Use Of Community Treatment Orders Research Articles

Use of community treatment orders in an inner-London assertive outreach service.

Aims and method To compare admission rates and bed occupancy before and after the introduction of community treatment orders (CTOs) in 37 assertive outreach service patients. The effect of CTOs on treatment adherence and illicit drug use were also evaluated. The views of patients and care coordinators were obtained through a focus group.Results When CTOs were introduced, admission rates fell from 3.3 to 0.3 per year and average bed occupancy declined from 133.2 to 10.8 days per year. Treatment adherence improved from 4 (10.8%) to 31 (83.7%) patients, and an objective reduction in substance misuse was observed in 25 (67.5%) patients. Whereas patients expressed ambivalence towards CTOs, their care coordinators generally had a more positive view.Clinical implications The decline in hospital usage following the introduction of CTOs is encouraging and could reflect improved adherence and engagement through intensive case management, leading to a reduction in readmissions. However, further studies need to look at quality of life, cost-effectiveness and the impact on patients.

Compulsion in the community: mental health professionals' views and experiences of CTOs

Aims and methodWe surveyed the views and experiences of all mental health professionals in adult community mental health teams and approved mental health professionals in 2Gether and Oxford Health NHS Foundation Trusts, regarding the use of community treatment orders (CTOs).ResultsA total of 288 surveys were completed (response rate 48%). Forty-eight (83%) psychiatrists and 142 (67%) non-psychiatrist mental health professionals were in favour of CTOs. The decision-making regarding CTOs was overwhelmingly clinically oriented for all professional groups. However, there were significant differences in views between groups regarding the effects of bureaucracy, the infringement of human rights and coercion.Clinical implicationsMultidisciplinary team involvement is crucial in decisions regarding CTOs and may protect against idiosyncratic or unhelpful practice. Further training for staff is urgently required and there may be a case for creating small local reference groups that can develop expertise and provide advice and support for clinical teams.

The subjective experience of community treatment orders: Patients’ views and clinical correlations

There is little objective evidence to support the use of community treatment orders (CTOs) from randomized controlled trials. Qualitative research indicates more negative than positive responses to the use of CTOs. Nonetheless, the use of CTOs is growing internationally. There is no research to identify for whom CTOs may be a positive experience. To assess patients' perspectives of CTOs, assessing for correlates with clinical and demographic variables. Patients currently or previously subject to a CTO were assessed quantitatively to identify their experience. Demographic data, the experience of coercion, views of detention, satisfaction with care, social functioning and psychopathology were correlated using SPSS. Fifty-three per cent of patients felt that they were, on balance, better off when treated informally in the community. Patients described greater coercion and less satisfaction with care when subject to a CTO. These factors, and being in employment, identified patients whom felt harmed by CTOs 61% of the time. This paper highlights that more than half of patients under a CTO consider it negatively. This group is identified by patients who work, experience coercion and are unsatisfied with care. This has implications for the application of CTOs.

A Factor Analysis of Patients’ Views of Compulsory Community Treatment Orders: The Factors Associated with Detention

Quantitative analysis of patients’ views about compulsory community treatment has not been undertaken although qualitative analysis identifies some positive and negative themes. This research is designed to identify the factor structure of patients’ subjective experience of community detention in a quantitative fashion. The authors assessed 79 psychiatric patients either currently or previously detained under a compulsory community treatment order for in excess of 6 months. A structured questionnaire was used to assess patients’ views of community detention and exploratory factor analysis was performed. Principal component analysis with oblique rotation identified three factors associated with detention. Although overlapping, these factors represent interpersonal difficulties, intrapsychic threat and a safety factor associated with detention. The safety factor also loaded for unhappiness. These factors accounted for 60% of the variance in the data set. Recognizing these factors may improve the use of community treatment orders and make them more acceptable to patients.

Liberty or dignity: community treatment orders and rights.

