Community treatment orders (CTO’s) provide compulsory supervision outside of psychiatric hospital. They require patients to accept clinical monitoring in the community and enable them to be recalled to hospital for assessment if necessary. They do not authorise forcible treatment; however whilst on a CTO a patient may be ordered to meet certain requirements, such as taking medication or living in a specified place, which if violated may result in them facing readmission to hospital.
Since the introduction of CTO’s across England and Wales in 2008, approximately 4000 have been used each year. However despite seemingly wide use of the orders, very little evidence exists to support their efficacy, and clinical opinion appears to be divided across either side of the fence. The difficulties in testing a legal requirement through a randomised control trial have hindered possible research, as major legal and ethical barriers need to be overcome. It appears almost ethically impossible to evaluate the use of CTO’s in this way; you can’t withhold compulsory treatment from somebody who requires it by allocating them to a control condition, in the same way that you cannot allocate somebody who does not require compulsory treatment to receive it. Only two previous randomised controlled trails on CTO’s have been published (Swartz et al., 1999; Steadman et al., 2001); both of these were conducted in the USA and both failed to find any support for the use of the orders in terms of reduced readmission rates.
A randomised control trial (Burns et al., 2013) aimed to test whether patients with psychosis who were discharged from hospital on a CTO would have a lower rate of readmission to hospital over 12 months than those discharged on Section 17 leave. By law patients must be treated using the least restrictive option; however a legal opinion was unclear as to whether one of the regimes was more restrictive than the other. As it is also possible for a person to meet the criteria for both a CTO and Section 17 leave; the two options were able to be compared in this way. Both groups received equivalent levels of clinical contact but different lengths of compulsory supervision.
A total of 333 patients were included in the trial (166 allocated to CTO and 167 to Section 17 leave) from 32 NHS trusts; predominantly in the Midlands and southern England. Eligible participants were aged between 18 and 65, had a diagnosis of psychosis, had been involuntarily admitted to a psychiatric hospital, had capacity to give consent, were not subject to any other legal restrictions and were deemed suitable for supervised outpatient care by their clinician.
The primary outcome for the trial was whether or not the patient was readmitted to hospital in the 12 month follow up period. Secondary outcomes included; length of time to the first readmission, number of readmissions, total amount of time spent in hospital, clinical functioning, and social functioning.
- No significant differences were found across any of the outcomes at the 12 month follow up
- Just over a third (36%) of participants in each condition were readmitted to hospital within a year
This is the third, and largest, randomised control trial of CTO’s to date. The study found no evidence to suggest that CTO’s achieve their purpose of reducing readmission to hospital amongst people with psychosis, and consequently support the findings of the previous two trials.
The evidence is now building to suggest that CTO’s may not be of benefit to patients, despite substantial deprivation of personal freedoms. A CTO is a legal requirement, so in the face of this evidence the question arises of ‘what happens next?’. The authors recommend that current use of CTO’s be urgently reviewed, with the lead author declaring that,
We were all a bit stunned by the result, but it was very clear data and we got a crystal clear result. So I’ve had to change my mind. I think sadly – because I’ve supported them for 20-odd years – the evidence is staring us in the face that CTOs don’t work.
Burns T, Rugkåsa J, Molodynski A, Dawson J, Yeeles K, Vazquez-Montes M, Voysey M, Sinclair J, Priebe S. Community treatment orders for patients with psychosis (OCTET): a randomised controlled trial. The Lancet 2013; in press [Pubmed abstract]
Swartz MS, Swanson JW, Wagner HR, Burns BJ, Hiday VA, Borum R. Can involuntary outpatient commitment reduce hospital recidivism?: findings from a randomized trial with severely mentally ill individuals. American Journal of Psychiatry 1999; 156: 1968–75.
Steadman HJ, Gounis K, Dennis D, Hopper K, Roche B, Swartz M, Clark Robbins P. Assessing the New York City involuntary outpatient commitment pilot program. Psychiatric Services 2001; 52: 330–36.
How could they possibly have done, @Mental_Elf ? Such Orders should be agreed, but are largely forced on patients, and foster readmission !
Community treatment orders fail to reduce psychiatric readmissions for people with psychosis: Community treatm… http://t.co/bfqvIDJZ52
CTO study summary from @Mental_Elf – findings show they don’t reduce readmissions for people with psychosis http://t.co/Skz882tKz1
@pmreid86 @mental_elf sadly we said this when they were being introduced but they did it anyway- ppl’s freedom limited for little/no gain
@pmreid86 @Ermintrude2 @Mental_Elf I get the feeling most patient see CTOs as a threat, not as a course of treatment
@D_JWhite @pmreid86 @Mental_Elf I suspect that’s the case with powers under MHA generally
@Ermintrude2 @D_JWhite @Mental_Elf Agree-can be difficult to square experience of compulsory treatment w/ talk of personalised care+recovery
@theagentapsley We’d be interested in yr thoughts on our blog. Do please read it and comment on the website: http://t.co/TP1CkII8HV
OK, @Mental_Elf !
I have spewed out my ideas, @Mental_Elf – thanks for the opportunity to do so !
One of the criteria for the trial is said to be ‘capacity to give consent’.
I wonder whether this is ‘a red herring’, if the seeming legal niceties of ‘putting someone’ (as it is often put) on a Community Treatment Order (CTO) are not actually observed.
From professional experience, I believe that the legal opinion has been expressed that it is possible under Mental Health Act 1983 (as amended), and without a patient ‘applying for’ it, for him or her to be given section 17 leave to, say, a care home or a non-NHS specialist unit. (I am thinking of someone on s. 3.)
