Community Treatment Orders Research Articles

What does being on a community treatment orders entail? A 3-year follow-up of the OCTET CTO cohort.

Community Treatment Orders lack evidence of effectiveness. Very little is known about how they are used in practice and over time in terms of what it obliges patients to do and the judicial threshold for remaining on an order. To investigate CTO implementation in England in terms of the use of specified conditions, and judicial hearings; whether these change over time, and; the level of continued coercion. 36-month observational prospective study of patients on CTO in the OCTET follow-up study. The number of CTO conditions remained stable over time but consolidated around medication adherence and remaining in contact with services. Ten percent of Mental Health Tribunal Hearings and only 1percent of Hospital Managers Hearings resulted in discharge. Twenty-seven percent of patients experienced more than one CTO episode and eighteen percent remained under compulsion until the end of follow-up. CTOs seem to be used primarily to oblige patients to take medication and stay in contact with services. There is agreement between clinical and legal judgements about their appropriateness and threshold for use. A pattern of continuous coercion for a significant group of patients raises concerns. If CTOs are to be continued to be imposed, their use should be carefully monitored with further cohort studies with long-term follow-up.

Involuntary Outpatient Commitment and the Elusive Pursuit of Violence Prevention.

Involuntary outpatient commitment (OPC)-also referred to as 'assisted outpatient treatment' or 'community treatment orders'-are civil court orders whereby persons with serious mental illness and repeated hospitalisations are ordered to adhere to community-based treatment. Increasingly, in the United States, OPC is promoted to policy makers as a means to prevent violence committed by persons with mental illness. This article reviews the background and context for promotion of OPC for violence prevention and the empirical evidence for the use of OPC for this goal. Relevant publications were identified for review in PubMed, Ovid Medline, PsycINFO, personal communications, and relevant Internet searches of advocacy and policy-related publications. Most research on OPC has focussed on outcomes such as community functioning and hospital recidivism and not on interpersonal violence. As a result, research on violence towards others has been limited but suggests that low-level acts of interpersonal violence such as minor, noninjurious altercations without weapon use and arrests can be reduced by OPC, but there is no evidence that OPC can reduce major acts of violence resulting in injury or weapon use. The impact of OPC on major violence, including mass shootings, is difficult to assess because of their low base rates. Effective implementation of OPC, when combined with intensive community services and applied for an adequate duration to take effect, can improve treatment adherence and related outcomes, but its promise as an effective means to reduce serious acts of violence is unknown.

The association between continuity of care and readmission to hospital in patients with severe psychosis.

PurposeProviding good continuity of care to patients is considered a vital component of community mental health services, but there is limited evidence that it is associated with good outcomes. We measured service use and a multidimensional concept of continuity of care in 323 patients who were to be discharged from hospital following compulsory treatment for psychosis to investigate the association between continuity and rehospitalisation.MethodsWe conducted a 36-month prospective cohort study of the patients recruited to the Oxford Community Treatment Order Trial (OCTET). We collected data from medical records on eight previously operationalized measures of continuity. We conducted regression analyses to determine the association between these measures and readmission to hospital, time to readmission, and the number of days spent in hospital.ResultsAlmost two thirds (n = 206, 63.8%) of patients were readmitted. Patients were seen frequently, with a mean of 2.9 (SD = 2.47) contacts a month throughout the follow-up. Less frequent contact was significantly associated with lower odds of rehospitalisation and fewer days in hospital. More changes in the patient’s care coordinator were associated with more time in hospital. Patients who had a higher proportion of clinical correspondence copied to them spent fewer days in hospital.ConclusionPatients with severe and relapsing psychotic illness are seen frequently and consistently in community mental health services. Higher levels of patient contact could be a response to the severity of illness rather than a marker of quality of care. Using a simple linear interpretation of contact frequency as a measure of continuity of care in this patient group may be of limited value in modern services.

