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CTOs: what is the state of the evidence?

Abstract

Purpose

Community Treatment Orders (CTOs) require outpatients to adhere to treatment and permit rapid hospitalisation when necessary. They have become a clinical and policy solution to repeated hospital readmissions despite some strong opposition and the contested nature of published evidence. In this article, we appraise the current literature on CTOs from the viewpoint of Evidence-Based Medicine and discuss the way forward for using and researching CTOs.

Results

Non-randomised outcome studies show conflicting results, but their lack of standardisation of methods and measures makes it difficult to draw conclusions. In contrast, all three randomised controlled trials (RCTs) conducted concur in their findings that CTOs do not impact on hospital outcomes. No systematic review or meta-analysis has identified any clear clinical advantage to CTOs.

Conclusion

The evidence-base does not support the use of CTOs in their current form. Involuntary clinical interventions must conform to the highest standard of evidence-based care. To enable clinicians to take an evidence-based approach and to settle remaining uncertainties about the current evidence, high-quality RCTs should be designed and undertaken, using standardised outcome measures.

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References

  1. Killespy H, Kingett S, Bebbington P et al (2009) Randomised evaluation of assertive community treatment: 3-year outcomes. Br J Psychiatry 195:81–82

    Article  Google Scholar 

  2. Sjöström S, Zetterberg L, Markström U (2011) Why community compulsion became the solution—reforming mental health law in Sweden. Int J Law Psychiatry 34:419–428

    PubMed  Article  Google Scholar 

  3. Churchill R, Owen G, Hotopf, M Singh S (2007) International experiences of using community treatment orders. London, Department of Health and the Institute of Psychiatry, King’s College

  4. Dawson J (2005) Community treatment orders: international comparisons. University of Otago, Otageo

    Google Scholar 

  5. Lawton-Smith S (2005) A question of numbers. The potential impact of community-based treatment orders in England and Wales. The King’s Fund, London

    Google Scholar 

  6. Care Quality Commission (2012) Monitoring the Mental Health Act in 2011/12. http://www.cqc.org.uk/sites/default/files/media/documents/cqc_mentalhealth_2011_12_main_final_web.pdf. Accessed 13 November 2013

  7. Manning C, Molodynski A, Rugkåsa J, Dawson J, Burns T (2011) Community treatment orders in England and Wales, clinicians’ views and use: a national survey. Psychiatrist 35:1–6

    Article  Google Scholar 

  8. SINTEF (2008) Bruk and tvungent psykisk helsevern uten døgnomsorg i 2007 [The use of community treatment orders in 2007]. SINTEF A8237. Trondheim, SINTEF Helse

  9. Dawson J, Szmukler G (2006) Fusion of mental health and incapacity legislation. Br J Psychiatry 188:504–509

    PubMed  Article  Google Scholar 

  10. Eastman N (2006) Reforming mental health law in England and Wales. Br Med J 332:737–738

    Article  Google Scholar 

  11. Dawson J (2002) Randomised controlled trials of mental health legislation. Med Law Rev 10:308–321

    PubMed  Article  Google Scholar 

  12. Swartz MS, Burns BJ, George LK et al (1997) The ethical challenges of a randomised controlled trial of Involuntary Outpatient Commitment. J Ment Health Adm 24:35–43

    CAS  PubMed  Google Scholar 

  13. Burns T, Dawson J (2009) Community treatment orders: how ethical without experimental evidence? Psychol Med 39:1583–1586

    CAS  PubMed  Article  Google Scholar 

  14. Romans S, Dawson J, Mullen R, Gibbs A (2004) How mental health clinicians view community treatment orders: a national New Zealand survey. Aust NZ J Psychiatry 38:836–841

    Article  Google Scholar 

  15. Mullen R, Dawson J, Gibbs A (2006) Dilemmas for clinicians in use of community treatment orders. Int J Law Psychiatry 29:535–550

    PubMed  Article  Google Scholar 

  16. Dawson J, Mullen R (2008) Insight and use of community treatment orders. J Ment Health 17:269–280

    Article  Google Scholar 

  17. O’Reilly R, Keegan D, Corring D, Shrikhande S, Natarajan D (2006) A qualitative analysis of the use of community treatment orders in Saskatchewan. Int J Law Psychiatry 29:516–524

    PubMed  Article  Google Scholar 

  18. Mullen R, Gibbs A, Dawson J (2006) Family perspective on community treatment orders: a New Zealand study. Int J Soc Psychiatry 52:469–478

    PubMed  Article  Google Scholar 

  19. Dawson J, Romans S, Gibbs A, Ratter N (2003) Ambivalence about community treatment orders. Int J Law Psychiatry 26:243–255

    PubMed  Article  Google Scholar 

  20. Gibbs A, Dawson J, Ansley C, Mullen A (2005) How patients in New Zealand view community treatment orders. J Ment Health 14:357–368

    PubMed  Article  Google Scholar 

  21. Schwartz K, O’Brien AM, Morel V, Armstrong M, Fleming C, Moore P (2010) Community treatment orders: the service user speaks. Exploring the lived experience of community treatment orders. Int J Psychosoc Rehab 15:39–50

