What is already known on this topic?

The use of coercion in the treatment of psychiatric patients is of growing concern, particularly in the context of United Nations Convention on the Rights of Persons with Disabilities (http://www.un.org/disabilities/convention/conventionfull.shtml). Increasing rates of compulsory admission are one example. It is therefore important to find interventions that can prevent compulsory admission to hospital for people with severe mental illness. Approaches to reduce compulsory admission such as advance directives or compulsory treatment orders have been studied in isolation.1 ,2

What this study adds

• This is the first study to evaluate the effect of all interventions designed to reduce compulsory admission.

• Studies on the following four interventions were identified, all of which could be included in a meta-analysis: community treatment orders (CTOs) (n=3), compliance enhancement (n=2), integrated treatment for the augmentation of standard care (n=4) and advance directives (n=4).

• Advance directives were the only intervention that had a statistically significant effect achieving a 23% reduction in admissions at 12–18-month follow-up (relative risk (RR) 0.77, 95% CI 0.60 to 0.98).

• Integrative treatments showed promise with a 29% in compulsory admissions, although this did not reach statistical significance (RR 0.71, 0.49–1.02).

• Other more coercive interventions did not reduce subsequent admission to hospital. These were CTOs (0.95, 0.81 to 1.10) and compliance enhancement (0.52, 0.11 to 2.37).

Limitations

• Only 13 studies were identified and follow-up was limited to between 6 and 18 months. There was evidence of moderate to substantial statistical heterogeneity in two out of the four interventions (I²=55.7% and 49.0%, respectively), as well as clinical heterogeneity in the integrated treatment subgroup where there was variability in the interventions and patient population. In addition, only four studies reported on the number of compulsory admissions expressed as a continuous variable, as opposed to just their dichotomised occurrence in terms of admitted patients. The results were non-significant (RR 0.76, 0.54 to 1.06) with considerable heterogeneity (I²=87.6%).

• In spite of the stated aims, the three studies of CTOs measured psychiatric admissions overall, not just compulsory admissions. The outcomes for these studies may not therefore be comparable to those of the other interventions and the specific effect on compulsory admission remains unknown.

• Study quality was not optimal with the risk of bias being either unclear or high for most criteria. Therefore, for some studies, the possibility of selection bias cannot be excluded.

What next in research

Traditional approaches to conducting RCTs may need to be modified when conducting studies in this area. This might include obtaining informed consent after randomisation so as to reduce selection bias. A greater understanding of how interventions work and predictors of success is also required.3

Do these results change your practices and why?

Yes. These findings suggest an increased role in the use of advance statements in clinical practice and their utility in reducing subsequent compulsory hospitalisation. Holistic interventions such as advance statements and integrated treatment may be more effective than those such as CTOs and compliance enhancement with a narrower, and possibly coercive, focus.3 The involvement of patients in planning their future treatment may, in particular, reduce compulsory admissions to hospital.4 However, it is also possible that the increase in involuntary admissions in most developed countries could be due to other factors that were not considered in this paper such as the decreasing availability of psychiatric beds.