Community Treatment Orders: An Essential Therapeutic Tool in the Face of Continuing Deinstitutionalization

Abstract

Although Dr Kisely will suggest that there is minimal evidence to indicate that CTOs work and, further, that CTOs have significant negative effects, I will show that both of these propositions are incorrect. Although this debate is an academic exercise, the decision to support or oppose CTOs has profound implications for people with severe mental illness. Most jurisdictions in the developed world have introduced or are considering the introduction of legislation to support CTOs. If Dr Kisely's position were to be adopted, clinicians would be prevented from using any form of mandatory treatment in the community. Currently, psychiatrists and other clinicians must strive to manage, in community settings, individuals who lack any awareness of their mental illness or of their need for treatment. This challenge is only going to get worse. Remember, deinstitutionalization is not a historical event-it is an ongoing process! In the coming years, patients suffering from psychosis and having increasingly problematic behaviours will be discharged to our communities. We have not been able to manage these individuals in hospitals without requiring them to take treatment. Why would anyone think that we are suddenly going to be able to do this in the community? In fact, the opposition to the introduction of CTOs is only the latest battleground for the groups that have campaigned against inpatient committal and compulsory inpatient treatment. However, a CTO makes it possible for a reluctant patient to receive essential treatment while living in his or her community and is thus consistent with the principle of using the least restrictive alternative. Only extreme libertarians such as Thomas Szasz, who disavow the very existence of mental illness, suggest that individuals who lose contact with reality should be left to fend for themselves. Most of us believe that a caring society has a responsibility to look after individuals who are unable to care for themselves. Individuals who do not recognize that they are ill do not seek treatment. Indeed, many actively reject treatment, even when they desperately need it. The first question, then, is whether CTOs actually increase the probability that an individual with a psychotic illness and a history of not following up with services will receive the treatment and supervision necessary to live safely in the community. This is an important, but also deceptively simplistic, question. The answer will in part depend on the specifics of the CTO legislation. For example, the legal powers available to clinicians to respond to a patient's refusal of treatment are likely to be important factors in determining effectiveness. The answer will also depend on the types of patients for whom CTOs are used. Space does not permit a full discussion of these issues, but I have discussed them elsewhere (1). Bearing these complexities in mind, there is extensive evidence that various forms of CTO legislation improve several important outcomes for patients with severe mental illness. Research has demonstrated that patients on a CTO are more likely to attend appointments and to have improved quality of life and that they are less likely to present at the emergency department, to be hospitalized, to be victimized, to be violent, or to be arrested (2). These studies have examined several legislative models used in Canada (3,4), as well as models in the United States, the United Kingdom, and Australia (2). Some of these studies have been criticized because of their small size, but critics duplicitously overlook the fact that others include more than 4000 subjects (5). Dr Kisely will probably try to ignore the numerous studies indicating positive effects of CTOs and suggest that only the findings from RCTs should be considered. This is a naive approach. The extensive research using the test-retest strategy and control groups does have methodological problems not present in the existing RCTs; however, the RCTs in turn have significant failings that do not compromise the other studies. …