How shortcomings in the mental health system affect the use of involuntary community treatment orders

Objective: 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 consisting of semi-structured interviews about CTO experiences with 38 purposively selected participants in New South Wales, Australia: 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: that CTOs are used to increase access to services, and that CTOs cannot remedy non-existent or inadequate services. Discussion: These findings 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), and about the utility of CTOs, justifications for CTO use, and the legal criteria regulating CTO implementation. Key questions summary 1. 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 community treatment orders (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. 2. What does this paper add? This paper provides an empirical basis for a link between the politics of mental health and the uptake and utility of CTOs. 3. 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 policymakers need to be candid about system limitations and how they factor in clinical and legal justifications for using involuntary treatment. These results provide data to support advocacy to improve policy accountability and resourcing of community mental health services