    Google Scholar 

  22. Swartz MS, Swanson JW, Wagner HR, Hannon MJ, Burns BJ, Shumway M (2003) Assessment of four stakeholder groups’ preferences concerning outpatient commitment for persons with schizophrenia. Am J Psychiatry 160:1130–1146

    Article  Google Scholar 

  23. Kisely S, Cambell LA (2007) Methodological issues in assessing the evidence for compulsory community treatment. Curr Psychiatry Rev 3:51–56

    Article  Google Scholar 

  24. O’Reilly R (2009) Research on community treatment orders. In: Vingilis ER, State SA (eds) Applied research and evaluation in community mental health services. McGill-Queen’s University Press, Montreal, pp 68–79

    Google Scholar 

  25. Maughan D, Molodynski A, Rugkåsa J, Burns T (2013) A systematic review of the effect of community treatment orders on service use. Soc Psychiatry Psychiatr Epidemiol. doi:10.1007/s00127-013-0781-0

    Google Scholar 

  26. Segal S, Burgess P (2006) Factors in the selection of patients for conditional release from their first psychiatric hospitalization. Psychiatr Serv 57:1614–1622

    PubMed  Article  Google Scholar 

  27. Segal S, Burgess P (2006) The utility of extended outpatient civil commitment. Int J Law Psychiatry 29:525–534

    PubMed  Article  Google Scholar 

  28. Swartz M, Wilder C, Swanson J et al (2010) Assessing outcomes for consumers in New York’s assisted outpatient treatment program. Psychiatr Serv 61:976–981

    PubMed  Article  Google Scholar 

  29. Van Dorn R, Swanson J, Swartz M et al (2010) Continuing medication and hospitalization outcomes after assisted outpatient treatment in New York. Psychiatr Serv 61:982–987

    PubMed  Article  Google Scholar 

  30. Hunt A, da Silva A, Lurie S, Goldbloom D (2007) Community treatment orders in Toronto: the emerging data. Can J Psychiatry 52:647–655

    PubMed  Google Scholar 

  31. Muirhead D, Harvey C, Ingram G (2006) Effectiveness of community treatment orders for treatment of schizophrenia with oral or depot antipsychotic medication: clinical outcomes. Aust NZ J Psychiatry 40:596–605

    Article  Google Scholar 

  32. Nakhost A, Perry JC, Frank D (2012) Assessing the outcome of compulsory treatment orders on management of psychiatric patients at two McGill University-associated hospitals. Can J Psychiatry 57:359–365

    PubMed  Google Scholar 

  33. Christy A, Petrila J, McCranie M, Lotts V (2009) Involuntary outpatient commitment in Florida: case information and provider experience and opinions. Int J Forensic Ment Health 8:122–130

    Article  Google Scholar 

  34. Segal S, Burgess P (2008) Use of community treatment orders to prevent psychiatric hospitalization. Aust NZ J Psychiatry 42:732–739

    Article  Google Scholar 

  35. Kisely S, Preston N, Xiao J et al (2013) An eleven-year evaluation of the effect of community treatment orders on changes in mental health service use. J Psychiatr Res 47:650–656

    PubMed  Article  Google Scholar 

  36. Segal S, Preston N, Kisely S, Xiao J (2009) Conditional release in Western Australia: effect on hospital length of stay. Psychiatr Serv 60:94–99

    PubMed  Article  Google Scholar 

  37. Burgess P, Bindman J, Leese M, Henderson C, Szmukler G (2006) Do community treatment orders for mental illness reduce readmission to hospital? An epidemiological study. Soc Psychiatry Psychiatr Epidemiol 41:574–579

    PubMed  Article  Google Scholar 

  38. Segal S, Burgess P (2006) Conditional release, a less restrictive alternative to hospitalization? Psychiatr Serv 57:1600–1606

    PubMed  Article  Google Scholar 

  39. Kisely S, Campbell LA, Preston NJ, Xiao J (2006) Can epidemiological studies assist in the evaluation of community treatment orders?—The experience of Western Australia and Nova Scotia. Int J Law Psychiatry 29:507–515

    PubMed  Article  Google Scholar 

  40. Zanni G, Stavis P (2007) The effectiveness and ethical justification of psychiatric outpatient commitment. Am J Bioethics 7:31–41

    Article  Google Scholar 

  41. O’Brien A, Farrell S, Faulkner S (2009) Community treatment orders: beyond hospital utilization rates examining the association of community treatment orders with community engagement and supportive housing. Comm Ment Health J 45:415–419

    Article  Google Scholar 

  42. Swartz MS, Swanson JW, Wagner HR, Burns BJ, Hiday VA, Borum R (1999) Can involuntary outpatient commitment reduce hospital recidivism?: findings from a randomized trial with severely mentally ill individuals. Am J Psychiatry 156:1968–1975

    CAS  PubMed  Google Scholar 

  43. Szmukler G, Hotopf M (2001) Effectiveness of involuntary outpatient commitment. Am J Psychiatry 158:653–654

    CAS  PubMed  Article  Google Scholar 

  44. Liberman J, Stroup T, McEvoy J et al (2005) Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. New Eng J Medicine 353:1209–1223