"Restricted Community Members": Research Protections and Opportunities for Individuals Committed to Assisted Outpatient Treatment.

Several forms of mandated community treatment exist in the United States. One mechanism, assisted outpatient treatment (AOT), has become both more common and more controversial in recent years. The status of individuals committed to AOT remains unclear within regulatory guidelines aimed at protecting research participants. Should individuals on AOT be considered psychiatric inpatients, prisoners, community members, or something else? The authors argue that persons on AOT inhabit a gray area wherein they should be given some of the ethical protections afforded to involuntary inpatients and prisoners, but they should also enjoy freedoms as members of the community. The authors' term for this population is "restricted community members." The need to protect individuals in this population from potentially coercive forces of AOT while also offering them the opportunity to participate in research is especially acute in areas of research where the need is great: serious mental illness and substance use disorders.

Involuntary Outpatient Commitment: The Limits of Prevention

Preventive outpatient commitment laws require people with mental illnesses to participate in mental health treatment before they meet the criteria for inpatient civil commitment — clear and convincing evidence of mental illness and dangerousness to self or others. These laws apply to people who are chronically ill but not imminently dangerous. Most outpatient commitment laws do not require a judicial determination of incompetence, nor do they require a criminal charge or a criminal conviction. As such, outpatient commitment statutes unearth an old question on law, ethics, and the limits of prevention: under what circumstances can we impose substantial restraints on individual liberty because we believe a person is likely to harm himself or others before he actually has done so?Although most authors rest the moral justification for outpatient commitment on a mental impairment — be it impaired insight, decisional-incapacity or incompetence to refuse treatment, this Article claims that government interventions into self-regarding harm and other-regarding harm require distinct moral justifications. When our primary concern is one of self-regarding harm, a court order to participate in outpatient treatment may be appropriate, but only for people with mental illnesses who are incompetent to make treatment decisions on their own. If, however, we are concerned about harm to others, a court order to participate in outpatient treatment may be appropriate, but only for people with mental illnesses who lack the moral capacities for criminal responsibility — either because they are unlikely to appreciate the wrongfulness of their conduct or because they are unable to conform their conduct to the requirements of the law.

Community Treatment Orders-A pause for thought.

Community Treatment Orders (CTO) have been available for several decades in some countries and are being progressively introduced worldwide, with significant uptake in Asian countries as they move more mental health care into the community. However the evidence for the effectiveness of CTOs is limited. The evidence from local audits and evaluations is conflicted with some studies showing clear benefit and others not. The same is the case for uncontrolled before and after studies. The higher levels of evidence such as randomised controlled trials, systematic reviews, and Cochrane reviews have consistently failed to demonstrate benefits from CTO use on key measures such as symptom levels, functioning, and healthcare use. Despite this they are increasingly available internationally and often greeted enthusiastically by clinicians and families who want to ensure care and follow up for the mentally ill. This article briefly discusses the evidence before describing potential alternatives to the use of compulsion that do have an evidence base, such as multidisciplinary community working, housing initiatives, and employment support.

Perceptions Among Psychiatric Staff of Creating a Therapeutic Alliance With Patients on Community Treatment Orders

A therapeutic alliance with a continuing collaboration between a patient and psychiatric staff is a resource for helping patients cope with the demands of coercive legislation. Knowledge exists describing coercion in inpatient care while the knowledge regarding the perceptions of creating a therapeutic alliance with patients on Community Treatment Orders (CTO) among psychiatric staff is scarce. To describe perceptions among psychiatric staff of creating a therapeutic alliance with patients on CTOs, an exploratory design using a phenomenographic method was employed. Thirteen semi-structured audio-taped interviews were conducted with psychiatric staff responsible for patients on CTOs. The staff worked in five different outpatient clinics and the interviews were conducted at their workplaces. The analysis resulted in in four metaphors: the persevering psychiatric staff, the learning psychiatric staff, the participating psychiatric staff, and the motivating psychiatric staff. Patients on CTOs were more time-consuming for psychiatric staff in care and treatment. Long-term planning is required in which the creation of a therapeutic alliance entails the patient gradually gaining greater self-awareness and wanting to visit the outpatient clinic. The professional–patient relationship is essential and if a therapeutic alliance is not created, the patient's continued care and treatment in the community is vulnerable.

