Comment

The CRIMSON trial10 assessed a contrasting and compulsory admissions, but, with the apparent failure of
less contentious strategy for reducing compulsory CTOs, we need to keep trying.
admissions, this time through joint crisis plans, intended
as a means of engaging patients and professionals in Sonia Johnson
active joint planning for future crises. An exploratory Mental Health Sciences Unit, University College London,
London W1W 7EY, UK
trial raised hopes with a signicant nding of reduced
[email protected]
compulsory admissions.15 Unfortunately, this result
I declare that I have no conicts of interest.
was not replicated in the subsequent multicentre trial.
1 Keown P, Weich S, Bhui KS, Scott J. Association between provision of
Chance could explain the earlier nding, but the authors mental illness beds and rate of involuntary admissions in the NHS in
England 19882008: ecological study. BMJ 2011; 343: d3736.
make a persuasive case from the studys qualitative 2 Wierdsma AI, Mulder CL. Does mental health service integration aect
component that patchy implementation and lack of compulsory admissions? Int J Integr Care 2009; 9: e90. http://www.ijic.org/
index.php/ijic/article/viewArticle/324/646 (accessed Feb 28, 2013).
real commitment are more likely culprits. Indeed, one 3 Schizophrenia Commission. The abandoned illness. London:
meeting between patients and professionals is unlikely The Schizophrenia Commission, 2012.
4 Jones J, Nolan P, Bowers L, et al. Psychiatric wards: places of safety?
to be sucient to counteract a culture of professional J Psychiatr Ment Health Nurs 2010; 17: 12430.
dominance in decision making where this prevails. 5 Tew J, Ramon S, Slade M, Bird V, Melton J, Le Boutillier C. Social factors and
recovery from mental health diculties: a review of the evidence.
These two excellent papers provide no clear means Br J Social Work 2012; 42: 44360.
of turning back the slowly rising tide of compulsory 6 Crawford V, Crome IB, Clancy C. Co-existing problems of mental health and
substance misuse (dual diagnosis): a literature review. Drugs Educ Prev Pol
admissions. Regarding future strategies, the door 2003; 10: 174.
7 Rowe R, Calnan M. Trust relations in health carethe new agenda.
remains open for further attempts to reduce compulsory Eur J Public Health 2006; 16: 46.
admissions by engaging service users more eectively 8 Johnson S, Nolan F, Pilling S, et al. Randomised controlled trial of acute
mental health care by a crisis resolution team: the north Islington crisis
in decisions about their care. However, widespread study. BMJ 2005; 331: 599602.
implementation might require a substantial cultural 9 Burns T, Rugksa J, Molodynski A, et al. Community treatment orders for
patients with psychosis (OCTET): a randomised controlled trial.
shift in relationships between patients and professionals. Lancet 2013; published online March 26. http://dx.doi.org/10.1016/S0140-
An important question is whether the long-established 6736(13)60107-5.
10 Thornicroft G, Farrelly S, Szmukler G, et al. Clinical outcomes of Joint Crisis
but little evaluated UK Care Programme Approach is Plans to reduce compulsory treatment for people with psychosis:
a randomised controlled trial. Lancet 2013; published online March 26.
really a useful framework for fostering greater equality http://dx.doi.org/10.1016/S0140-6736(13)60105-1.
and collaboration between service users and sta. More 11 Rugksa J, Burns T. Community treatment orders. Psychiatry 2009 8: 49395.
12 Kisely SR, Campbell LA, Preston NJ. Compulsory community and
engaging and acceptable continuing community care, involuntary outpatient treatment for people with severe mental disorders.
as seems to be provided by Early Intervention Services,3 Cochrane Database Syst Rev 2011; 2: CD004408.
13 Health and Social Care Information Centre (Government Statistical Service).
might in itself reduce compulsory admissions, and could Inpatients formally detained in hospitals under the Mental Health Act 1983,
also be a fruitful context for joint crisis plans. Making and patients subject to supervised community treatment, Annual gures,
England, 2011/12. https://catalogue.ic.nhs.uk/publications/mental-health/
inpatient environments less aversive and improving the legislation/inp-det-m-h-a-1983-sup-com-eng-11-12/inp-det-m-h-a-1983-
sup-com-eng-11-12-rep.pdf (accessed Feb 28, 2013).
quality of sta-patient alliances in this setting could also 14 Khurmi S, Curtice M. The supervised community treatment order and the
result in less need for compulsory admissions. We do Human Rights Act 1998. Adv Psychiatr Treat 2010; 16: 26371.
15 Henderson C, Flood C, Leese M, Thornicroft G, Sutherby K, Szmukler G.
not yet know whether changing relationships between Eect of joint crisis plans on use of compulsory treatment in psychiatry:
sta and patients can reverse the continuing rise in single blind randomised controlled trial. BMJ 2004; 329: 136.