    Article  Google Scholar 

  45. Austin P (2009) The relative ability of different propensity score methods to balance measured covariates between treated and untreated subjects in observational studies. Med Decis Mak 29:661–677

    Article  Google Scholar 

  46. Ioannis JP (2005) Why most published research findings are false. PLoS Med 2:696–701

    Google Scholar 

  47. Dahl F, Grotle M, Benth JS, Natvig B (2008) Data splitting as a countermeasure against hypothesis fishing: with a case study of predictors for low back pain. Eu J Epidemiol 23:237–242

    Article  Google Scholar 

  48. Dawson J, Burns T, Rugkåsa J (2011) Lawfulness of a randomised trial of the new community treatment order regime for England and Wales. Med Law Rev 19:1–26

    CAS  PubMed  Article  Google Scholar 

  49. Steadman H, Gounis K, Dennis D, Hopper K, Roche B, Swartz M et al (2001) Assessing the New York City involuntary outpatient commitment pilot programme. Psychiatr Serv 52:330–336

    CAS  PubMed  Article  Google Scholar 

  50. Burns T, Rugkåsa J, Molodynksi A et al (2013) Community treatment orders for patients with psychosis: a randomised controlled trial (OCTET). Lancet 381:1627–1633

    PubMed  Article  Google Scholar 

  51. Swartz M, Swanson J (2004) Involuntary outpatient commitment, community treatment orders, and assisted outpatient treatment: what’s in the data? Can J Psychiatry 49:585–591

    PubMed  Google Scholar 

  52. Kisely K, Cambell L (2006) Community treatment orders for psychiatric patients: the emperor with no clothes. Can J Psychiatry 51:683–685

    PubMed  Google Scholar 

  53. Telson H, Glickstein R, Trujillo M (1999) Report of the Bellevue Hospital Center outpatient commitment pilot program. Bellevue Hospital Center, Department of Psychiatry, New York

    Google Scholar 

  54. Kisely S, Cambell L, Scott A, Preston N, Xiao J (2007) Randomised and non-randomised evidence for the effect of compulsory and involuntary out-patient treatment of health service use: systematic review and meta-analysis. Psychological Med 37:3–14

    Article  Google Scholar 

  55. Nakhost A, Perry C, Simpson A (2013) Community treatment for patients with psychosis. Letter to the editor. Lancet 382:501

    PubMed  Article  Google Scholar 

  56. McCutcheon R (2013) Community treatment for patients with psychosis. Letter to the editor. Lancet 382:501

    PubMed  Article  Google Scholar 

  57. Geller J (2013) Community treatment for patients with psychosis. Letter to the editor. Lancet 382:501

    Article  Google Scholar 

  58. Naudet R (2013) Community treatment for patients with psychosis. Letter to the editor. Lancet 382:502

    Article  Google Scholar 

  59. Mustafa F (2013) On the OCTET and supervised treatment orders. Med Sci Law. doi:10.1177/0025802413506898

    Google Scholar 

  60. Segal S (2013) Commentary to Community treatment orders do not reduce hospital admissions in people with psychosis. Evid Based Ment Health. doi:10.1136/eb-2013-101438

    PubMed  Google Scholar 

  61. Sweetman E, Doig G (2011) Failure to report protocol violations in clinical trials: a threat to internal validity? Trials 12:214

    PubMed Central  PubMed  Article  Google Scholar 

  62. Lassen K, Høye A, Myrmel T (2012) Randomised trials in surgery: the burden of evidence. Rev Recent Clin Trials 7:244–248

    PubMed  Article  Google Scholar 

  63. Dawson J (2010) Community treatment orders. In: Gostin L, Bartlett P, Fennell P, McHale J, McKay R (eds) The principles of mental health law and policy. Oxford University Press, Oxford, pp 513–514

    Google Scholar 

  64. Department of Health (2008) Code of Practice: Mental Health Act 1983. Stationary Office, London

    Google Scholar 

  65. Kisely S, Campbell LA, Preston N (2009) Compulsory community and involuntary outpatient treatment for patients with severe mental health disorders. Cochrane database of systematic reviews 3

  66. Burns T (2007) Hospitalisation as an outcome measure in schizophrenia. Br J Psychiatry 161(suppl. 50):s37–s41

    Article  Google Scholar 

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Acknowledgments

We would like to thank Daniel Maughan for his input into this manuscript. We also thank the two reviewers for useful comments.

Conflict of interest

The authors are part of the OCTET study team.

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Correspondence to Jorun Rugkåsa.

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Rugkåsa, J., Dawson, J. & Burns, T. CTOs: what is the state of the evidence?. Soc Psychiatry Psychiatr Epidemiol 49, 1861–1871 (2014). https://doi.org/10.1007/s00127-014-0839-7

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  • DOI: https://doi.org/10.1007/s00127-014-0839-7

Keywords

  • Community treatment orders
  • Outpatient commitment
  • Evidence-based psychiatry
  • Community coercion
  • Mental health law