Barnett, P., Matthews, H., Lloyd-Evans, B., Mackay, E., Pilling, S., & Johnson, S. (2018). Compulsory community treatment to reduce readmission to hospital and increase engagement with community care in people with mental illness: a systematic review and meta-analysis. The Lancet Psychiatry, 5(12), 1013-1022.
"We found no consistent evidence that CCT reduces readmission or length of inpatient stay, although it might have some benefit in enforcing use of outpatient treatment or increasing service provision, or both. Future research should focus on why some people do not engage with treatment offered and on enhancing quality of the community care available."
Burns, T., Rugkåsa, J., Molodynski, A., Dawson, J., Yeeles, K., Vazquez-Montes, M., ... & Priebe, S. (2013). Community treatment orders for patients with psychosis (OCTET): a randomised controlled trial. The Lancet, 381(9878), 1627-1633.
"In well coordinated mental health services the imposition of compulsory supervision does not reduce the rate of readmission of psychotic patients. We found no support in terms of any reduction in overall hospital admission to justify the significant curtailment of patients' personal liberty."
Kisely, S., & Hall, K. (2014). An updated meta-analysis of randomized controlled evidence for the effectiveness of community treatment orders. The Canadian Journal of Psychiatry, 59(10), 561-564.
"CTOs may not lead to significant differences in readmission, social functioning, or symptomatology, compared with standard care. Their use should be kept under review."
Rugkåsa, J. (2016). Effectiveness of community treatment orders: the international evidence. The Canadian Journal of Psychiatry, 61(1), 15-24.
"The results from more than 50 nonrandomized studies show mixed results. Some show benefits from CTOs while others show none on the most frequently reported outcomes of readmission, time in hospital, and community service use. Results from the 3 existing randomized controlled trials (RCTs) show no effect of CTOs on a wider range of outcome measures except that patients on CTOs are less likely than controls to be a victim of crime. Patients on CTOs are, however, likely to have their liberty restricted for significantly longer periods of time. Meta-analyses pooling patient data from RCTs and high quality nonrandomized studies also find no evidence of patient benefit, and systematic reviews come to the same conclusion. There is no evidence of patient benefit from current CTO outcome studies. This casts doubt over the usefulness and ethics of CTOs."
Rugkåsa, J., Molodynski, A., Yeeles, K., Vazquez Montes, M., Visser, C., Burns, T., & OCTET Group. (2015). Community treatment orders: clinical and social outcomes, and a subgroup analysis from the OCTET RCT. Acta Psychiatrica Scandinavica, 131(5), 321-329.
"There was no significant difference at 12 months between the two arms in any of the reported outcomes, except a small difference in patients' view of the effectiveness of treatment pressure, which is unlikely to be clinically meaningful. Two statistically significant interactions were found in the subgroup analysis: symptoms interacted with age and with education, but no pattern was demonstrated. CTOs do not have benefit on any of the tested outcomes, or for any subgroup of patients. Their continued use should be carefully reconsidered."
Vergunst, F., Rugkåsa, J., Koshiaris, C., Simon, J., & Burns, T. (2017). Community treatment orders and social outcomes for patients with psychosis: a 48-month follow-up study. Social Psychiatry and Psychiatric Epidemiology, 52, 1375-1384.
"CTO duration was not associated with improvements in patients’ social outcomes even over the long term. This study adds to growing concerns about CTO effectiveness and the justification for their continued use."
Corderoy, A., Kisely, S., Zirnsak, T., & Ryan, C. J. (2024). The benefits and harms of inpatient involuntary psychiatric treatment: a scoping review. Psychiatry, Psychology and Law, 1-48.
"...this review has found that involuntary admission may in and of itself be associated with a number of harms. Of concern was the significant confusion among people on both voluntary and involuntary care concerning their legal status or rights when admitted to hospital, which indicates that patients do not adequately understand their legal rights in hospital. Involuntary admission may trigger a ‘cycle of coercion’ in which the initial act of admission is linked to poorer clinical rapport, an increase in both perceived and objective measures of coercive care, increased likelihood of further coercive interactions with the healthcare system in future, increased health care costs and decreased satisfaction with care. In addition, we found little evidence that involuntary admission was protective against suicide, and some evidence that it may in fact be a risk factor for inpatient suicide. This is in line with one meta-analysis of inpatient suicide, which reported an 87% increased risk of suicide among people admitted involuntarily. It has been proposed that psychiatric inpatient admission in and of itself may increase the likelihood of some people to attempt suicide, in a phenomenon termed ‘nosocomial suicide’. Nosocomial harms associated with involuntary admission should therefore be acknowledged in service planning and provision."
Jones, N., Gius, B. K., Shields, M., Collings, S., Rosen, C., & Munson, M. (2021). Investigating the impact of involuntary psychiatric hospitalization on youth and young adult trust and help-seeking in pathways to care. Social Psychiatry and Psychiatric Epidemiology, 1-11.