Community treatment orders – what are the views of decision makers?

Background: Community treatment orders (CTOs) are being increasingly used in Western countries. The scheme implies that mental health patients can live outside a hospital, but still be subject to coercive care to ensure compliance with their treatment. There is limited knowledge of how the scheme is practised.Aims: To gain knowledge of how decision makers weigh and evaluate various considerations when making decisions on CTOs.Method: Qualitative in-depth interviews with decision makers responsible for CTOs in Norway.Results: Decision makers viewed CTOs as a useful scheme to ensure control, continuity and follow-up care in the treatment of outpatients with a history of poor treatment motivation. They had varied interest in and knowledge of the patient’s life situation and how the scheme affects the patient’s everyday life. Little attention was devoted to patient experiences of formal and informal coercion.Conclusion: When deciding on CTOs, decision makers should pay more attention to the negative consequences that patients may experience. In many cases, decision makers are probably not aware of these coercive factors.

Are community treatment orders counterproductive?

This article briefly reviews the literature pertaining to community treatment orders (CTOs) specifically how and why they are utilised and how effective mandated community treatment really is. This review discusses the use of CTOs in the context of the recovery model. This article highlights the shortfalls in the current CTO system while also demonstrating the increase in acute coercive care. The literature pertaining to the effectiveness of CTOs is inconsistent with more recent reviews denoting that there is now robust evidence the CTOs are not effective. Further treatment that aligns with the recovery model as oppose to mandated treatment is known to increase treatment compliance.

How shortcomings in the mental health system affect the use of involuntary community treatment orders.

Objective The aim of the present study was to examine stakeholder perspectives on how the operation of the mental health system affects the use of involuntary community treatment orders (CTOs). Methods A qualitative study was performed, consisting of semi-structured interviews about CTO experiences with 38 purposively selected participants in New South Wales (NSW), Australia. Participants included mental health consumers (n=5), carers (n=6), clinicians (n=15) and members of the Mental Health Review Tribunal of NSW (n=12). Data were analysed using established qualitative methodologies. Results Analysis of participant accounts about CTOs and their role within the mental health system identified two key themes, namely that: (1) CTOs are used to increase access to services; and (2) CTOs cannot remedy non-existent or inadequate services. Conclusion The findings of the present study indicate that deficiencies in health service structures and resourcing are a significant factor in CTO use. This raises questions about policy accountability for mental health services (both voluntary and involuntary), as well as about the usefulness of CTOs, justifications for CTO use and the legal criteria regulating CTO implementation. What is known about this topic? Following the deinstitutionalisation of psychiatric services over recent decades, community settings are increasingly the focus for the delivery of mental health services to people living with severe and persistent mental illnesses. The rates of use of involuntary treatment in Australian community settings (under CTOs) vary between state and territory jurisdictions and are high by world standards; however, the reasons for variation in rates of CTO use are not well understood. What does this paper add? This paper provides an empirical basis for a link between the politics of mental health and the uptake and usefulness of CTOs. What are the implications for practitioners? This paper makes explicit the real-world demands on the mental health system and how service deficiencies are a significant determinant in the use of CTOs. Practitioners and policy makers need to be candid about system limitations and how they factor in clinical and legal justifications for using involuntary treatment. The results of the present study provide data to support advocacy to improve policy accountability and resourcing of community mental health services.