The use of community treatment orders (CTOs) remains controversial despite their widespread use in a number of different countries. The focus of a CTO should be on individuals with severe and enduring mental disorders, typically requiring adherence with recommended outpatient treatment in the community and requiring that they allow access to members of the clinical team for the purpose of assessment. There is no current provision for CTOs under Irish mental health legislation, although patients who are involuntarily detained under the MHA 2001 (Ireland) can be granted approved leave from hospital. This provision allows for the patient to be managed in the community setting, though, while technically on leave, they remain as inpatients detained under the MHA 2001 (Ireland). This article describes the use of CTOs and considerations relating to their implementation. There is discussion of the ethical grounds and evidence base for their use. Ethical considerations such as balancing autonomy against health needs and the utilisation of capacity principles need to be weighed by clinicians considering the use of CTOs. Though qualitative research provides some support for the use of CTOs, there remains a clear lack of robust evidence based findings to support their use in terms of hospitalisation rates, duration of illness remission and improved social functioning.

The use of Community Treatment Orders in an intellectual disability service

Purpose – The literature on the use of Community Treatment Orders (CTOs) is primarily focused on people without intellectual disabilities. This paper aims to explore how CTOs are used in people with intellectual disability in the UK.Design/methodology/approach – An audit was conducted among Consultant Psychiatrists in intellectual disability psychiatry in Nottinghamshire Healthcare NHS Trust. Each consultant was asked to provide information on demographic data of their patients on CTOs, reasons for being on a CTO, conditions specified, patients' capacity to consent and their understanding of their CTOs. Conditions of CTOs were analysed using thematic analysis.Findings – There were 17 CTOs done for patients with intellectual disability from November 2008 to May 2011. Mean age was 38 with a range of 20‐59. All patients had a mild or moderate intellectual disability. Only a small percentage of patients had a diagnosis of schizophrenia. More than 50 per cent had a diagnosis of pervasive developmental disorder...

An eleven-year evaluation of the effect of community treatment orders on changes in mental health service use

Many studies of compulsory community treatment have assessed their effect early on after the implementation of legislation. Although compulsory community treatment may not prevent readmission to hospital, there is evidence of an effect on length of stay before and after the intervention when compared to controls. This paper examines whether outcomes change as clinicians gain experience in the use of community treatment orders (CTOs). Cases and controls from three linked Western Australian databases were matched on age, sex, diagnosis and time of hospital discharge or community placement. We compared changes in bed-days and outpatient visits of CTO cases and controls using multivariate analyses to further control for confounders. We identified 2958 CTO cases and controls from November 1997 to December 2008 (total n = 5916). The average age was 37 years and 64% were male. Schizophrenia and other non-affective psychoses were the commonest diagnoses (73%). CTO placement was associated with a mean decrease of 5 bed-days from before the order when compared to controls (B = −5.23, s.e. = 1.60, t = −3.26, p < 0.001). There was an increase of 8 days in outpatient contacts (B = 8.31, s.e. = 1.17, t = 7.11, p < 0.001). There was little change in CTO use and outcomes over the 11 years. Compared to controls, CTOs may therefore reduce lengths of stay from before placement on the order. They also increase outpatient contacts. This study illustrates the importance of selecting an outcome that directly addresses the objective of the intervention.

Community treatment orders in Australia: rates and patterns of use

Community treatment orders (CTOs) allow clinicians to provide unconsented outpatient treatment to people living with mental illness. Though controversial and of uncertain efficacy, CTOs are used throughout Australia and internationally. We sought to determine the prevalence of CTO use in Australian states and territories, and to examine changes in the pattern of use over time. Australian state and territory mental health review tribunals and health departments were surveyed for the most recent annual data on the total number of CTOs made and the total number of individual people placed on a CTO. Rates of CTO use range from 30.2 per 100,000 population (in Tasmania) to 98.8 per 100,000 population (in Victoria). Use of CTOs in Australia is high by world standards, appears to be increasing over time, and varies significantly across jurisdictions. The high (by world standards), increasing and variable use of CTOs in Australia is concerning and raises important implications for mental health policymakers and legislators. Current mental health policy activity, particularly the new National Mental Health Commission, provides a unique opportunity to enhance transparency and accountability if regular and nationally uniform CTO data are collected and publically reported.