The contraceptive revolution: focused eorts are still needed

Published Online In The Lancet, Leontine Alkema and colleagues1 illustrate or cohabiting women: use of any contraceptive method
March 12, 2013
http://dx.doi.org/10.1016/
the usefulness of rigorous modelling to provide (contraceptive prevalence) and non-use in women who
S0140-6736(13)60588-7 convincing estimates of health indicators when empirical want to avoid childbearing for at least 2 years (unmet
See Articles page 1642 data are patchy or non-existent. Their report presents need). Worldwide, contraceptive prevalence increased
by far the most complete country-specic information during this 20-year period from 55% to 63%, and
about trends between 1990 and 2010, with projections unmet need decreased from 15% to 12%, but glaring
to 2015, in two key family planning indicators for married disparities between countries remain. For example, in

1604 www.thelancet.com Vol 381 May 11, 2013

 Comment

2010, contraceptive prevalence was less than 20% in Traditional methods Other modern methods
Male condom Intrauterine device Injectable or implant
23 countries (all in Africa) and unmet need exceeded Pill Sterilisation
30% in 12 African countries and three in other regions. 100
These estimates support the call at the 2012 London 90

Summit on Family Planning for a focused eort to bring 80

Contraceptive users (%)

70
contraception to people in countries where its use is still
60
conned to a minority.2
50
These two indicators respond to dierent agendas
40
but are complementary. Contraceptive prevalence is the 30
main determinant of fertility; typically, an increase of 20
1517 percentage points in prevalence reduces fertility 10
(and thus population growth) by one birth per woman.3 0

08

04

07

04

02

8
In the past 50 years, most governments in developing
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growth through promotion of family planning as a part
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of development. However, in contrast to demographic Figure: Percentage of contraceptive users, by type of method used, in
targets for death reduction, targets for birth reduction married or in-union women
have proved controversial because of concerns that
couples might be pressured or even coerced into use in prevalence and substantial falls in unmet need have
of contraception. occurred in western and southern Asia and in northern
By responding to the human rights agenda of repro- and southern Africa, but the most marked increase in
ductive choice, unmet need avoids these concerns. use, from 12% to 33%, has taken place in eastern Africa,
From its origins in the knowledge, attitude, and largely because of greater government commitment and
practice of family planning (KAP) surveys of the 1960s, improved community-based services.8 However, unmet
which rst identied the disjuncture between family need in this subregion has decreased only modestly, from
size preferences and contraceptive use (the KAP gap), 30% in 1990 to 26% in 2010, indicating that increased
its measurement has been rened.4,5 Unmet need need, stemming from sharp reductions in desired
has become a central rationale for donor support numbers of children, has almost matched increased use.9
and advocacy and a crucial guide for interventions, By contrast, progress in western and central Africa has
culminating in its addition in 2007 as one of the been poor. Nigeria, the most populated country in sub-
indicators to monitor progress in target 5b of the Saharan Africa, is typical. Contraceptive prevalence has
Millennium Development Goals to achieve, by 2015, risen from 7% to only 14% in 20 years and unmet need
universal access to reproductive health. has remained static at 21%.1 Of greatest concern are the
Fortunately, although the fertility reduction and Sahelian countries of Chad, Mali, Mauritania, and Niger,
reproductive rights agendas dier in principle, they are where the combined population is projected to increase
mutually reinforcing.6 The historic mandate of family threefold, from 456 million in 2010 to 1319 million in
planning programmes has been to reduce unmet 2050,10 which presents an impossible burden for fragile
need through a decrease in the costs (broadly dened) ecosystems.
of contraception, and reduction in unmet need is An estimated 146 million married women had an
responsible for most of the increase in contraceptive use unmet need in 2010.1 Knowledge of methods and access
in the past few decades.7 Countries with high fertility to services are inadequate in some countries, but these
rates also record high unmet need. are not the main reasons for the persistence of unmet
By 1990, contraceptive use was high and unmet need need in most settings. In western and central Africa,
low not only in developed countries but also in Latin ambivalence or even hostility towards contraception
America and much of Asia. Thus, the main interest lies in is a serious obstacle, but concerns about the perceived
the straggler areas: southern and western Asia and Africa. adverse health eects of particular methods are a more
Progress since 1990 has been variable. Notable increases widespread problem.11