An empirical ethical analysis of community treatment orders within mental health services in England

Community treatment orders are a legal mechanism to extend powers of compulsion into outpatient mental health settings in certain circumstances. Previous ethical analyses of these powers have explored a perceived tension between a duty to respect personal freedoms and autonomy and a duty to ensure that patients with the most complex needs are able to receive beneficial care and support that maximises their welfare in the longer-term. This empirical ethics paper presents an analysis of 75 interviews with psychiatrists, patients and family carers to show how these ethical considerations map onto the different ways that community treatment orders are used and experienced in practice. A complex and nuanced account of how the requirements to respect patients’ autonomy, to respect patients’ liberty and to act beneficently should be interpreted in order to make judgements about the ethics of community treatment orders is presented. The article argues that, due to such complexity, no general ethical justification for community treatment orders can be provided, but a justification on the basis of the promotion of patients’ autonomy could provide an ethical reason for community mental health practitioners to make use of a community treatment order in some limited circumstances.

Interventions to Reduce Compulsory Psychiatric Admissions: A Systematic Review and Meta-analysis.

Compulsory admissions, defined as admissions against the will of the patient (according to local judicial procedures), have a strong effect on psychiatric patients. In several Western countries, the rate of such admissions is tending to rise. Its reduction is urgently needed. To establish which interventions effectively reduce compulsory admissions in adult psychiatric patients in outpatient settings. A systematic computerized literature search was performed using EMBASE, MEDLINE, Web of Science, PsycINFO, CINAHL, PubMed (not yet indexed for MEDLINE), Cochrane Central, and Google Scholar. Every database was searched from its inception until April 30, 2015. Randomized clinical trials (RCTs) that studied any kind of intervention designed to reduce compulsory admission rates in adult psychiatric patients (age range, 18-65 years) in outpatient settings were eligible. Eligibility was independently assessed by 2 of us. Two of us independently extracted relevant data. The Cochrane Collaboration's tool was used for assessing risk of bias. Overall risk reduction (random-effects estimate) was calculated in the following 4 subgroups of interventions: advance statements, community treatment orders, compliance enhancement, and integrated treatment. Relative risk (RR) was calculated on the basis of the number of patients who had been compulsorily admitted. Our meta-analyses included 13 RCTs comprising 2970 psychiatric patients. The meta-analysis of the RCTs on advance statements showed a significant 23% (RR, 0.77; 95% CI, 0.60-0.98; I2 = 2.2%) (n = 1102) risk reduction in compulsory admissions. In contrast, the RCTs on community treatment orders (RR, 0.95; 95% CI, 0.81-1.10; I2 = 0.0%) (n = 742), compliance enhancement (RR, 0.52; 95% CI, 0.11-2.37; I2 = 55.7%) (n = 250), and integrated treatment (RR, 0.71; 95% CI, 0.49-1.02; I2 = 49.0%) (n = 876) showed no significant risk reduction in compulsory admissions. The meta-analysis of the RCTs on advance statements showed a statistically significant and clinically relevant 23% reduction in compulsory admissions in adult psychiatric patients, whereas the meta-analyses of the RCTs on community treatment orders, compliance enhancement, and integrated treatment showed no evidence of such a reduction. To date, only 13 RCTs have used compulsory admissions as their primary or secondary outcome measure. This demonstrates the need for more research in this field.

