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.

The most recent legal regulations in the Republic of Croatia govern the process of criminal procedure for persons in pre-trial detention who have a temporary mental disturbance for which psychiatric treatment is needed. The Prison Director is in this case obliged to seek psychiatric treatment for such persons who are then hospitalized in a psychiatric institution instead of a prison hospital or prison that meets the requirements prescribed by law for the accommodation of pre-trial detainees. Forensic departments of the five psychiatric hospitals in Croatia accept mentally incapable persons subject to court order, but not persons in custody, i.e. in pre-trial detention. Pre-trial detention is a measure imposed in the previous proceedings to ensure that the person to whom the measure is imposed is present during the pre-trial stage and the hearing stage, i.e. after the final judgment has been rendered until it becomes final. According to Croatian laws, a person who has been sentenced to pre-trial detention and who has mental disorders is entitled to a range of rights that must be respected, and at the same time, there are strict restrictions in exercising those same rights for the reason of sentencing to pre-trial detention.

The article points to several problems that have arisen in practice due to the under-regulation of pre-trial detention measures.

Perspective, opinion, and commentary article.

Perspective, opinion, and commentary article.

The authors discuss legal, medical, and ethical issues, but also the financial framework of such a process.

Schedule II of the 2013 Mental Health Act is part of the legal framework for involuntary admission to a licensed mental healthcare facility in Malta (Mount Carmel Hospital) for observation.

To identify trends in presenting features cited by registered specialists in psychiatry in Schedule II applications as well as impact of time of day on involuntary admission.

Schedule II forms relating to all involuntary admissions to Mount Carmel Hospital between 01 June 2018 and 01 June 2019 were retrieved from paper files (n=364). Details relating to reason for using this legal framework were recorded and processed through custom linguistic analysis. Timings of application were also assessed. Data Protection permissions to retrospectively access patient files were obtained. All data collected was de-identified at source.

The commonest reason for use of Schedule II was psychosis (n=139). Substance abuse was recorded in 68 cases, with alcohol and cannabinoids the commonest substances cited. 155 instances relate to situations of increased risk, the commonest being aggressive behaviour (n=74). 61 cases recorded suicidal intent. Peak use of this schedule occurs between 17:00 and 18:00, which is outside normal working hours.

Predominance of psychosis as a reason for involuntary admission concurs with trends reported internationally, including recent German, Irish and Dutch reports, as does increased use of involuntary admission with out-of-hours presentations. Practices relating to involuntary admission to a mental healthcare facility in Malta appear to reflect general trends in other European cohorts, despite differing legal frameworks.

In March 2020, the UK government ordered mental health services to free up bed space to help manage the COVID-19 pandemic. This meant service users detained under the Mental Health Act were discharged at a higher rate than normal. We analysed whether this decision compromised the safety of this vulnerable group of service users.

We utilised a cohort study design and allocated service users to either the pre-rapid discharge, rapid discharge or post-rapid discharge group. We conducted a recurrent event analysis to assess group differences in the risk of experiencing negative outcomes during the 61 days post-discharge. We defined negative outcomes as crisis service use, re-admission to a psychiatric ward, community incidents of violence or self-harm and death by suicide.

The pre-rapid discharge cohort included 258 service users, the rapid discharge cohort 127 and the post-rapid discharge cohort 76. We found no statistical association between being in the rapid discharge cohort and the risk of experiencing negative outcomes (HR: 1.14, 95% CI: 0.72–1.8, p = 0.58) but a trend towards statistical significance for service users in the post-rapid discharge cohort (HR: 1.61, 95% CI: 0.91–2.83, p = 0.1).

We did not find evidence that service users rapidly discharged from section experienced poorer outcomes. This raises the possibility that the Mental Health Act is applied in an overly restrictive manner, meaning that sections for some formally detained service users could be ended earlier without compromising safety.

Black, Asian and minority ethnicity groups may experience better health outcomes when living in areas of high own-group ethnic density – the so-called ‘ethnic density’ hypothesis. We tested this hypothesis for the treatment outcome of compulsory admission.

Data from the 2010–2011 Mental Health Minimum Dataset (N = 1 053 617) was linked to the 2011 Census and 2010 Index of Multiple Deprivation. Own-group ethnic density was calculated by dividing the number of residents per ethnic group for each lower layer super output area (LSOA) in the Census by the LSOA total population. Multilevel modelling estimated the effect of own-group ethnic density on the risk of compulsory admission by ethnic group (White British, White other, Black, Asian and mixed), accounting for patient characteristics (age and gender), area-level deprivation and population density.

Asian and White British patients experienced a reduced risk of compulsory admission when living in the areas of high own-group ethnic density [odds ratios (OR) 0.97, 95% credible interval (CI) 0.95–0.99 and 0.94, 95% CI 0.93–0.95, respectively], whereas White minority patients were at increased risk when living in neighbourhoods of higher own-group ethnic concentration (OR 1.18, 95% CI 1.11–1.26). Higher levels of own-group ethnic density were associated with an increased risk of compulsory admission for mixed-ethnicity patients, but only when deprivation and population density were excluded from the model. Neighbourhood-level concentration of own-group ethnicity for Black patients did not influence the risk of compulsory admission.

We found only minimal support for the ethnic density hypothesis for the treatment outcome of compulsory admission to under the Mental Health Act.

The steep rise in the rate of psychiatric hospital detentions in England is poorly understood.

To identify explanations for the rise in detentions in England since 1983; to test their plausibility and support from evidence; to develop an explanatory model for the rise in detentions.

Hypotheses to explain the rise in detentions were identified from previous literature and stakeholder consultation. We explored associations between national indicators for potential explanatory variables and detention rates in an ecological study. Relevant research was scoped and the plausibility of each hypothesis was rated. Finally, a logic model was developed to illustrate likely contributory factors and pathways to the increase in detentions.

Seventeen hypotheses related to social, service, legal and data-quality factors. Hypotheses supported by available evidence were: changes in legal approaches to patients without decision-making capacity but not actively objecting to admission; demographic changes; increasing psychiatric morbidity. Reductions in the availability or quality of community mental health services and changes in police practice may have contributed to the rise in detentions. Hypothesised factors not supported by evidence were: changes in community crisis care, compulsory community treatment and prescribing practice. Evidence was ambiguous or lacking for other explanations, including the impact of austerity measures and reductions in National Health Service in-patient bed numbers.

Better data are needed about the characteristics and service contexts of those detained. Our logic model highlights likely contributory factors to the rise in detentions in England, priorities for future research and potential policy targets for reducing detentions.