Supervised community treatment: 2-year follow-up study in Suffolk

Aims and methodTo describe the use of community treatment orders (CTOs) and outcomes for patients placed under CTOs within the first 8 months of use in Suffolk. We performed retrospective and prospective examination of health records to collect sociodemographic and clinical measurements with a specific data-collection tool.ResultsAll of the patients studied had a major psychotic mental illness. A significant proportion of the patients had a history of alcohol or substance misuse and contact with judicial services. Implementation of a CTO was associated with an increase in engagement, a decrease in the number of admissions, and increased time spent outside hospital.Clinical implicationsThis small localised study indicates that supervised community treatment can have benefits for some patients. The challenge now is to examine the practice of supervised community treatment and to receive meaningful feedback from people who are subject to such treatment.

P-646 - Using institutional ethnography to explore community treatment orders

There is considerable debate concerning the use of Community Treatment Orders (CTOs) in mental health practice. CTOs mandate individuals with mental illness to engage in community treatment (e.g. medication or other therapy) against their will (CMHA, 1998). The purpose of this presentation is to present the preliminary findings of a study using Institutional Ethnography (IE) that is exploring the consideration and implementation of CTOs in Newfoundland and Labrador, Canada. Interestingly, this province has CTO implementation rates that are far less than the Canadian average. Using IE offers the potential to elucidate the everyday work/life experiences occurring within an institution and to show how they are influenced by institutional social structures and discourses known as ruling relations (Smith, 2005). Participants in this study include clients, family members, and health professionals who have experience with the consideration or use of CTOs in mental health settings. Data collected through interviews and review of institutional documents are examined for evidence of the social web of influence that governs everyday actions. These social and ruling relations are mapped in accordance to their relationship to and influence over one another. The results obtained are of considerable interest to practitioners, advocacy groups, families, and individuals with mental health concerns. In bringing these social patterns and structures to light, there is hope that the resulting awareness will foster a greater willingness for individuals involved with CTOs and the mental health system to engage with one another on a more meaningful level.

Community treatment orders in England and Wales: national survey of clinicians' views and use

Aims and methodTo ascertain the views and experiences of psychiatrists in England and Wales regarding community treatment orders (CTOs). We mailed 1928 questionnaires to members of the Royal College of Psychiatrists.ResultsIn total, 566 usable surveys were returned, providing a 29% response rate. Respondents were generally positive about the introduction of the new powers, more so than in previous UK studies. They reported that their decision-making regarding compulsion was based largely on clinical grounds.Clinical implicationsIn the absence of research evidence or a professional consensus about the use of CTOs, multidisciplinary input in decision-making is essential. Further research and training are urgently needed.

Increased use of antipsychotic long-acting injections with community treatment orders

Community treatment orders (CTOs) are increasingly being used, despite a weak evidence base, and problems continue regarding Second Opinion Appointed Doctor (SOAD) certification of medication. The aim of the current study was to describe current CTO usage regarding patient characteristics, prescribed medication and CTO conditions. A 1-year prospective cohort study with consecutive sampling was conducted for all patients whose CTO was registered in a large mental health trust. Only the first CTO for each patient was included. Measures included sociodemographic variables, psychiatric diagnosis, CTO date of initiation and conditions, psychotropic medication and date of SOAD certification for medication. This study was conducted in the first year of CTO legislation in England and Wales. A total of195 patients were sampled (mean age 40.6 years, 65% male, 52% black ethnic origin). There was significant geographical variability in rates of CTO use (χ(2) = 11.3, p = 0.012). A total of 53% had their place of residence specified as a condition and 29% were required to allow access into their homes. Of those with schizophrenia, 64% were prescribed an antipsychotic long-acting injection (LAI). Of the total group, 7% received high-dose antipsychotics, 10% were prescribed two antipsychotics and only 15% received SOAD certification in time. There was geographical and ethnic variation in CTO use but higher rates of hospital detention in minority ethnic groups may be contributory. Most patients were prescribed antipsychotic LAIs and CTO conditions may not follow the least restrictive principle.

