Tom Patrick Burns

University of Oxford | OX · Department of Psychiatry

PurposeCurrent RCT and meta-analyses have not found any effect of community treatment orders (CTOs) on hospital or social outcomes. Assumed positive impacts of CTOs on quality-of-life outcomes and reduced hospital costs are potentially in conflict with patient autonomy. Therefore, an analysis of the cost and quality-of-life consequences of CTOs was...

Objective: The triple bottom line (TBL) of sustainability is an important emerging conceptual framework which considers the combined economic, environmental and social impacts of an activity. Despite its clear relevance to the healthcare context, it has not yet been applied to the evaluation of a healthcare intervention. The aim of this study was...

Abstract Background Patient reported outcome measures (PROMs) are widely used in mental healthcare research for quality of life assessment but most fail to capture the breadth of health and non-health domains that can be impacted. We report the psychometric validation of a novel, multi-dimensional instrument based on Amartya Sen’s capability approa...

Purpose: Community treatment orders (CTOs) are widely used internationally despite a lack of evidence supporting their effectiveness. Most effectiveness studies are relatively short (12-months or less) and focus on clinical symptoms and service data, while a little attention is given to patients' social outcomes and broader welfare. We tested the...

Background Most studies investigating the effectiveness of Community Treatment Orders (CTOs) use readmission to hospital as the primary outcome. Another aim of introducing CTOs was to improve continuity of care. Our study was a 3-year prospective follow-up which tested for associations between CTOs and continuity of care. Methods Our study sample i...

Purpose: Community Treatment Orders lack evidence of effectiveness. Very little is known about how they are used in practice and over time in terms of what it obliges patients to do and the judicial threshold for remaining on an order. Aims: To investigate CTO implementation in England in terms of the use of specified conditions, and judicial he...

Background: Coercion comprises formal coercion or compulsion [treatment under a section of the Mental Health Act (MHA)] and informal coercion (a range of treatment pressures, including leverage). Community compulsion was introduced in England and Wales as community treatment orders (CTOs) in 2008, despite equivocal evidence of effectiveness. Little...

Aims: A pilot randomized controlled trial (RCT) to assess the feasibility and potential efficacy of assertive community treatment (ACT) in adults with alcohol dependence. Methods: Single blind, individually randomized, pilot RCT of 12 months of ACT plus treatment as usual (TAU) versus TAU alone in adults (age 18+ years) with alcohol dependence and...

Purpose: Providing good continuity of care to patients is considered a vital component of community mental health services, but there is limited evidence that it is associated with good outcomes. We measured service use and a multidimensional concept of continuity of care in 323 patients who were to be discharged from hospital following compulsory...

Background Randomised studies consistently show that Community Treatment Orders (CTOs) do not have the intended effect of preventing relapse and readmissions of patients with severe and enduring mental illness. Critics suggest this in part can be explained by RCTs studying newly introduced CTO regimes and that patients therefore were not brought ba...

The use of coercion is one of the defining issues of mental health care. Since the earliest attempts to contain and treat the mentally ill, power imbalances have been evident and a cause of controversy. There has always been a delicate balance between respecting autonomy and ensuring that those who most need treatment and support are provided with...

The autonomy preference index scale (API) has been designed to measure patient preference for 2 dimensions of autonomy: Their desire to take part in making medical decisions (decision making, [DM]) and their desire to be informed about their illness and the treatment (information seeking; [IS]). The DM dimension is measured by 6 general items toget...

Background: Continuity of care (COC) is central to the organization and delivery of mental health services. Traditional definitions have excluded service users, and this lack of involvement has been linked to poor conceptual clarity surrounding the term. Consequently, very little is known about the differences and similarities in the conceptualiza...

Competence to consent to treatment has not previously been examined in a personality disorder cohort without comorbid mental disorder. We examined competence and coercion in 174 individuals diagnosed with severe personality disorder using two validated tools (the MacArthur Competence Assessment Tool for Treatment and the MacArthur Coercion Assessme...

Background: Offering a modest financial incentive to people with psychosis can promote adherence to depot antipsychotic medication, but the cost-effectiveness of this approach has not been examined. Methods: Economic evaluation within a pragmatic cluster-randomised controlled trial. 141 patients under the care of 73 teams (clusters) were randomi...

