Kisely Steve R, Campbell Leslie A
School of Medicine, The University of Queensland, Princess Alexandra Hospital, Ipswich Road Woolloongabba, Queensland, QLD 4102, Australia.
Cochrane Database Syst Rev. 2014(12):CD004408. doi: 10.1002/14651858.CD004408.pub4. Epub 2014 Dec 4.
There is controversy as to whether compulsory community treatment (CCT) for people with severe mental illness (SMI) reduces health service use, or improves clinical outcome and social functioning.
To examine the effectiveness of CCT for people with SMI.
We searched the Cochrane Schizophrenia Group's Trials Register and Science Citation Index (2003, 2008, and 2012). We obtained all references of identified studies and contacted authors where necessary. We further updated this search on the 8 November 2013.
All relevant randomised controlled clinical trials (RCTs) of CCT compared with standard care for people with SMI (mainly schizophrenia and schizophrenia-like disorders, bipolar disorder, or depression with psychotic features). Standard care could be voluntary treatment in the community or another pre-existing form of compulsory community treatment such as supervised discharge.
Review authors independently selected studies, assessed their quality and extracted data. We used The Cochrane Collaboration's tool for assessing risk of bias. For binary outcomes, we calculated a fixed-effect risk ratio (RR), its 95% confidence interval (CI) and, where possible, the weighted number needed to treat statistic (NNT). For continuous outcomes, we calculated a fixed-effect mean difference (MD) and its 95% CI. We used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to create a 'Summary of findings' table for outcomes we rated as important and assessed the risk of bias of included studies.
All studies (n=3) involved patients in community settings who were followed up over 12 months (n = 752 participants).Two RCTs from the USA (total n = 416) compared court-ordered 'Outpatient Commitment' (OPC) with voluntary community treatment. OPC did not result in significant differences compared to voluntary treatment in any of the main outcome indices: health service use (2 RCTs, n = 416, RR for readmission to hospital by 11-12 months 0.98 CI 0.79 to 1.21, low grade evidence); social functioning (2 RCTs, n = 416, RR for arrested at least once by 11-12 months 0.97 CI 0.62 to 1.52, low grade evidence); mental state; quality of life (2 RCTs, n = 416, RR for homelessness 0.67 CI 0.39 to 1.15, low grade evidence) or satisfaction with care (2 RCTs, n = 416, RR for perceived coercion 1.36 CI 0.97 to 1.89, low grade evidence). However, risk of victimisation decreased with OPC (1 RCT, n = 264, RR 0.50 CI 0.31 to 0.80). Other than perceived coercion, no adverse outcomes were reported. In terms of numbers needed to treat (NNT), it would take 85 OPC orders to prevent one readmission, 27 to prevent one episode of homelessness and 238 to prevent one arrest. The NNT for the reduction of victimisation was lower at six (CI 6 to 6.5).One further RCT compared community treatment orders (CTOs) with less intensive supervised discharge in England and found no difference between the two for either the main outcome of readmission (1 RCT, n = 333, RR for readmission to hospital by 12 months 0.99 CI 0.74 to 1.32, medium grade evidence), or any of the secondary outcomes including social functioning and mental state. It was not possible to calculate the NNT. The English study met three out of the seven criteria of The Cochrane Collaboration's tool for assessing risk of bias, the others only one, the majority being rated unclear.
AUTHORS' CONCLUSIONS: CCT results in no significant difference in service use, social functioning or quality of life compared with standard voluntary care. People receiving CCT were, however, less likely to be victims of violent or non-violent crime. It is unclear whether this benefit is due to the intensity of treatment or its compulsory nature. Short periods of conditional leave may be as effective (or non-effective) as formal compulsory treatment in the community. Evaluation of a wide range of outcomes should be considered when this legislation is introduced. However, conclusions are based on three relatively small trials, with high or unclear risk of blinding bias, and evidence we rated as low to medium quality.
对于严重精神疾病患者实施强制社区治疗（CCT）是否能减少医疗服务使用，或改善临床结局及社会功能，存在争议。
研究CCT对严重精神疾病患者的有效性。
我们检索了Cochrane精神分裂症研究组试验注册库和科学引文索引（2003年、2008年和2012年）。我们获取了已识别研究的所有参考文献，并在必要时联系了作者。我们于2013年11月8日进一步更新了此检索。
所有将CCT与严重精神疾病患者的标准治疗（主要为精神分裂症及类精神分裂症障碍、双相情感障碍或伴有精神病性特征的抑郁症）进行比较的相关随机对照临床试验（RCT）。标准治疗可以是社区中的自愿治疗或另一种现有的强制社区治疗形式，如监督出院。
综述作者独立选择研究、评估其质量并提取数据。我们使用Cochrane协作网的偏倚风险评估工具。对于二分法结局，我们计算固定效应风险比（RR）、其95%置信区间（CI），并在可能的情况下计算加权治疗所需人数统计量（NNT）。对于连续性结局，我们计算固定效应平均差（MD）及其95%CI。我们使用GRADE（推荐分级评估、制定与评价）方法为我们认为重要的结局创建一个“结果总结”表，并评估纳入研究的偏倚风险。
所有研究（n = 3）均纳入社区环境中的患者，并进行了12个月的随访（n = 752名参与者）。美国的两项RCT（共n = 416）比较了法庭命令的“门诊强制治疗”（OPC）与社区自愿治疗。在任何主要结局指标方面，OPC与自愿治疗相比均未产生显著差异：医疗服务使用（2项RCT，n = 416，11至12个月再次住院的RR为0.98，CI为0.79至1.21，低质量证据）；社会功能（2项RCT，n = 416，11至12个月至少被捕一次的RR为0.97，CI为0.62至1.52，低质量证据）；精神状态；生活质量（2项RCT，n = 416，无家可归的RR为0.67，CI为0.39至1.15，低质量证据）或对治疗的满意度（2项RCT，n = 416，感觉受到强制的RR为1.36，CI为0.97至1.89，低质量证据）。然而，OPC使受侵害风险降低（1项RCT，n = 264，RR为0.50，CI为0.31至0.80）。除感觉受到强制外，未报告其他不良结局。就治疗所需人数（NNT）而言，需要85项OPC命令才能预防一次再次住院，27项预防一次无家可归事件，238项预防一次被捕。降低受侵害风险的NNT较低，为6（CI为6至6.5）。另一项RCT在英国比较了社区治疗令（CTO）与强度较低的监督出院，发现两者在再次住院这一主要结局（1项RCT，n = 333，12个月再次住院的RR为0.99，CI为0.74至1.32，中等质量证据）或任何次要结局（包括社会功能和精神状态）方面均无差异。无法计算NNT。英国的这项研究符合Cochrane协作网偏倚风险评估工具的七项标准中的三项，其他研究仅符合一项，大多数被评为不清楚。
与标准自愿治疗相比，CCT在服务使用、社会功能或生活质量方面未产生显著差异。然而，接受CCT的人成为暴力或非暴力犯罪受害者的可能性较小。尚不清楚这种益处是由于治疗强度还是其强制性。短期的有条件休假在社区中可能与正式的强制治疗一样有效（或无效）。在引入这项立法时，应考虑对广泛结局进行评估。然而，结论基于三项相对较小的试验，存在高或不清楚的盲法偏倚风险，且我们将证据质量评为低至中等。
