Skip to main content Accessibility help
×
Home

Information:

  • Access
  • Open access
  • Cited by 4

Actions:

      • Send article to Kindle

        To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

        Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

        Find out more about the Kindle Personal Document Service.

        Little evidence for community treatment orders – a battle fought with heavy weapons
        Available formats
        ×

        Send article to Dropbox

        To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

        Little evidence for community treatment orders – a battle fought with heavy weapons
        Available formats
        ×

        Send article to Google Drive

        To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

        Little evidence for community treatment orders – a battle fought with heavy weapons
        Available formats
        ×
Export citation

Summary

This editorial discusses the pros and cons of community treatment orders (CTOs) from the perspective of community general adult psychiatry. There is little scientific evidence supporting the application of CTOs. Preconditions of a CTO to work are likely to be met by few patients. The time for the application of a CTO may be better spent for patient-centred care until there is sufficient new and robust evidence that identifies the patients that might profit.

Footnotes

Declaration of interest

R.H., S.D. and P.R. are members of the Executive Committee of the Faculty of General Adult Psychiatry of the Royal College of Psychiatrists.

The legislative framework for treatment of mental disorder has evolved in the UK over more than a hundred years, with the successive acts of 1890, 1930, 1959 consolidating and refining the preceding common-law and statutory acts into a framework that became the Mental Health Act 1983. Community treatment orders (CTOs) were implemented in the 2007 Mental Health Bill amending the Mental Health Act.

The discussion about CTOs seems to be ongoing and is fought on both sides with heavy weapons – science, personal experience and best intentions. Sadly, there seems to be no resolution or agreement in sight among patients, carers and professionals. Reference Light1,Reference Stroud, Banks and Doughty2 Supporters argue that we must help unwilling patients to take their medication and accept treatment in their own best interest or in the interest of others around them, even if it is with coercion under a CTO; uncontrolled real-life trials, anecdotal personal evidence and CTO use in 70 jurisdictions Reference Rugkåsa, Dawson and Burns3 have suggested that CTOs may work. Reference Mustafa4 In contrast, opponents aver that all three randomised controlled CTO trials and their meta-analysis have shown absolutely no evidence that CTOs have any significant effect on the treatment outcome of patients. Reference Kisely and Campbell5

This editorial will provide an overview of the arguments on both sides. We will also focus on the practical side of implementation within the current legal framework: what are the preconditions for a CTO to do what it is intended to do, that is reduce hospital admissions and improve outcomes? These practical issues may not have been fully assessed in previous discussions about the CTO. We will refer to the literature and contextualise this to our clinical experience as general psychiatrists with several years' experience of working with CTOs within community services. We will end with some specific recommendations.

The arguments on the pro-side

Supporters of CTOs put forward a number of arguments in their favour, some of which are listed below.

  1. Coercion with treatment for mental disorder in the patients' best interest is justified on ethical grounds and is a feature of the legislative arrangements in many jurisdictions. Reference Dale6

  2. There is no clear logical reason why this right or duty to appropriate treatment should be available in the restrictive hospital setting, but not in the community.

  3. For this purpose, it can be necessary to force non-adherent patients to accept necessary treatment and medication. Reference Mustafa4

  4. There is sufficient professional experience of patients improving under a CTO to justify this type of coercion. Reference Mustafa4

  5. Many clinical studies of CTOs have shown relevant benefits for patients. Reference Nakhost, Perry and Frank7Reference Maughan, Molodynski, Rugkåsa and Burns10

  6. Randomised controlled trials (RCTs) with negative results have not included the right group of patients that are likely to benefit from a CTO Reference Mustafa4 or have not applied the CTO appropriately. Reference Curtis11

The arguments on the con-side

Counter-arguments are being proposed by those who believe CTOs are not as beneficial to patient care as their supporters assert. We have collected some of those arguments below.

