Compulsory psychiatric treatment checklist: Instrument development and clinical application Sofia Brissos a, ⁎, Filipe Vicente b , João Miguel Oliveira a , Gonçalo Santos Sobreira a , Zita Gameiro a , Cátia Alves Moreira a , Mariana Pinto da Costa c,d,e , Marta Queirós c , Eva Mendes f , Susana Renca f , Henrique Prata-Ribeiro a , Maurício Scopel Hoffmann g , Fernando Vieira a a Centro Hospitalar Psiquiátrico de Lisboa, Lisbon, Portugal b Hospital Garcia de Orta, Almada, Portugal c Hospital Magalhães Lemos, Porto, Portugal d Institute of Biomedical Sciences Abel Salazar (ICBAS), University of Porto, Porto, Portugal e Unit for Social and Community Psychiatry (WHO Collaborating Centre for Mental Health Services Development), Queen Mary University of London, London, United Kingdom f Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal g Universidade Federal de Santa Maria, Santa Maria, RS, Brazil abstract article info Article history: Received 1 December 2016 Received in revised form 19 May 2017 Accepted 31 July 2017 Available online xxxx Instruments designed to evaluate the necessity of compulsory psychiatric treatment (CPT) are scarce to non-existent. We developed a 25-item Checklist (scoring 0 to 50) with four clusters (Legal, Danger, Historic and Cognitive), based on variables identified as relevant to compulsory treatment. The Compulsory Treatment Checklist (CTC) was filled with information on case (n = 324) and control (n = 251) subjects, evaluated under the Portuguese Mental Health Act (Law 36/98), in three hospitals. For internal validation, we used Confir- matory Factor Analysis (CFA), testing unidimensional and bifactor models. Multilevel logistic regression model (MLL) was used to predict the odds ratio (OR) for compulsory treatment based on the total scale score. Receiver Operating Characteristic analysis (ROC) was performed to predict compulsory treatment. CFA revealed the best fit indexes for the bifactor model, with all items loading on one General factor and the residual loading in the a priori predicted four specific factors. Reliability indexes were high for the General factor (88.4%), and low for spe- cific factors (b 5%), which demonstrate that CTC should not be performed in the subscales to access compulsory treatment. MLL reveals that for each item scored in the scale, it increases the OR by 1.26 for compulsory treatment (95%CI 1.21–1.31, p b 0.001). Based on the total score, accuracy was 90%, and the best cut-off point of 23.5 detects compulsory treatment with a sensitivity of 75% and specificity of 93.6%. The CTC presents robust internal structure with a strong unidimensional characteristic, and a cut-off point for compulsory treatment of 23.5. The improved 20-item version of the CTC could represent an important instrument to improve clinical decision regarding CPT, and ultimately to improve mental health care of patients with severe psychiatric disorders. © 2017 Elsevier Ltd. All rights reserved. 1. Introduction Compulsory psychiatric treatment (CPT) of individuals with mental disorders is characterized by a conflict of opposing interests and moral values (Simonović, Nenadović, & Momcilović, 2011), due to the depriva- tion of liberty and intrusion of the personal integrity of an individual who has not committed any crime (Simonović et al., 2011). However, families and physicians consider CPT beneficial, and some patients subjected to CPT consider this a positive step (Wyder, Bland, Herriot, & Crompton, 2015), suggesting that there is no single definitive experience or view of Compulsory Outpatient Treatment (COT) (Canvin, Rugkåsa, Sinclair, & Burns, 2014). Therefore, it remains a controversial and complex ethical and legal problem, raising human rights concerns (Bartlett, 2011; Brown, 2016). Whether CPT reduces health service use, and/or improves outcomes, remains an unresolved question and there is a lack of standards and proof of effectiveness (Jacobsen, 2012). The few studies available have shown contradictory results (Høyer, 2008; Kallert et al., 2011; Okai et al., 2007; Prinsen & van Delden, 2009; Sibitz et al., 2011), with obser- vational studies showing positive effects (Bursten, 1986; Durst, Teitelbaum, Bar-El, Shlafman, & Ginath, 1999; Fernandez & Nygard, 1990; Geller, Grudzinskas, McDermeit, Fisher, & Lawlor, 1998; Hiday & Scheid-Cook, 1989; Munetz, Grande, Kleist, & Peterson, 1996; Preston, Kisely, & Xiao, 2002; Zanni & deVeau, 1986), whereas higher levels of evidence have failed to demonstrate benefits, namely for COT regarding service use, symptom levels, social functioning or quality of life as International Journal of Law and Psychiatry 54 (2017) 36–45 ⁎ Corresponding author. E-mail address: brissos.sofia@gmail.com (S. Brissos). http://dx.doi.org/10.1016/j.ijlp.2017.07.004 0160-2527/© 2017 Elsevier Ltd. All rights reserved. Contents lists available at ScienceDirect International Journal of Law and Psychiatry