What is the value of Forensic Orders?

To the Editor

We read with interest the recent study by Harris et al. (2018). Using data from more than 5000 patients under community treatment order (CTO), the authors found that CTOs were effective in (1) reducing readmission rates, (2) increasing the time to their first readmission and (3) reducing the number of hospital admissions. In the accompanying debate piece, Ryan (2018) draws less optimistic conclusions about the clinical significance of these findings: Ten people would need to be treated involuntarily in the community to avoid one fewer admission, and 48 would need to be treated involuntarily to prevent future readmission for a single patient.

Across Australia and New Zealand, there is legislation facilitating the treatment of ‘forensic patients’ who have been charged with a serious offence. In Queensland, Forensic Orders (FOs) are made by the Mental Health Court (MHC) (www.mhrt.qld.gov.au). The responsibility to provide care for patients on FOs in the community lies with the treating psychiatrist. The ongoing status of a FO is reviewed every 6 months by the Mental Health Review Tribunal (MHRT). The Tribunal can set maximum limits of community treatment or order the patient to be inpatient independent of clinical indication. The order also imposes conditions set by the MHC or MHRT (which may include the residence, driving and substance use) that cannot be changed by the treating psychiatrist.

We are not aware of any research exploring the impact of FO on the prevention of future serious offences. However, it is fair to assume that the number needed to treat (under a FO) to prevent any future similar serious offences would be much larger than 48 given the small absolute number of the outcome (i.e. serious offences) compared to that of hospitalization. In other words, many more than 48 people need to be placed under FOs to prevent one single serious offence. FOs are restrictive and include prescriptions that are not determined by the psychiatrist involved in directly in the provision of care. The stigmatizing nature of the ‘forensic’ label on the patient, including how the health service responds to them needs to be considered. The nature of these orders fundamentally shifts the doctor-patient relationship, and there is a risk that the focus of care becomes custodial rather than recovery-oriented. Better understanding of the effectiveness of this special class of CTO is needed.