  1. Many patients relapse under a CTO. Reference Smith, Branton and Cardno12

  2. CTOs increased health service use. Reference Preston, Kisely and Xiao13

  3. A number of non-randomised studies have provided negative and conflicting results and thus have not provided sufficient evidence to support CTOs. Reference Rugkåsa, Dawson and Burns3,Reference Kisely, Xiao, Crowe, Paydar and Jian14,Reference Castells-Aulet, Hermnandez-Viadel, Jimenez-Martos, Canete-Nicolas, Bellido-Rodriguez and Calabuig-Crespo15

  4. Three independent RCTs and a meta-analysis of their data have shown no benefit of the CTO on the number of hospital admissions and other relevant outcomes. Reference Swartz, Swanson, Wagner, Burns, Hiday and Borum16Reference Rugkåsa, Molodynski, Yeeles, Vazquez Montes, Visser and Burns20

  5. Patients on a CTO have shown even less adherence to depot injections than those not on a CTO. Reference Suetani, Foo and Wilson21

  6. Anecdotal reports do not provide significant evidence for the efficacy of a CTO. They may be the result of the regression to the mean (i.e. the CTO is implemented at a time when the patient is at their most ill) and improvements are therefore the likely results of natural variance of the disease course. Reference Hunt, da Silva, Steve Lurie and Goldbloom22

  7. Patients' human rights might be violated by CTOs. Reference O'Brien23

  8. Owing to flaws in the application of compulsory community care, patients are at risk of being subjected to new forms of social control of an unclear nature without proper legal protection. Reference Zetterberg, Sjöström and Markström24

  9. Without evidence there cannot be any ethical justification to use coercion and severe deprivation of freedom and liberty against psychiatric patients. Reference Rugkåsa, Dawson and Burns3

Necessary conditions for a CTO to work in principle

Psychiatrists in the National Health Service (NHS) work within a legislative framework that includes CTOs. Community psychiatrists with typically sized case-loads will inevitably have experience of working with patients who are subject to CTOs and will have experienced the ethical dilemmas they present. Assuming that CTOs are effective in at least some individual patients, there are necessary preconditions which must be fulfilled for the order to work.

  1. The patient has a treatable mental disorder (i.e. a disorder that has shown some response to treatment).

  2. The patient does not want to continue to take the medication that is likely, from the perspective of the treating psychiatrist, to help maintain improvement and reduce risk of relapse. This may be for a range of reasons including side-effect burden, a disagreement that the medication is responsible for any improvement, a subjective perception that the medication has not helped, a belief that the medication is not necessary to maintain wellness or a disagreement that the problem being treated is a treatable mental disorder.

  3. The subjective, implicit or explicit, benefit–disadvantage evaluation of the patient has thus led to a decision against the treatment continuing in the community.

  4. Previous treatment in the hospital has not been sufficiently effective to lead to remission or improvement and has not increased the insight of the patient into their condition and their willingness to accept treatment.

  5. The patient is fully informed about the CTO and understands the conditions of the CTO. Reference Stroud, Banks and Doughty2

  6. They then accept and submit to the conditions of the CTO. Reference Stroud, Banks and Doughty2

  7. The patient's experience of a hospital stay was negative and the possibility of a hospital readmission is seen as a sufficiently coercive or aversive threat.

  8. This threat is sufficient enough to make the patient change their previous rejection and to accept treatment they otherwise would not accept.

  9. This treatment then improves the patient's mental health and reduces the likelihood of admission to hospital.

The number of patients for whom all these conditions apply may be limited.

Some practical points to consider

There are additional, very relevant issues, including some practical points to consider which we draw from our previous experience with CTOs in the UK since 2008.

  1. The administration of a CTO is time consuming, bureaucratic and draws time away from appropriate patient-centred care. (In our experience, mental health tribunal reports, manager's report, capacity assessments and CTO renewal assessment can take up to 8–20 h, depending on the patient.)

  2. A doctor writing a report or completing the necessary forms does not provide any direct, if any, therapeutic benefit for or influence on the day-to-day care of a patient.

  3. The increase in CTO use with the associated costly legal machinery of mental health tribunals has led to an increase in expenditure which diverts spending from direct patient care.

  4. Threats and coercion may negatively affect the patient–psychiatrist relationship. The applications of a CTO may support paternalistic practice, Reference Patel25 and thus have an impact on the psychiatrist's role as a patient supporter, therefore limiting their influence on the patient.

  5. Many patients do not know that they are under a CTO, are not fully informed or do not understand the regulations of a CTO. Reference Rolfe, Sheehan and Davidson26

  6. CTOs are favoured by relatives and carers, Reference Vine and Komiti27 possibly to force patients to comply with their wishes; this may on some occasions be in their own, but not necessarily in the patient's, best interest.