www.thelancet.com Vol 381 May 11, 2013 1605

 Comment

Expansion of services, especially in the form of need can now be monitored by regular updates of the
community-based provision in rural Africa, is a priority, modelling devised by Alkema and colleagues.
but equally important is the need to address social
obstacles and health concerns through mass media and *John Cleland, Iqbal H Shah
focused eorts to engage the support of religious and Department of Population Health, London School of Hygiene
and Tropical Medicine, University of London, London WC1E 7HT,
community leaders.
UK (JC); and The Susan Thompson Buett Foundation, Omaha,
An important but neglected contributor to unmet NE, USA (IHS)
need is the narrow range of methods used in many [email protected]
high-prevalence and low-prevalence countries We declare that we have no conicts of interest.
(gure).12 For example, in India, female sterilisation 1 Alkema L, Kantorova V, Menozzi C, Biddlecom A. National, regional, and
global rates and trends in contraceptive prevalence and unmet need for
accounts for two-thirds of all contraceptive use and family planning between 1990 and 2015: a systematic and comprehensive
eective reversible methods are rare. An unfortunate analysis. Lancet 2013; published online March 12. http://dx.doi.
org/10.1016/S0140-6736(12)62204-1.
consequence is that the prevalence of short inter-birth 2 Carr B, Gates MF, Mitchell A, Shah R. Giving women the power to plan their
intervals, which pose a threat to infant health and families. Lancet 2012; 380: 8082.
3 Cleland J, Conde-Agudelo A, Peterson H, Ross J, Tsui A. Contraception and
survival, has remained unchanged in the past 20 years.13 health. Lancet 2012; 380: 14956.
Conversely, in neighbouring Bangladesh, where most 4 Westo CF. The unmet need for birth control in ve Asian countries.
Fam Plann Perspec 1978; 10: 17381.
women use pills or injectable contraceptives, a pressing 5 Bradley SEK, Croft TN, Fishel JD, Westo CF. Revising unmet need for family
planning. DHS analytical studies no 25. Calverton: ICF International, 2012.
need exists for greater use of long-acting methods, such
6 Casterline JB, Sinding SW. Unmet need for family planning in developing
as intrauterine devices or sterilisation. In Bangladesh, countries and implications for population policy. Popul Dev Rev 2000;
26: 691723.
most women have achieved their desired family size by 7 Feyisetan B, Casterline JB. Fertility preferences and contraceptive change in
25 years of age.14 developing countries. Int Fam Plann Perspect 2000; 26: 10009.
8 USAID. Three successful sub-Saharan Africa family planning programs:
In sub-Saharan Africa, pills and injectables also dom- lessons for meeting the MDGs. Washington, DC: USAID Africa Bureau, 2012.
inate contraceptive use. Discontinuation of these two 9 Westo CF, Bankole A. Reproductive preferences in developing countries at
the turn of the century. DHS comparative reports no 2. Calverton:
methods is common. Typically between 20% and 30% ORC Macro, 2002.
of women stop use within 1 year of starting because 10 United Nations Population Division. World population prospects: the 2010
revision. http://esa.un.org/unpd/wpp/index.htm (accessed Feb 18, 2013).
of side-eects or health concerns.15 In this region, 11 Bongaarts J, Bruce J. The causes of unmet need for contraception and the
an increasing proportion of unmet need stems from social context of services. Stud Fam Plann 1995; 26: 5775.
12 United Nations Population Division. World contraceptive use 2011.
women who have unsuccessfully tried one or both of New York: United Nations Population Division, 2012.
these two methods, but do not have alternative options. 13 Rutstein SO. Trends in birth spacing. DHS comparative reports no 28.
Calverton: ICF Macro, 2011.
This trend emphasises the potentially huge benet that 14 Bangladesh Demographic and Health Survey 2011. Dhaka, Bangladesh:
could be achieved by increasing the range of methods National Institute of Population Research and Training/Mitra and
Associates; Calverton: ICF Macro, 2012.
available to, and used by, women, thereby better meet- 15 Ali MM, Cleland J, Shah IH. Causes and consequences of contraceptive
discontinuation: evidence from 60 demographic and health surveys.
ing their reproductive rights and needs. The success of Geneva: World Health Organization, 2012.
eorts to increase contraceptive use and reduce unmet

Annual Report of the Chief Medical Ocer: infection and the

rise of antimicrobial resistance
Published Online The second of the two volumes of the Chief Medical health. The report identies antimicrobial resistance as
March 11, 2013
Ocer for Englands Annual Report on the state of the a cross-societal and therefore cross-governmental issue
http://dx.doi.org/10.1016/
S0140-6736(13)60604-2 publics health is released this week.1 The report includes that encompasses both a market failure to produce
recommendations aimed specically at politicians and new antibiotics and the need for better antibiotic
highlights the need for strong action on antimicrobial stewardship. A key recommendation of the report is
resistance, since this issue has the potential to be as that resistance should be placed on the UK national
important as global warming in terms of its impact on risk register (specically, the National Security Risk

1606 www.thelancet.com Vol 381 May 11, 2013