"Three quarters of the youth reported negative impacts of IH on trust, including unwillingness to disclose suicidal feelings or intentions. Selective non-disclosure of suicidal feelings was reported even in instances in which the participant continued to meet with providers following discharge. Factors identified as contributing to distrust included perceptions of inpatient treatment as more punitive than therapeutic, staff as more judgmental than empathetic, and hospitalization overall failing to meet therapeutic needs."
Jones, N., Gius, B., Shields, M., Florence, A., Collings, S., Green, K., ... & Munson, M. (2022). Youths’ and young adults’ experiences of police involvement during initiation of involuntary psychiatric holds and transport. Psychiatric services, 73(8), 910-917.
"In-depth interviews were conducted with 40 participants (ages 16–27) who had experienced an involuntary hold; the 28 participants who reported police involvement are the focus of this analysis. Data were inductively coded, and codes were grouped into larger themes. A majority of participants reported negative experiences; major themes characterizing negative encounters were the framing of distress as criminal or of intervention as disciplinary rather than therapeutic, perceived aggression and callousness from police officers, and poor communication. "
Lewis, A., Lee, H. S., Zabelski, S., & Shields, M. C. (2025). Institutional betrayal in inpatient psychiatry: effects on trust and engagement with care. Psychiatric Services, 76(3), 218-225.
"Institutional betrayal is one mechanism through which inpatient psychiatric facilities may cause iatrogenic harm, and the potential for betrayal was larger at for-profit facilities. Further research is needed to identify the determinants of institutional betrayal and strategies to support improvement in care quality."
Sugiura, K., Pertega, E., & Holmberg, C. (2020). Experiences of involuntary psychiatric admission decision-making: a systematic review and meta-synthesis of the perspectives of service users, informal carers, and professionals. International journal of law and psychiatry, 73, 101645.
"A lack of communication and a power imbalance among the stakeholders hindered respect for the service users' rights, will, and preferences. This was exacerbated by professionals rationalizing coercion and assuming that service users were incapable of understanding information. Services that encourage communication and overcome power imbalances (e.g. Crisis Plans, Family Group Conferencing) combined with stronger community mental health support will respect service users' rights, will, and preferences and avoid substituted decision-making on issues such as involuntary admission and forced medication."
Ward-Ciesielski, E. F., & Rizvi, S. L. (2021). The potential iatrogenic effects of psychiatric hospitalization for suicidal behavior: A critical review and recommendations for research. Clinical Psychology: Science and Practice, 28(1), 60-70.
"Suicide rates have risen in the United States, and there has been a simultaneous, nearly ubiquitous decrease in services provided on psychiatric inpatient units (e.g., shorter stays, almost exclusive emphasis on crisis management). Despite limited research demonstrating its efficacy for reducing suicide risk, inpatient hospitalization remains the treatment of choice (and often legally mandated) for highly suicidal individuals. In this review, we discuss the sometimes-confusing guidelines providers follow concerning psychiatric hospitalization for suicidal individuals. We then highlight the considerable evidence of heightened suicide risk and other negative outcomes during and immediately following hospitalization. Finally, we propose critical research directions to rigorously evaluate whether psychiatric hospitalization is iatrogenic, at least for some individuals. Such research has far-reaching implications for practice and policy."
Borecky, A., Thomsen, C., & Dubov, A. (2019). Reweighing the ethical tradeoffs in the involuntary hospitalization of suicidal patients. The American Journal of Bioethics, 19(10), 71-83.
"Three arguments are presented: (1) that inadequate attention has been given to the harms resulting from the use of coercion and the loss of autonomy, (2) that inadequate evidence exists that involuntary hospitalization is an effective method to reduce deaths by suicide, and (3) that some suicidal patients may benefit more from therapeutic interventions that maximize and support autonomy and personal responsibility. Considering this evidence, we argue for a policy that limits the coercive hospitalization of suicidal individuals to those who lack decision-making capacity."
Kerman, N., Kidd, S. A., & Stergiopoulos, V. (2023). Involuntary hospitalization and coercive treatment of people with mental illness experiencing homelessness—going backward with foreseeable harms. JAMA Psychiatry, 80(6), 531-532.
"Mental health and homeless service systems in the US and Canada have long grappled with the enduring ill effects of deinstitutionalization on homelessness among people with serious mental illness. Shortages in affordable and permanent supportive housing continue to undermine a foundational component of mental health recovery: stable housing. As a result, homelessness and serious mental illness have become an intractable wicked problem. In the absence of substantial government investments and intergovernmental and cross-sectoral collaboration, well-meaning but regressive policies that lead people with mental illness experiencing homelessness to be moved “out of sight, out of mind” have become more overt."
Shields, M. C., & Ne'eman, A. (2018). Expanding Civil Commitment Laws Is Bad Mental Health Policy. Health Affairs Forefront.
"Expanding civil commitment and mental health institutionalization is a convenient tool for politicians seeking to deflect public pressure for gun control laws. And yet, while such measures are politically convenient, they are far from an effective solution to the challenges of mental illness or gun violence."