***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: After nearly three decades of studies evaluating the legal practice of involuntary outpatient commitment  , there is yet little consensus about its effectiveness and only limited implementation . Debate continues over how best to assist adults with serious mental illnesses who are unable or unwilling to participate in prescribed community treatment and as a result experience repeated involuntary hospitalizations or involvement with the criminal justice system . The authors comment on the Oxford Community Treatment Order Evaluation Trial ( OCTET ) , a recently conducted r and omized trial of outpatient commitment , and discuss the limitations of the study 's design for resolving the persistent question of whether compulsory treatment is more effective than purely voluntary treatment for this difficult-to-reach target population . The authors conclude that the search for a definitive and generalizable r and omized trial of outpatient commitment may be a quixotic quest ; the field should , rather , welcome the results of well-conducted , large-scale , quasi-experimental and naturalistic studies with rigorous multivariable statistical controls The use of coercion to assure that people with a mental illness receive treatment has been the focus one of the longest running controversies among mental health professionals . Until quite recently , however , this debate has been almost entirely based on abstract principles . Empirical research concerning coercion was quite limited . Recently , however , research in this field has blossomed . The development of a vali date d measure of perceived coercion has spawned a variety of new studies . A five-nation study in Sc and inavia has begun the difficult task of assessing the impact of different legal systems and systems of care on perceived coercion . Two new studies have used r and om assignment design s to study the impact of outpatient commitment . This article review s these and other studies and describes what they do , and do not , tell us about  coercion  in mental health treatment OBJECTIVE Despite the frequent use of the Positive and Negative Syndrome Scale ( PANSS ) for rating the symptoms of schizophrenia , the clinical meaning of its total score and of the cut-offs that are used to define treatment response ( e.g. at least 20 % or 50 % reduction of the baseline score ) are as yet unclear . We therefore compared the PANSS with simultaneous ratings of Clinical Global Impressions ( CGI ) . METHOD PANSS and CGI ratings at baseline ( n = 4091 ) , and after one , two , four and six weeks of treatment taken from a pooled data base of seven pivotal , multi-center antipsychotic drug trials on olanzapine or amisulpride in patients with exacerbations of schizophrenia were compared using equipercentile linking . RESULTS Being considered " mildly ill " according to the CGI approximately corresponded to a PANSS total score of 58 , " moderately ill " to a PANSS of 75 , " markedly ill " to a PANSS of 95 and severely ill to a PANSS of 116 . To be " minimally improved " according to the CGI score was associated with a mean percentage PANSS reduction of 19 % , 23 % , 26 % and 28 % at weeks 1 , 2 , 4 and 6 , respectively . The corresponding figures for a CGI rating " much improved " were 40 % , 45 % , 51 % and 53 % . CONCLUSIONS The results provide a better framework for underst and ing the clinical meaning of the PANSS total score in drug trials of schizophrenia patients with acute exacerbations . Such studies may ideally use at least a 50 % reduction from baseline cut-off to define response rather than lower thresholds . In treatment resistant population s , however , even a small improvement can be important , so that a 25 % cut-off might be appropriate Supervised community treatment to address ' revolving door ' care is part of the new Mental Health Act in Engl and and Wales . Two recent epidemiological studies in Australia ( n>118 000 ) , as well as a systematic review of all previous literature using appropriately matched or r and omised controls ( n=1108 ) , suggest that it is unlikely to help How does society protect some of its most vulnerable and disadvantaged patients while respecting individual autonomy ? This is the dilemma facing many Canadian jurisdictions as they consider the extension of compulsory treatment to community setting s. Canada is not unique but part of a trend to enforce  outpatient treatment  in many jurisdictions , including Australia , New Zeal and , the United States , and the European Union ( 1,2 ) . What is the basis for this enthusiasm ? Certainly , research published in this journal has endorsed the measure to varying degrees ( 3 ) , as does the position paper of the Canadian Psychiatric Association ( 4 ) . We wonder whether this confidence is misplaced , and we critically examine several troubling aspects of the literature on CTOs . Opinion Is Not Evidence One approach to the evaluation of  CTOs  has been to ask practising psychiatrists for their opinion on the utility of the orders ( 3 ) . These suggest general support for the measure . However , surveys of psychiatrists ' views