Background: Community treatment orders (CTOs) have not been shown in randomised trials to reduce readmission to hospital in patients with psychosis, but these trials have been short (11-12 months). We previously investigated the effect of CTOs on readmission rates over 12 months in a randomised trial (OCTET). Here, we present follow-up data for a...

Background Individual placement and support (IPS) has been repeatedly demonstrated to be the most effective form of mental health vocational rehabilitation. Its no-discharge policy plus fixed caseloads, however, makes it expensive to provide.AimsTo test whether introducing a time limit for IPS would significantly alter its clinical effectiveness an...

The aim was to apply a structured questionnaire, the Inventory of Stigmatizing Experiences (ISE), to study experiences of stigma (associated stigma) among relatives of persons with schizophrenia who attended outpatient clinics, using an approach based on assertive community treatment in a Swedish major city. A second aim was to explore the relation...

Research investigating the association between continuity of care (CoC) and patient outcomes in mental health care is limited. A previous review (1970-2002) concluded that evidence for an association between CoC and outcomes was inconsistent and limited. This systematic review, conducted a decade later, provides an update. Searches (1950-2014) were...

Objective Despite widespread use internationally, there is no convincing evidence that community treatment orders (CTO) (legal regimes making out-patient treatment compulsory), reduce readmission rates or have wider patient benefit. The primary and secondary outcomes of the Oxford Community Treatment Order Evaluation Trial (OCTET) (hospitalisation)...

Homelessness has serious implications for the health of individuals and populations. Primary health-care programmes specifi cally tailored to homeless individuals might be more eff ective than standard primary health care. Standard case management, assertive community treatment, and critical time intervention are eff ective models of mental health-...

The aims of this naturalistic non-interventional study were to quantify the level of stigma and discrimination in persons with schizophrenia and to test for potential associations between different types of stigma and adherence to antipsychotics. Antipsychotic medication use was electronically monitored with a Medication Event Monitoring System (ME...

Experimental research suggests that dysfunctional forms of cognitive processing help to cause and maintain emotional disorders (Clark & Beck, 2010; Williams, Watts, MacLeod, & Mathews, 1997). Successful cognitive thera-pies involve identifying and challenging these dysfunc-tional cognitions. One example is biased attentional processing of emotional...

Mental health care in the second half of the 20th century in much of the developed world has been dominated by the move out from large asylums. Both in response to this move and to make it possible, a pattern of care has evolved which is most commonly referred to as 'Community Psychiatry'. This narrative review describes this process, from local ex...

Purpose: Current literature on personal experiences of community treatment orders (CTO) is limited. This paper examines participants' experiences of the mechanisms via which the CTO was designed to work: the conditions that form part of the order and the power of recall. We also report an emergent dimension, legal clout and participants' impressio...

Topic: Individual Placement and Support (IPS) is a psychosocial intervention with a considerable body of evidence for its effectiveness in helping people with severe psychiatric disorders to obtain and maintain competitive jobs. In the last decades several European studies have replicated earlier American outcomes, generating widespread interest a...

The emphasis on care in the community in current mental health policy poses challenges for community mental health professionals with responsibility for patients who do not wish to receive services. Previous studies report that professionals employ a range of behaviors to influence reluctant patients. We investigated professionals' own conceptualiz...

Background. There has been major concern about the 'over-representation' of Black and ethnic minority groups amongst people detained under the Mental Health Act (MHA). We explored the effect of patient ethnicity on detention following an MHA assessment, once confounding variables were controlled for. Method. Prospective data were collected for all...

Community Treatment Orders (CTOs) require outpatients to adhere to treatment and permit rapid hospitalisation when necessary. They have become a clinical and policy solution to repeated hospital readmissions despite some strong opposition and the contested nature of published evidence. In this article, we appraise the current literature on CTOs fro...

Leverage is a particular type of treatment pressure that is used within community mental health services to increase patients' adherence to treatment. Because leverage involves practitioners making proposals that attempt to influence patients' behaviours and choices, the use of leverage raises ethical issues. To provide guidance that can assist pra...