  7. The functional split between in-patient and out-patient consultants makes regulations and administration difficult. An in-patient consultant may utilise a CTO for one purpose, such as with a view to shorten an in-patient admission, without proper consultation with the psychiatrist and team who will have the task of implementing the order in the community over the longer term. In practice, it is our experience that collaborative planning of CTOs between in-patient and out-patient consultants is not a routine occurrence. Reference Stroud, Banks and Doughty2

  8. The power to recall a patient to hospital by one doctor alone may reduce clinical governance in comparison with a full Mental Health Act assessment. It may have the advantage of being implemented more easily than a full Mental Health Act assessment but this is potentially at the expense of a less complete and balanced assessment.

  9. The recall of a CTO does not allow treatment. Patients who are recalled may stay on a ward for up to 72 h just to wait for a Mental Health Act assessment to happen.

  10. The CTO may be used to submit a patient to less than optimal depot medication, and may prevent the search for better suitable alternative treatments. Reference Lambert, Singh and Patel28

  11. It may be difficult to assume that the simple threat of a hospital admission actually reduces such admissions and our experience has been that this has not appeared to be sufficient. On the other hand, we also have anecdotal examples of patients who may have done well under the framework.

Conclusions

The scientific evidence that CTOs work is weak at best. Reference Rugkåsa, Dawson and Burns3,Reference Maughan, Molodynski, Rugkåsa and Burns10 The likelihood that three independent controlled studies and their meta-analysis have led to false negative results is low. Under these circumstances, no clinical procedure would have any support from any regulatory institution. The use of coercion without or even against scientific evidence may be seen as unethical and might violate the patients' human rights. These circumstances may increase the stigma against psychiatry. Reference Mfoafo-M'Carthy29 However, it is impossible to disprove that CTOs may not work at an individual level in some patients. Those most likely to benefit would appear to be those where the above-mentioned individual conditions are all concurrently met. If any such cases had been included in these controlled studies, their positive outcome must have been mirrored by other patients with an equivalent negative outcome, namely more admissions and worse outcome.

Some of the conditions for a CTO to work are unfavourable: the initial subjective benefit of the treatment is low; the treatment in hospital has not been fully efficient to lead to remission and to sufficient insight; the hospital must be perceived as a sufficient threat to trigger better adherence in the community. This may increase the stigma against psychiatry.

Recommendations

It could be argued that the time, money and resources spent on administration and report writing within the current CTO legislative framework would be better spent working with patients on developing more collaborative approaches to the ongoing management of their condition.

There may be nothing lost if the current CTO is replaced by the better governed use of Section 2 or 3 of the Mental Health Act, utilising the existing provisions of the Act, until the proponents of CTOs have, with some scientific rigour, identified the subgroup of patients for whom it may help and that it does what it is intended to do.

If there is a subset of patients who may benefit from this extension of coercion into the community, it is important that there is a better delineation of the group of patients who benefit through a proper scientific evaluation that does not rely on anecdotal evidence. Such studies are urgently needed to justify the continued application of CTOs in the UK and also worldwide Reference Light1,Reference Kisely and O'Reilly30,Reference Rugkåsa and Dawson31 within mental health systems that are continually under resource pressures.

It may also be helpful to look at how other countries, which have or do not have a comparable legislation, deal with this subgroup of non-adherent patients Reference O'Brien23 and indeed what other paths the UK could have taken in 2007.

We believe also that there is an urgent need for greater transparency over the resource costs associated with the system that has developed over the past 7 years and a debate over how such sums of money are best spent for the benefit of patients.