on CTOs provide only Level 3 evidence , in contrast to the Level 1 evidence from appropriately conducted RCTs and the Level 2 evidence from well- design ed non- RCT studies , such as case-control studies or interrupted time series . Such surveys have little place in an era of evidence -based practice and , in the absence of other data , would not be accepted as a reason to introduce any other psychiatric intervention . No Controls , Little Evidence Early uncontrolled studies , largely from the United States , suggested that patients on CTOs had reduced rates of rehospitalization and shorter stays in hospital , associated with increased compliance . However , there were no significant differences between the 2 groups when control subjects not subject to a compulsory treatment order were included ( 5 - 7 ) . The weakness of uncontrolled design s is the difficulty in determining the reason for any change in outcome . Aside from the effect of the intervention , other possible explanations include regression to the mean , other treatment , life events , or changes in social circumstances . These often overestimate the effect of the intervention of interest . Controlled studies without r and omization also have shortcomings . There may always be another reason why patients were placed on treatment and the control subjects were not . They may be less insightful about their illness or more likely to have a history of aggressive behaviour . Only one matched control study controlled for forensic history ( 7 ) . What About RCTs ? RCTs address many of these problems but are very difficult to conduct where mental health legislation policy is implemented at a state , provincial , or national level . There have therefore only been 2 RCTs , and both were in the United States ( New York and North Carolina ) ( 8 - 11 ) . These trials have been the subject of much debate in terms of subjects , design , analysis , and generalizability . Selection and Follow-Up Bias : Were the Patients Typical ? Both RCTs excluded patients with a history of violence from r and omization . Although underst and able from an ethical and legal st and point , this limits their applicability because recent dangerousness , particularly violence against others , is often the reason for compulsory treatment in hospital or in the community . One study did include a nonr and omized violent subgroup in the analysis , but this negates the whole point of an RCT ( see below ) ( 9 - 11 ) . Selection bias was further compounded by high dropout rates . Of the 577 patients identified as eligible for participation in the New York and North Carolina studies , including the violent subgroup , only 292 ( 51 % ) were followed up 1 year later . Although the North Carolina study had a higher completion rate among r and omized patients than the New York study ( 82 % and 45 % , respectively ) , data were not available for all patients for all of the outcomes . The 1 -year follow-up is therefore of a highly selected and potentially unrepresentative population that was not dangerous and was sufficiently compliant to participate in baseline and follow-up assessment s. Aims and method Community treatment orders ( CTOs ) were introduced in Scotl and in 2005 , but are controversial owing to a lack of supportive r and omised evidence . The non-r and omised studies provide mixed results on their efficacy and utility . We aim ed to examine hospital bed day usage across Scotl and both before and after CTOs were initiated in a national cohort of patients , spanning 5 years . Results In total , 1558 individuals who were subject to a CTO between 2007 and 2012 , of whom 63 % were male , were included . After CTO initiation the number of hospital bed days fell , on average , from 66 to 39 per annum per patient . Those with a longer psychiatric history appeared to benefit more from a CTO , in terms of reduced time in hospital . Clinical implication s Our data offer cautious support for the use of CTOs in routine practice , in terms of reducing time spent in psychiatric hospital . This finding is balanced by the more rigorous r and omised studies which do not find any benefit to CTOs Background : Supervised Discharge Orders ( SDOs ) were introduced in 1995 , as an amendment to the Mental Health Act in Engl and and Wales . They require patients to abide by specific conditions on discharge from hospital , but can not enforce medication compliance . On introduction , SDOs were received with scepticism by the psychiatric profession . The purpose of this study was to describe the use of  SDOs  in Engl and and the characteristics of patients made subject to these orders , and to evaluate the effectiveness of the order in securing treatment compliance on discharge from hospital . Method : A survey was conducted of 170 mental health provider Trusts in Engl and . Interviews with senior managers in 12 Trusts and associated Local Authorities were subjected to qualitative analysis , and a cohort of patients subject to SDOs  in 56 r and omly sample d Trusts was described . Results : SDOs were being used for 596 patients ( 1.2 per 100,000 total population ) at the survey date in 1999 , and use