Community treatment orders (CTOs) were introduced into the UK despite unconvincing international evidence for their effectiveness. The Oxford Community Treatment Order Evaluation Trial (OCTET) is a multisite randomised controlled trial of 333 patients with psychosis conducted in the UK. It confirms an absence of any obvious benefit in reducing rela...

The primary aim was to compare objective and subjective measures of adherence in a naturalistic cohort of schizophrenia outpatients over 12 months between October 2008 and June 2011. Antipsychotic medication adherence was monitored in 117 outpatients diagnosed with schizophrenia or schizophrenia-like psychosis according to DSM-IV criteria in a natu...

The evidence regarding community treatment order effectiveness has been conflicting. This systematic review aims to bring up to date the review performed by Churchill and colleagues in 2005 by assessing and interpreting evidence of CTO effectiveness defined by admission rates, number of inpatient days, community service use, and medication adherenc...

Reporting a complex randomised control trial (RCT) in 3000 words can lead to some misunderstandings, and Oxford Community Treatment Order Trial (OCTET) 1 is being clarified in the Lancet correspondence columns. We restricted ourselves in this first paper to those outcomes for which the trial was designed and powered. Segal (EBMH on line 2013) confu...

To test whether offering financial incentives to patients with psychotic disorders is effective in improving adherence to maintenance treatment with antipsychotics. Cluster randomised controlled trial. Community mental health teams in secondary psychiatric care in the United Kingdom. Patients with a diagnosis of schizophrenia, schizoaffective disor...

The aim was to investigate clinical predictors of adherence to antipsychotics. Medication use was electronically monitored with a Medication Event Monitoring System (MEMS(®)) for 12 months in 112 outpatients with schizophrenia and schizophrenia-like psychosis according to DSM-IV. Symptom burden, insight, psychosocial function (PSP) and side effects...

Service user contributions to mental health conferences are now routine. How effective they are at promoting dialogue is not clear. We report a difficult exchange following a presentation about coercive treatment, with our individual reflections on what we learnt. Suggestions are made to improve both the clinical practice and the dialogue.

Purpose High-risk mentally disordered offenders present a diverse array of clinical characteristics. To contain and effectively treat this heterogeneous population requires a full understanding of the group’s clinical profile. This study aimed to identify and validate clusters of clinically coherent profiles within one high-risk mentally disordered...

There has been major concern about the 'over-representation' of Black and ethnic minority groups amongst people detained under the Mental Health Act (MHA). We explored the effect of patient ethnicity on detention following an MHA assessment, once confounding variables were controlled for. Method Prospective data were collected for all MHA assessmen...

The past 30 years have produced no discoveries leading to major changes in psychiatric practice. The rules regulating research and a dominant neurobiological paradigm may both have stifled creativity. Embracing a social paradigm could generate real progress and, simultaneously, make the profession more attractive.

It has been estimated that as many as two thirds of patients with schizophrenia are unable to perform basic personal and social roles or activities. Occupational functioning and social functioning, as well as independent living, are considered as core domains of patient functioning. Improvement in patient functioning has also been recognized as an...

Background: Compulsory supervision outside hospital has been developed internationally for the treatment of mentally ill people following widespread deinstitutionalisation but its efficacy has not yet been proven. Community treatment orders (CTOs) for psychiatric patients became available in England and Wales in 2008. We tested whether CTOs reduce...

A high proportion of people with severe mental health problems are unemployed but would like to work. Individual Placement and Support(IPS) offers a promising approach to establishing people in paid employment. In a randomized controlled trial across six European countries, we investigated the economic case for IPS for people with severe mental hea...

Purpose High-risk mentally disordered offenders present a diverse array of clinical characteristics. To contain and effectively treat this heterogeneous population requires a full understanding of the group’s clinical profile. This study aimed to identify and validate clusters of clinically coherent profiles within one high-risk mentally disordered...

Many patients with schizophrenia show major difficulties in performing basic social roles. Occupational and social functioning (and independent living) are considered domains of functioning. Improvement in functioning is recognized as an important aim in treatment guidelines and as an outcome by regulatory agencies.Objectives The Europe, Middle Eas...