Involuntary treatment in the community: role of community treatment orders

SummaryAlthough community treatment orders (CTOs) have been used internationally since the 1980s, they were only introduced into England and Wales in 2007 by amendments to the 1983 Mental Health Act. Aimed to replace the common use of extended Section 17 leave to enforce community treatment, CTOs are believed to offer patients more protection owing to stringent criteria for their use. Literature reviews, however, do not demonstrate any evidence favouring the use of CTOs and in this age of evidence-based medicine it is questionable whether psychiatrists will change from a familiar practice to an unproven one.

The supervised community treatment order and the Human Rights Act 1998

SummaryThe introduction of the supervised community treatment order (CTO) was a major and significant change to the Mental Health Act 1983 following the 2007 amendments to the Act. Owing to paternalistic aspects of psychiatry, such new legislation brings with it the potential to impinge on the human rights of patients. Any new legislation must be read and implemented to be compliant with the Human Rights Act 1998. Of all the articles comprising the Human Rights Act, Article 3 (the right to freedom from inhuman and degrading treatment), Article 5 (the right to liberty and security) and Article 8 (the right to respect for family and private life, home and correspondence) are of particular relevance to CTOs. We consider here the potential implications of the use of CTOs with regard to the Human Rights Act.

Community treatment orders and their use in the UK

SummaryDespite the lack of supportive scientific evidence, the uptake of community treatment orders (CTOs) in England and Wales since their introduction in late 2008 has been higher than expected, although there has been a relative dearth of second opinion appointed doctors. In Scotland, CTOs now constitute about 30% of all long-term civil detentions, with lack of insight and lack of treatment adherence given as the major reasons for CTO use. Ethical considerations such as balancing autonomy against health needs will continue to be weighed by clinicians considering compulsory treatment in the community.

COMMUNITY TREATMENT ORDERS, ETHNICITY, CONDITIONS AND PSYCHOTROPIC MEDICATION: THE FIRST SIX MONTHS (N = 126)

Background: Community treatment order (CTO) legislation was initiated in November 2008 in England and Wales. Due to high rates of uptake, a shortage of second opinion appointed doctors (SOADs) to complete authorization of medication within the given timeframe for CTOs was soon identified. A strong link in the use of CTOs in combination with antipsychotic long acting injections (LAIs) has been previously identified. LAI use for patients with schizophrenia is 35% on UK acute inpatient wards. The aims of this cross-sectional observational study in the first year of CTO legislation were to (i) identify patient characteristics for those commenced on a CTO; (ii) identify the nature of psychotropic medication prescribing at CTO initiation. Hypothesis: patients with schizophrenia have higher than average rates of LAI use as compared with national prescribing data. Methods: The setting was the South London and Maudsley NHS Foundation Trust in London, United Kingdom, which provides secondary care level psychiatric services for a local population of 1.1million people, plus specialist tertiary referral inpatient facilities and forensic wards. Consecutive sampling was conducted for all patients whose CTO was registered in the Trust. Only the first CTO for each patient was included. Data for 126 patients from the first six months of data collection is presented (03/11/08-30/04/09). Measures included: sociodemographic variables, psychiatric diagnosis, CTO date of initiation, statutory reasons and stated conditions, psychotropic medication and date of Second Opinion Appointed Doctor (SOAD) authorization for medication. Results: There was geographical variability in rates of CTO use between the 4 geographical sub-regions. 52% of the 126 patients were of black ethnic origin. 52% had stated conditions regarding their place of residence and 37% were required to allow access into their homes. 99% were prescribed an antipsychotic, 27% a mood stabilizer, 8% an antidepressant, 5% a benzodiazepine. First generation antipsychotic LAIs were the most commonly prescribed group of antipsychotics (40%). 69% of those with schizophrenia on a CTO were prescribed an antipsychotic LAI. Regarding antipsychotic doses, the mean BNF% dose was 60.6% (sd 39.1 range 2.5%-183.3%). 8% of the total sample had antipsychotic (combined) doses exceeding 100%BNF dose limits. 10% were prescribed two antipsychotics. Prior to CTO initiation, 21% were LAI-naive and 78% were clozapine naive. SOAD certification of medication occurred approximately 2 months after CTO initiation (mean 59.9 days, sd 39.1, range 1-175 days). For 24% of the sample, SOAD certification was not completed within the first 6 months. Discussion: Variation in CTO use exists for geographical areas but not for ethnic diversity once other factors such as rates of hospital detention are considered. Conditions of CTOs may not follow the least restrictive principle, particularly for requirements regarding a patient's place of residence; clearer guidance for setting of conditions is required. The finding of 69% of those with schizophrenia on a CTO being prescribed an LAI is double that reported in national prescribing data. SOAD authorization of medication commonly occurs after the legal deadline and a small proportion did not achieve SOAD certification before the CTO expired.