In theory, if hospital authorities needed to, ‘reasonable force’ could be used to oblige him or her to go. Forget how ‘untherapeutic’ that is, because the general regime of psychiatric units (e.g. locked wards, compulsion as to ‘treatment’ under the Act – usually an injection, and the dehumanizing environment and attitudes) can hardly be conceived of as therapeutic – or, when it is not that, it is cajoling, coercing, wheedling and blackmailing to seek (a form of) compliance.
Almost certainly, someone whose consideration for a CTO is ‘triggered’ by the Act (e.g. by application or referral to a First-Tier Tribunal, or at the time of contemplating s. 17 leave) will have been plenty depersonalized and demoralized by all of this already, before one even gets in sniffing distance of a formal meeting ‘to consider’ the Order.
Where the Principle of Least Restraint then (not least if no one cannot work out whether it is the CTO regime or that of s. 17, including the example that I gave above, that amounts to least restraint) ?
Patients who have already been brutalized by a place such as I describe (and will typically lack self-confidence and self-esteem), even if formally given the choice to consent to an Order [I understand that they aren’t actually ‘Orders’, and the question of consent is more honoured ‘in the breach’, I gather], have no obvious reason to say No, when it means that they can go home.
(I believe that anyone would snatch at going home, whatever they are asked to agree to, because he or she (wrongly, I think, because not informed) assumes that it is that, or staying put.)
No reason obvious to the patients, then. If they were properly and independently advised as to (a) being able to say No, and (b) What, if they did say No, would be the Responsible Clinician’s (RC’s) options then, the position might be different :
If the RC cannot secure agreement from the patient to meet the conditions that are sought and / or the Approved Mental Health Professional (AMHP) won’t countermand the Order, there is still a position to fall back onto, i.e. s. 17 leave, or even discharge (since there no longer is supervised discharge).
But how many patients oppose a CTO ? How many think – more relevantly, are told – what happens, if they state openly that they will not comply with the conditions, rendering the notion of putting them on an Order ‘dead in the water’ ?
The RC has beds ‘to unblock’, considering a CTO is forced by certain events, but, if the patient is patently saying No, what will the RC do ?
So an Order is effectively dangled, and capacity to consent is really falsified : the patient is not allowed to weigh up whether to agree to the conditions for a CTO in compliance with the test under the Mental Capacity Act 2005 (as amended) simply because he or she is almost certainly not given the full information, which, if he or she had, could be understood and applied.
In truth, I think that the real scenario of a CTO coming about is having huge debts, but being marched down to a bank and told that you need a personal loan from that specific bank.
So not told any safeguards, e.g. that :
(a) the bank can advise only on its own products, and there may be other products
(b) even if the borrower won the Lotto that night and could pay back the loan, interest is charged up front;
(c) there are arrangement fees;
(d) the Bank of Mum and Dad is only too willing to help out, etc., etc.
Such a transaction, if challenged, wouldn’t stand up to the Financial Services Authority (FSA). For me, the way that CTOs are ‘secured’ is no better, but there is no adequate FSA, and patients affected are unlikely to have recourse to one, because they just ‘wanted to go home’.
Pls RT @Rethink_ “Compulsory supervision does not reduce the rate of readmission of psychotic patients” http://t.co/TP1CkII8HV
Pls RT @MindCharity “Compulsory supervision does not reduce the rate of readmission of psychotic patients” http://t.co/TP1CkII8HV
The evidence shows that Community Treatment Orders don’t work. Read @kathryn_amy87’s blog on the OCTET trial http://t.co/TP1CkII8HV
RT @mental_elf Compulsory supervision does not reduce the rate of readmission of psychotic patients http://t.co/gaPhxM0Is6
New trial suggests CTOs don’t work and should be reviewed via @Mental_Elf http://t.co/TuggnzqA1W
I’ve put a modestly sized mega-comment on The @Mental_Elf’s blog for those who like their Community Treatment pure : http://t.co/6D07FWnVmk.
New Lancet RCT finds that CTO’s may not help patients, despite substantial deprivation of personal freedoms http://t.co/TP1CkII8HV
RT @mental_elf: New Lancet RCT finds CTOs may not help patients, despite substantial deprivation of personal freedoms http://t.co/l64OZ5qW6H
The OCTET trial recommends that Community Treatment Orders are urgently reviewed http://t.co/TP1CkII8HV @TheLancet
Community treatment orders fail to reduce psychiatric readmissions for people with psychosis – http://t.co/ftx1l5fCC3
Community treatment orders fail to reduce psychiatric readmissions for people with psychosis http://t.co/yRrVyClwjz via @Mental_Elf #CTOs
Community treatment orders fail to reduce psychiatric readmissions for people with psychosis http://t.co/GxoyaLywxG via @sharethis
Separately, my long comment on Kathryn Walsh’s report on Community Treatment Orders (CTOs) via @Mental_Elf’s Tweets : http://t.co/ow4fHcWmao
@MHFAEngland great blog via @Mental_Elf: Community Treatment Orders show fail to reduce readmissions http://t.co/3i37JQasdi #bigMHdebate
Community Treatment Orders?? What do you think? http://t.co/uvNzIxdXUY
Top blog this week: Community treatment orders fail to reduce psychiatric readmissions for ppl w/ psychosis http://t.co/TP1CkII8HV
Thanks @geoffhuggins What do you think @kathryn_amy87 Worth a little addendum or comment on your blog? http://t.co/TP1CkII8HV
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[…] look too grand either…so let’s turn to Community Treatment Orders. Er, looks like they fail to reduce psychiatric readmissions for people with psychosis. What about persoanlisation in mental health. Slow progress to say the least, but here is an […]
What about possible benefits to the community around the patients? Did nobody examine this?