatient contacts in the year before the index date.

The Mental Health Information System was linked to a database administered by the Mental Health Review Board in terms of involuntary admissions under the Mental Health Act. This enabled us to include all patients who had been made subject to a community treatment order for the entire state of Western Australia.

	Results

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	Discussion

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Limitations of the study
Although the matching process allowed selection of controls with similar characteristics to the patients placed on community treatment orders, significant differences in prior outpatient contacts and inpatient bed days existed. This meant that these variables had to be included in the regression models to control for their effects. Controlling for variables, however, may not be sufficient, and additional confounders may be present. For example, it was not possible to control for variables such as social disability or dangerousness with the available database. Patients placed on an order may have greater degrees of dangerousness or social disability. These factors, in turn, may effect subsequent use of health services.

Both groups showed a reduction in inpatient bed days, suggesting a regression to the mean in that patients with high rates of use will have lower rates of subsequent use. The finding that this effect was seen equally in both groups may indicate that the groups were similar. The regression results for within pair differences in inpatient admissions or bed days, and their covariates, also showed the similarity of the two groups. In addition, the design permitted a before and after comparison of subjects and controls.

Are community treatment orders effective?
This study provides mixed results. Although orders reduce admission rates and bed days, the effect is no greater than that seen in a group of patients who are not on such an order, after adjustment for possible confounders. The study therefore raises questions about the effectiveness of such an invasive procedure as enforcing treatment in the community. If efficacy is in part defined by reduced hospital admissions and length of stay, our results suggest that the policy is no more effective than not enforcing community treatment. Our results are consistent with previous studies of community treatment orders, which showed no significant improvements in outcome compared with matched controls, ^{10 11} but not with findings from England and Massachusetts, where patients on "extended leave" or involuntary outpatient treatment spent less time in hospital than did matched controls. ^{6 11} Possible explanations might be differing selection criteria and the fact that only age, sex, and diagnosis were controlled for in the design of both these studies. On the other hand, the British study included an assessment of dangerousness that was not recorded in the Western Australia Mental Health Information System.

This study examines only whether community treatment orders reduce immediate use of health services, as this has been the main reason for their introduction and hence the focus of previous research into their effectiveness.⁶ Such orders may reduce use of health services in the longer term or produce benefits in other areas, such as psychosocial functioning.

Some researchers have called for randomised assignment of patients to community treatment orders as a way of measuring the efficacy within a quasi-experimental paradigm,¹² but this can be logistically difficult if the order is tied to statutory legislation. An alternative would be to compare patients from jurisdictions with and without community treatment orders and matched on sociodemographic, clinical, and health service characteristics.

This study shows that legislative solutions such as community treatment orders may not always offer a solution to the need to provide appropriate services for psychiatric patients within limited resources. It is important to examine what role such orders have in providing effective mental health treatment and whether therapeutic gains could be better delivered by enhancing the quality and assertiveness of community treatment for high risk patients.