References

1 Light, E. The epistemic challenges of CTOs. Psychiatric Bull 2014; 38: 68.
2 Stroud, J, Banks, L, Doughty, K. Community treatment orders: learning from experiences of service users, practitioners and nearest relatives. J Ment Health 2015; 24: 8892.
3 Rugkåsa, J, Dawson, J, Burns, T. CTOs: what is the state of the evidence? Soc Psychiatry Psychiatr Epidemiol 2014; 49: 1861–71.
4 Mustafa, FA. Why clinicians still use community treatment orders. Acta Psychiatr Scand 2015; 132: 309–10.
5 Kisely, SR, Campbell, LA. Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Schizophr Bull 2015; 41: 542–3.
6 Dale, E. Is supervised community treatment ethically justifiable? J Med Ethics 2010; 36: 271–4.
7 Nakhost, A, Perry, JC, Frank, D. Assessing the outcome of compulsory treatment orders on management of psychiatric patients at 2 McGill University-associated hospitals. Can J Psychiatry 2012; 5: 359–65.
8 Kjellin, L, Pelto-Piri, V. Community treatment orders in a Swedish county – applied as intended? BMC Res Notes 2014; 7: 879.
9 Rawala, M, Gupta, S. Use of community treatment orders in an inner-London assertive outreach service. Psychiatric Bull 2014; 38: 13–8.
10 Maughan, D, Molodynski, A, Rugkåsa, J, Burns, T. A systematic review of the effect of community treatment orders on service use. Soc Psychiatry Psychiatr Epidemiol 2013; 49: 651–3.
11 Curtis, D. OCTET does not demonstrate a lack of effectiveness for community treatment orders. Psychiatr Bull 2014; 38: 36–9.
12 Smith, M, Branton, T, Cardno, A. Is the bark worse than the bite? Additional conditions used within community treatment orders. Psychiatric Bull 2014; 38: 912.
13 Preston, NJ, Kisely, S, Xiao, J. Assessing the outcome of compulsory psychiatric treatment in the community: epidemiological study in Western Australia. BMJ 2002; 324: 1244.
14 Kisely, S, Xiao, J, Crowe, E, Paydar, A, Jian, L. The effect of community treatment orders on outcome as assessed by the Health of the Nation Outcome Scales. Psychiatry Res 2014; 215: 574–8.
15 Castells-Aulet, L, Hermnandez-Viadel, M, Jimenez-Martos, J, Canete-Nicolas, C, Bellido-Rodriguez, C, Calabuig-Crespo, R, et al. Impact of involuntary out-patient commitment on reducing hospital services: 2-year follow-up. Psychiatr Bull 2015; 29: 196–9.
16 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. Am J Psychiatry 1999; 156: 1968–75.
17 Steadman, HJ, Gounis, K, Dennis, D, Hopper, K, Roche, B, Swartz, M, et al. Assessing the New York City involuntary outpatient commitment pilot program. Psychiatr Serv 2001; 52: 330–6.
18 Burns, T, Rugkåsa, J, Molodynski, A, Dawson, J, Yeeles, K, Vazquez-Montes, M, et al. Community treatment orders for patients with psychosis (OCTET): a randomised controlled trial. Lancet 2013; 381: 1627–33.
19 Kisely, S, Hall, K. An updated meta-analysis of randomized controlled evidence for the effectiveness of community treatment orders. Can J Psychiatry 2014; 59: 561–4.
20 Rugkåsa, J, Molodynski, A, Yeeles, K, Vazquez Montes, M, Visser, C, Burns, T. Community treatment orders: clinical and social outcomes, and a subgroup analysis from the OCTET RCT. Acta Psychiatr Scand 2015; 131: 321–9.
21 Suetani, S, Foo, E, Wilson, D. We need to talk about depot: effect of community treatment order on depot antipsychotic medication compliance. Australas Psychiatry 2014; 22: 357–9.
22 Hunt, AM, da Silva, A, Steve Lurie, S, Goldbloom, DS. Community treatment orders in Toronto: the emerging data. Can J Psychiatry 2007; 52: 647–56.
23 O'Brien, AJ. Community treatment orders in New Zealand: regional variability and international comparisons. Australas Psychiatry 2014; 22: 352–6.
24 Zetterberg, L, Sjöström, S, Markström, U. The compliant court–procedural fairness and social control in compulsory community care. Int J Law Psychiatry 2014; 37: 543–50.
25 Patel, G. Community treatment orders in Victoria: a clinico-ethical perspective. Australas Psychiatry 2008; 16: 340–3.
26 Rolfe, T, Sheehan, B, Davidson, R. Are consumers on community treatment orders informed of their legal and human rights? A West Australian study. Int J Mental Health Nurs 2008; 17: 3643.
27 Vine, R, Komiti, A. Carer experience of Community Treatment Orders: implications for rights based/recovery-oriented mental health legislation. Australas Psychiatry 2015; 23: 154–7.
28 Lambert, TJ, Singh, BS, Patel, MX. Community treatment orders and antipsychotic long-acting injections. Br J Psychiatry 2009; 195: s5762.
29 Mfoafo-M'Carthy, M. Community treatment orders and the experiences of ethnic minority individuals diagnosed with serious mental illness in the Canadian mental health system. Int J Equity Health 2014; 13: 69.
30 Kisely, S, O'Reilly, R. Reappraising community treatment orders – can there be consensus? Med J Aust 2015; 202: 415–6.
31 Rugkåsa, J, Dawson, J. Community treatment orders: current evidence and the implications. Br J Psychiatry 2013; 203: 406–8.