Joint Decision Making and Reduced Need for Compulsory Psychiatric Admission

The article by de Jong et al1 in this issue of JAMA Psychiatry raises fundamental questions about the practice of psychiatry. In essence, the review finds that advance statements can reduce the occurrence of compulsory admissions by approximately one-quarter, while community treatment orders, medication compliance enhancement, and integrated treatment measures were ineffective in reducing compulsory admissions. Why is this issue important? Writing in On Liberty, John Stuart Mill differentiated between liberty as the freedom to act and liberty as the absence of coercion. Yet, it is clear that inmost countries of theworld (whether codified and regulated by law or not) measures to treat people withmental illness on a basis of compulsory admissions are used and are sometimes commonly used. Within the psychiatric profession, therehasbeenanuneasyelisionbetween theduty tocare forpatientsandtheresponsibilitytoact forsociety,onwhosebehalfphysiciansoftenusecompulsoryadmissions (eg, toprotect the public from risk by peoplewho arementally unwell). Variouswordinghasbeenusedtotry toreconcile theseseparateand oftencontradictory roles, suchas theprovisionof the“least restrictive alternative” formof treatment by the physician. This dual professional role is now subject to a profound challenge from the United Nations Convention on the Rights of PersonsWithDisabilities (CRPD).2 Amongmany other provisions, the CPRDmakes clear that direct decisionmaking by patients and forms of supported decisionmaking are permissibleunder the convention, but that substituteddecisionmaking (which is the essence of compulsory treatment decisions by psychiatrists) is not allowed. Because the CPRD has now been signedby 159 countriesworldwide and ratified (made legally binding) by 151, a vital question arises over whether the traditional practices of psychiatrists’ exercising legally authorizedordefactopowersofcompulsoryadmissions, inbothhospital and community settings, are compatible with the CRPD or not.3 These considerations are complex issues that need to respect the fundamental human rights of all persons, including those with disabilities. They also need to take into account theday-to-dayclinicaldilemmas facedbystaffwho treat and care for people who at timesmay lackmental capacity in specific domains andwho, for example,mayactively threaten toharmthemselvesorothers.Therefore, theresponsible implementationof theCRPD is a pressing international challenge to the mental health sector. Against this background, the article by de Jong et al1 adds important evidence to support these debates on how to reduce compulsory admissions in mental health care. The authors tested the following 4 candidate interventions to reduce compulsoryhospital admissions: community treatment orders (sometimes called involuntary outpatient commitment) (3studies), complianceenhancement techniques (2studies), and augmentation of standard care (which they termed integrated treatment) (4 studies), alongside assessing the effect of advance statements (including advance directives and joint crisisplans [JCPs]) (4 studies).For the first 3options, there was no evidence that they were effective. Admittedly, the samplesize foreachcategorywassmall, andarguably theyeach contained somewhat heterogeneous interventions. For example, integrated treatment included several different types of augmented standard care, namely, crisis resolution teams, integrated treatment in first-episode schizophrenia, and psychoeducation. For the community treatment orders and compliance enhancement interventions, these studies (both individually and when analyzed by group) also demonstrated no evidence of benefit, as shown in the forest plot in the article by de Jong et al.1 Yet, advance statements showed a 23% risk reduction in compulsory admissions. The term advance statements covers a rangeof decision-making interventions,whichvarywith respect to their basis in legislation and the manner in which health professionals are involved in their creation.4 Advance directives lie at one extreme of this range because their content is determined solely by the patient or consumer. In the United States, supporting people to create a psychiatric advance directive is viewed as a component of recoveryoriented treatmentplanning, and indeed thesedirectivesmay have the power of law. Psychiatric advance directives aim to promoteconsumerchoice,prioritize thegoalof autonomy,and improve the working alliance withmental health professionals. However, they have not been shown to have an effect on ratesof involuntaryhospitalization.Themost likely reason for this observation is that they are enactedonlywhen theholder is deemed to have lost capacity tomake treatment decisions, are onlyused at a late stage of a relapse of illness, andmaynot be able to prevent such admissions. Routine treatment or care plans lie at the other, more paternalistic, end of the crisis planning spectrum because they may be produced without any patient or consumer involvement, although by consensus it is not seen as good practice. This formof treatmentplanninghasgenerallyactedas thecontrol in trials of other types of advance statements. In addition to advanced statement and care plans, the third type of such advance statements includes JCPs, which lie toward the cenRelated article page 657 Opinion

Evidence-Based Practice in Use of CTOs

Drs Karagianis, Hastings, and Gray disagree with our assessment of the evidence on the effectiveness of community treatment orders (CTOs). In our reviews of studies from Canada and abroad, we apply recognised principles of evidence-based medicine (EBM) to assess the quality of the research. We found some studies show therapeutic benefits for CTOs. These include studies commissioned by governments, often conducted by nonacademic consultancies and not subject to peer review, and a number of small-scale, uncontrolled studies. These are the kinds of studies conducted in Canada. They do not provide robust evidence for efficacy of CTOs, especially when few high-quality studies report positive outcomes, and all the randomized studies and the best nonrandomized ones find no evidence of therapeutic benefit.