Purpose: This study aimed at establishing the validity and reliability of an English language version of the Mini-ICF-APP. Methods: One hundred and five patients under the care of secondary mental health care services were assessed using the Mini-ICF-APP and several well-established measures of functioning and symptom severity. 47 (45 %) patient...

Emotion processing is known to be impaired in psychopathy, but less is known about the cognitive mechanisms that drive this. Our study examined experiencing and suppression of emotion processing in psychopathy. Participants, violent offenders with varying levels of psychopathy, viewed positive and negative images under conditions of passive viewing...

Poor staff morale is a pressing problem in UK mental health services, especially for acute in-patient wards, community mental health teams and social workers. Instead of interpreting low morale using a demand-control-support model, it is suggested here that simply being honest about what should be expected of staff and stopping constant criticism a...

Introduction: Continuity of care has been demonstrated to be important for service users and carer groups have voiced major concerns over disruptions of care. We aimed to assess the experienced continuity of care in carers of patients with both psychotic and non-psychotic disorders and explore its association with carer characteristics and psychol...

Clinicians often consider whether or not offenders with psychosis have a history of offending pre-dating the onset of their illness. The typology of offenders based on age at first offence, developed in the field of criminology, has been recently extended to mentally disordered groups, but this ignores the potential role of illness onset. Using a l...

Despite the importance of continuity of care [COC] in contemporary mental health service provision, COC lacks a clearly agreed definition. Furthermore, whilst there is broad agreement that definitions should include service users' experiences, little is known about this. This paper aims to explore a new construct of service user-defined COC and its...

Involuntary outpatient treatment (IOT) is used as a tool to promote stability among people with psychotic disorders. The authors drew on quantitative research surveys, qualitative studies, and official guidelines to describe clinicians' views of IOT and reported practices in England, Canada, Australia, and New Zealand. Overall, clinicians prefer a...

As part of an evaluation of the Dangerous and Severe Personality Disorder (DSPD) Programme, we conducted in-depth interviews with 60 participants purposely sampled across four pilot DSPD units. This report is limited to the finding with potential `conceptual generalisability': namely the unanticipated finding of negative and hostile attitudes of pa...

To determine (1) inter-relationships between social network size and quality and therapeutic relationship ratings and (2) inter-relationships between attachment style, team attachment, therapeutic relationships, social networks, and clinical and social functioning. A cross-sectional survey. A sample of 93 people using community mental health teams...

Alcohol dependence is a significant and costly problem in the UK yet only 6% of people a year receive treatment. Current service provision based on the treatment of acute episodes of illness and emphasising personal choice and motivation results in a small proportion of these patients engaging with alcohol treatment. There is a need for interventio...

Making threats and offers to patients is a strategy used in community mental healthcare to increase treatment adherence. In this paper, an ethical analysis of these types of proposal is presented. It is argued (1) that the primary ethical consideration is to identify the professional duties of care held by those working in community mental health b...

This article debates and defends the lawfulness of a randomised controlled trial of compulsory outpatient treatment under the mental health legislation for England and Wales. The trial is designed to compare the outcomes for patients of their treatment under the new Community Treatment Order (CTO) regime with their treatment under the older leave s...

The interrelation between needs for care and quality of life has been described and replicated by several studies. The present work aims to add to the understanding of longitudinal interrelations between needs for care, quality of life, and other outcome measures by analyzing a sample of patients at the onset of schizophrenia. This study relied on...

This study aimed to identify the course of unmet needs by patients with a first episode of schizophrenia and to determine associated variables. We investigated baseline assessments in the European First Episode Schizophrenia Trial (EUFEST) and also follow-up interviews at 6 and 12 months. Latent class growth analysis was used to identify patient gr...

Objective: The correlates of parental burden in schizophrenia may differ between ethnic groups, but few studies have examined this in a UK setting. Our aim was to identify the correlates of burden in a UK sample of first-generation North Indian Punjabi Sikh parents and their white British counterparts. Method: Test the association of burden with...

Positive relationships between employment and clinical status have been found in several studies. However, an unequivocal interpretation of these relationships is difficult on the basis of common statistical methods. In this analysis, a structural equation model approach for longitudinal data was applied to identify the direction of statistical rel...