had been increasing steadily since its introduction . The order is not systematic ally considered for all potential cases . The majority of the 182 patients in the cohort had complied , if sometimes intermittently , with conditions of the order . Conclusions : For patients compliant with SDOs , the pressures necessary to treat effectively need not involve powers to enforce medication compliance This study examines self-reported coercion in subjects with severe mental illness who were r and omly assigned in an experimental study to continue under , or be released from , involuntary outpatient commitment ( OPC ) subsequent to hospital discharge . After review of bivariate relationships , multivariable analyses demonstrated significantly higher levels of reported coercion among subjects who experienced longer periods of OPC ; who were African American ; who were single and not cohabiting ; and who had ongoing substance abuse problems , poor insight into illness , and severe symptoms . Case managers ' verbal reminders to subjects about the consequences of nonadherence to treatment partially account for higher reports of coercion . Previous reports from this study have found that OPC , if sustained and combined with frequent outpatient mental health services , can improve some outcomes . The current analyses demonstrate that a consequence of OPC is increased perceptions of coercion in the treatment process , which is partially explained by the increased attention by case managers to noncompliance with treatment PURPOSE The study evaluated whether seclusion and coercive incidents would be reduced in extent and number if involuntary medication was the first choice of intervention . Patients admitted to an acute psychiatric ward were r and omly allocated to two groups . In Group 1 , involuntary medication was the intervention of first choice for dealing with agitation and risk of violence . In Group 2 , seclusion was the intervention of first choice . Patients ' characteristics between the groups were compared by Pearson χ(2 ) and two- sample t-tests ; the incidence rates and risk ratios ( RRs ) were calculated to examine differences in number and duration of coercive incidents . In Group 1 , the relative risk of being secluded was lower than in Group 2 , whereas the risk of receiving involuntary medication was higher . However , the mean duration of the seclusion incidents did not differ significantly between the two groups ; neither did the total number of coercive incidents . Although the use of involuntary medication could successfully replace and reduce the number of seclusions , alternative interventions are needed to reduce the overall number and duration of coercive incidents . A new policy for managing acute aggression - such as involuntary medication - can be implemented effectively only if certain conditions are met The authors estimated components of variance and intraclass correlation coefficients ( ICCs ) to aid in the design of complex surveys and community intervention studies by analyzing data from the Health Survey for Engl and 1994 . This cross-sectional survey of English adults included data on a range of lifestyle risk factors and health outcomes . For the survey , households were sample d in 720 postal code sectors nested within 177 district health authorities and 14 regional health authorities . Study subjects were adults aged 16 years or more .  ICCs and components of variance were estimated from a nested r and om-effects analysis of variance . Results are presented at the district health authority , postal code sector , and household levels . Between-cluster variation was evident at each level of clustering . In these data , ICCs were inversely related to cluster size , but design effects could be substantial when the cluster size was large . Most ICCs were below 0.01 at the district health authority level , and they were mostly below 0.05 at the postal code sector level . At the household level , many ICCs were in the range of 0.0 - 0.3 . These data may provide useful information for the design of epidemiologic studies in which the units sample d or allocated range in size from households to large administrative areas OBJECTIVE The authors ' goal was to evaluate the effectiveness of outpatient commitment in reducing victimization among people with severe mental illness . METHOD One hundred eighty-four involuntarily hospitalized patients were r and omly assigned to be released ( N=99 ) or to continue under outpatient commitment ( N=85 ) after hospital discharge . An additional group of patients with a recent history of serious violent behavior ( N=39 ) was nonr and omly assigned to at least a brief period of outpatient commitment following hospital disharge . All three groups were followed for 1 year , and case management services plus additional outpatient treatment were provided to all subjects . Outcome data were based on interviews with the patients and informants as well as service records 
    Output:
    
CCT results in no significant difference in service use , social functioning or quality of life compared with st and ard 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 .