Time to review the use of community treatment orders

When compulsory treatment in the community was introduced into mental health legislation in November 2008 widespread concerns were expressed by interested parties that it would be overused. Figures released by the government, which suggest that more than 4,000 people are now subject to community treatment orders (CTOs), show that those fears were justified (pages 7 and 8).

Coercion in the Community: A Situated Approach to the Examination of Ethical Challenges for Mental Health Social Workers

Increasingly, mental health social workers in the United Kingdom and elsewhere in the world are employing coercive interventions with clients. This paper explores this trend in the context of community-based settings, using national and international research literature on this subject. It begins with a discussion about the complex, contested nature of ideas on coercion. The authors then explore debates about how coercion is perceived and applied in practice. They choose two forms of coercion—informal types of leverage, and the legally mandated use of Community Treatment Orders—to highlight the range of ethical problems and dilemmas that confront practitioners in this field. The authors conclude by developing a tentative, explanatory model to explain how and why mental health social workers should consider a more holistic, situated approach to help deal with ethical concerns about the use of coercion.

Qualitative outcome for community treatment orders

The new Mental Health Act 2007 introduced supervised community treatment orders (CTO) as an additional tool for management of complex service users who have a disorder of the mind. The theoretical framework for CTO use and implementation has been clearly highlighted in the current literature.

Learning From the Past, Looking to the Future: Is Victorian Mental Health Law Ripe for Reform?1

It is almost 30 years since the policy which underpins the current Victorian Mental Health Act was developed. The delivery of mental health services has changed dramatically over those years. As a result, the Act has been amended on numerous occasions, rendering it inaccessible for most people other than mental health law specialists. This article suggests that it may be time to legislate again, despite acknowledging that legislation tends to follow rather than precede change in mental health service delivery. The article traces the history of Victorian mental health legislation, from the opening of the first asylum in 1848, to the agitation for reform in the late 1970s which led to the passage of the current Act. Law reform is enhanced by clear identification of the values that underpin our laws. The new Victorian Charter of Human Rights and Responsibilities Act and the UN Convention on the Rights of Persons with Disabilities may assist in identifying important contemporary values which should inform new mental health laws. The following areas merit consideration when new mental health laws are considered: advance directives, the interaction between mental health and guardianship laws, information for family and friends of patients, the extended use of community treatment orders, the grounds for civil commitment, the jurisdiction of the Mental Health Review Board of Victoria, and the establishment of a commission to coordinate research and planning for the delivery of mental health services.