***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: 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 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. 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 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 . RESULTS Subjects who were ordered to outpatient commitment were less likely to be criminally victimized than those who were released without outpatient commitment . Multivariate analysis indicated that each additional day of outpatient commitment reduced the risk of criminal victimization and that outpatient commitment had its effect through improved medication adherence , reduced substance use or abuse , and fewer violent incidents . CONCLUSIONS Protection from criminal victimization appears to be a positive , unintended consequence of outpatient commitment OBJECTIVE The goal of this study was to evaluate the effectiveness of involuntary outpatient commitment in reducing rehospitalizations among individuals with severe mental illnesses . METHOD Subjects who were hospitalized involuntarily were r and omly assigned to be released ( N = 135 ) or to continue under outpatient commitment ( N = 129 ) after hospital discharge and followed for 1 year . Each subject received case management services plus additional outpatient treatment . Outpatient treatment and hospital use data were collected . RESULTS In bivariate analyses , the control and outpatient commitment groups did not differ significantly in hospital outcomes . However , subjects who underwent sustained periods of outpatient commitment beyond that of the initial court order had approximately 57 % fewer readmissions and 20 fewer hospital days than control subjects . Sustained outpatient commitment was shown to be particularly effective for individuals with nonaffective psychotic disorders , reducing hospital readmissions approximately 72 % and requiring 28 fewer hospital days . In repeated measures multivariable analyses , the outpatient commitment group had significantly better hospital outcomes , even without considering the total length of court-ordered outpatient commitments . However , in subsequent repeated measures analyses examining the role of outpatient treatment among psychotically disordered individuals , it was also found that sustained outpatient commitment reduced hospital readmissions only when combined with a higher intensity of outpatient treatment . CONCLUSIONS Outpatient commitment can work to reduce hospital readmissions and total hospital days when court orders are sustained and combined with intensive treatment , particularly for individuals with psychotic disorders . This use of outpatient commitment is not a substitute for intensive treatment ; it requires a substantial commitment of treatment re sources to be effective Objective : The objective of this study was to investigate the readmission rate , and the level of patient disturbance and community care associated with readmission following Community Treatment Orders ( CTOs ) in New South Wales , Australia . Method : The readmission rates of all patients given CTOs  within a 4-year period and a matched comparison group were investigated . The following factors were compared before , during and following a CTO : medication non-compliance , number of clinical services and duration of disturbed behaviour preceding hospitalisations . Results : Of 123 patients on CTOs ( mean length , 288 days ; SD , 210 days ) , 38 were readmitted during the CTO , the majority in the first 3 months and a further 21 patients were readmitted following termination of the CTO . Evidence of lower severity of illness in the comparison patients prevented meaningful evaluation of the readmission rates of the two groups . While on CTOs , patients receiving depot medications showed high compliance and a significantly reduced readmission rate compared with that of patients receiving oral medications . In the 2 months prior to hospitalisations during CTOs , compared with those before or after CTOs , patients received more frequent consultations and showed a shorter duration of medication non-compliance and disturbed behaviour . The level of services in the 3 months following discharge were comparable for patients on CTOs and the comparison group . Conclusions : CTOs may reduce rehospitalisations by use of depot medication . Earlier and possibly more frequent readmissions in the CTO group shortened the disturbance associated with illness recurrence . It would appear that to establish a control group with equivalent severity of disorder necessary to evaluate the impact of CTOs requires a r and om allocation design OBJECTIVE The types and amounts of crime experienced by persons with severe mental illness were examined to better underst and criminal victimization in this population . METHODS Subjects were 331 involuntarily admitted psychiatric in patients who were ordered by the court to outpatient commitment after discharge .  Extensive interviews provided information on subjects ' experience with crime in the previous four months and their perceived vulnerability to victimization , as well as on their living conditions and substance use . Medical records provided clinical data . RESULTS The rate of nonviolent criminal victimization  ( 22.4 percent ) was similar to that in the general population ( 21.1 percent ) . The rate of violent criminal victimization was two and a half times greater than in the general population --8.2 percent versus 3.1 percent . Being an urban resident , using alcohol or drugs , having a secondary diagnosis of a personality disorder , and experiencing transient living conditions before hospitalization were significantly associated with being the victim of a crime . In the multivariate analysis , substance use and transient living conditions were strong predictors of criminal victimization ; no demographic or clinical variable was a significant predictor . ( Given the relatively high crime rates , subjects ' perce 
    Output:
    
Compulsory community treatment results in no significant difference in service use , social functioning or quality of life compared with st and ard care .
People receiving compulsory community treatment  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 .