Doubting the Doubts About the Clinical Effectiveness of Community Treatment Orders

Doubting the Doubts About the Clinical Effectiveness of Community Treatment Orders

Community Treatment Orders Disconnect

Community Treatment Orders Disconnect

Community Treatment Orders (CTOs): a demographic cross-sectional analysis

Existing research on Community Treatment Orders (CTOs) questions what purposes they serve, for whom and for how long. This study aimed to identify demographics of the CTO population, differences between individuals who require short CTOs from those who require repeat CTO and clinician-determined factors which influence these decisions. Using a cross-sectional snapshot method, 301detailed audits were analysed for frequencies and relationships between variables. People on CTOs (n = 301) comprised 9% of the community mental health population (n = 3268); 21% (n = 62) having it be their first CTO, 50% (n = 149) on repeat CTOs (continuous) and 29% (n = 85) on second episode or more of CTOs (non-continuous). There were 82% (n = 231) of people on a CTO who had a primary diagnosis of schizophrenia. There was a higher occurrence of males with co-existing factors of aggression and current substance misuse. Age had a relationship with length of actual and predicted CTOs. Men of middle age, with a diagnosis of schizophrenia, a history of aggression, current substance misuse and reported previous CTO efficacy are the primary individuals predicted to require ongoing CTOs. Improving CTO efficacy should focus on providing targeted intervention for this group and a closer analysis of the use of CTOs in other groups.

Rate of community treatment orders and readmission orders following reconfiguration of community mental health services.

Community treatment orders (CTOs) are a controversial practice as they extend the practice of involuntary treatment into the community. This study aimed to determine whether there was a difference in the rate of CTOs and revocation (readmission) orders following the implementation of a recovery-orientated model across four adult mental health services. A retrospective cohort study was conducted prior to and after the reconfiguration of services. Population data for those aged 15 to 65 were obtained from a census and rate rates were calculated. Prior to the reconfiguration, there were 893 individuals subject to a CTO and 136 of these individuals had a revocation of their CTO (i.e. were involuntarily readmitted). This represented a rate of 100.8 individuals on CTOs per 100,000 population and a rate of 15.4 revocations per 100,000 population. Following the reconfiguration, the rate of CTOs increased by 10% and there was a trend for the rate of revocation orders to have decreased by 17%. Rates of CTOs and readmissions varied across services and further research is warranted to identify factors associated with these increased rates. Additionally, the very high rate of CTOs in the catchment areas warrants further examination.

Community treatment orders and reduced time in hospital: a nationwide study, 2007-2012.

Aims and method Community treatment orders (CTOs) were introduced in Scotland in 2005, but are controversial owing to a lack of supportive randomised evidence. The non-randomised studies provide mixed results on their efficacy and utility. We aimed to examine hospital bed day usage across Scotland both before and after CTOs were initiated in a national cohort of patients, spanning 5 years.Results In total, 1558 individuals who were subject to a CTO between 2007 and 2012, of whom 63% were male, were included. After CTO initiation the number of hospital bed days fell, on average, from 66 to 39 per annum per patient. Those with a longer psychiatric history appeared to benefit more from a CTO, in terms of reduced time in hospital.Clinical implications Our data offer cautious support for the use of CTOs in routine practice, in terms of reducing time spent in psychiatric hospital. This finding is balanced by the more rigorous randomised studies which do not find any benefit to CTOs.

Little evidence for community treatment orders - a battle fought with heavy weapons.

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.