Community treatment order (CTO) use in Australia and New Zealand ranges from less than 40 per 100 000 population in Western Australia and Canterbury to over 100 per 100 000 in Victoria, South Australia and Waitemata. Recent publications on CTO use now permit a meta-regression to investigate whether differences in CTO use by jurisdiction affect either the possible predictors or outcomes of CTOs.

To assess whether factors associated with CTO placement or subsequent outcomes vary by rates of use.

A systematic search of PubMed/Medline, Embase, CINAHL, the Cochrane Central Register of Controlled Trials and PsycINFO for any Australian or New Zealand study comparing CTO cases with controls receiving voluntary psychiatric treatment. This study was prospectively registered with PROSPERO (protocol registration number: CRD42022351500).

There were 35 articles from 16 studies identified in the search, plus unpublished data from a further study. Of these, 29 publications were included in meta-analyses. Two were from New Zealand. People who were male, single and not engaged in work, study or home duties were significantly more likely to be on CTOs. In addition, those from migrant backgrounds were 47% more likely to be on an order. On meta-regression, cases in jurisdictions with higher CTO rates had higher proportions of females or individuals with diagnoses other than non-affective psychoses. High-use jurisdictions were also less likely to show reductions in readmission rates or bed-days.

There are marked differences in the possible predictors and outcomes of CTO placement between high- and low-use jurisdictions in Australia and New Zealand. These findings may have implications elsewhere and indicate that better-targeted CTO placement might improve outcomes.

In 2017, a capacity-based criterion was added to the Norwegian Mental Health Act, stating that those with capacity to consent to treatment cannot be subjected to involuntary care unless there is risk to themselves or others. This was expected to reduce incidence and prevalence rates, and the duration of episodes of involuntary care, in particular regarding community treatment orders (CTOs).

The aim was to investigate whether the capacity-based criterion had the expected impact on the use of CTOs.

This retrospective case register study included two catchment areas serving 16% of the Norwegian population (aged ≥18). In total, 760 patients subject to 921 CTOs between 1 January 2015 and 31 December 2019 were included to compare the use of CTOs 2 years before and 2 years after the legal reform.

CTO incidence rates and duration did not change after the reform, whereas prevalence rates were significantly reduced. This was explained by a sharp increase in termination of CTOs in the year of the reform, after which it reduced and settled on a slightly higher leven than before the reform. We found an unexpected significant increase in the use of involuntary treatment orders for patients on CTOs after the reform.

The expected impact on CTO use of introducing a capacity-based criterion in the Norwegian Mental Health Act was not confirmed by our study. Given the existing challenges related to defining and assessing decision-making capacity, studies examining the validity of capacity assessments and their impact on the use of coercion in clinical practice are urgently needed.

Community treatment orders (CTOs) enable patients to be treated in the community rather than under detention in hospital. Population-based studies of suicide among patients subject to a CTO are scarce.

To compare suicide rates among patients subject to a CTO with all discharged psychiatric patients and those detained for treatment but not subject to a CTO at discharge (‘CTO-eligible’ patients).

From a national case series of patients who died by suicide within 12 months of contact with mental health services in England during 2009–2018, we estimated average annual suicide rates for all discharged patients, those on a CTO at the time of suicide, those ever treated under a CTO and CTO-eligible patients.

Suicide rates for patients on a CTO at the time of suicide (191.3 per 100 000 patients) were lower than all discharged patients (482.3 per 100 000 discharges). Suicide rates were similar in those ever treated under a CTO (350.1 per 100 000 CTOs issued) and in CTO-eligible patients (382.9 per 100 000 discharges). Suicide rates within 12 months of discharge were higher in persons ever under a CTO (205.1 per 100 000 CTOs issued) than CTO-eligible patients (161.5 per 100 000 discharges), but this difference was reversed for rates after 12 months of discharge (153.2 per 100 000 CTOs issued v. 223.4 per 100 000 discharges).

CTOs may be effective in reducing suicide risk. The relative benefits of CTOs and intensive aftercare may be time-dependent, with the benefit of a CTO being less before 12 months after discharge but greater thereafter. CTO utilisation requires a careful balancing of patient safety versus autonomy.

Outpatient civil commitment (OCC) provisions, community treatment orders (CTOs) in Australia and Commonwealth nations, are part of mental health law worldwide.

This study considers whether and by what means OCC provides statutorily required “needed-treatment” addressing two aspects of its legal mandate to protect the safety of self (exclusive of deliberate-self-harm) and others.

Over a 12.4-year period, records of hospitalized-psychiatric-patients, 11,424 with CTO-assignment and 16,161 without CTO-assignment were linked to police-records. Imminent-safety-threats included perpetrations and victimizations by homicides, rapes, assaults/abductions, and robberies. “Need for treatment” determinations were validated independently by Health of the Nations Scale (HoNOS) severity-score-profiles. Logistic regressions, with propensity-score- adjustment and control for 46 potential confounding-factors, were used to evaluate the association of CTO-assignment with occurrence-risk of perpetrations and victimizations.

CTO-assignment was associated with reduced safety-risk: 17% in initial-perpetrations, 11% in initial-victimizations, and 22% for repeat-perpetrations. Each ten-community-treatment-days in interaction with CTO-assignment was associated with a 3.4% reduced-perpetration-risk. CTO-initiated-re-hospitalization was associated with a 13% reduced-initial-perpetration-risk, a 17% reduced-initial-victimization-risk, and a 22% reduced-repeat-victimization-risk. All risk-estimates appear to be the unique contributions of the CTO, CTO-initiated-re-hospitalization, or the provision of ten-community-treatment-days—i.e. after accounting for the influence of prior crimes and victimizations, ethnic-bias, neighborhood disadvantage and other between-group differences in the analysis.

CTO assignment’s association with reduced criminal-victimization and perpetration-risk, in conjunction with requiring participation in needed-treatment via re-hospitalization and community-service, adds support to the conclusion that OCC is to some extent fulfilling its legal objectives related to protecting safety of self (exclusive of deliberate-self-harm), and others.