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Community Treatment Orders don’t work

The findings of the OCTET trial of Community Treatment Orders (CTOs) were published online in The Lancet today. The paper reported that outcomes of people on CTOs were no different from those on s.17 leave.

People detained under s.3 of the Mental Health Act (MHA) can be placed on a CTO if there are significant concerns that they may relapse and require further hospital treatment. CTOs have a power of recall which enable people to be returned to hospital without undertaking a further MHA assessment, unlike supervised discharge which was its predecessor prior to the changes in the law in 2007. CTOs are requested by psychiatrists, but signed off by Approved Mental Health Professionals (AMHPs).

This is an important study as it is the first that I am aware of in the UK which has randomly allocated people to receive a Mental Health Act (MHA) intervention. Participants were randomly allocated to either a CTO or s.17 leave of absence from hospital. Both are provisions of the MHA, but the CTO can require people to receive particular treatments or interventions which are more difficult to enforce under s.17 leave. Being a randomised controlled trial, the ‘gold standard’ method of evaluating intervention effectiveness, it provides robust evidence about outcomes.

The study reported that the number of people readmitted did not vary between the two groups. There were also no differences in clinical outcomes. The only difference between those on CTOs and those on s.17 leave was the length of time under legal compulsion in the community. This raises an important ethical issue about the use of CTOs. If they do not improve outcomes, but require a restriction of liberties, should they be avoided?

Other studies have indicated that psychiatrists prefer CTOs as they provide enhanced control over people who are likely not to take their medication on discharge from hospital. As this study has found that they are no more successful at preventing readmission than using s.17 leave, the only improved outcome is perhaps the reduced anxiety of the psychiatrist who is concerned about being sued if an adverse event were to occur when their patient was on leave.

An interesting finding of this study was that the number of self-reported contacts people had with mental health services per month was, on average, the same per group. The intervention group had a mean of 3 contacts and the control group had a mean of 4 contacts. No data is presented on what went on during these contacts but it is clear that no additional support was provided by the mental health service to people on a CTO. Surely the use of legal powers should be matched by increased support from the service enforcing it? One would expect to see additional contact with those on CTOs, if only to monitor their mental health.

This study was led by Tom Burns, Professor of Psychiatry at the University of Oxford, who also led the largest trial of intensive care management (assertive outreach) in the UK almost 15 years ago. That study also found that more assertive approaches made no difference to outcomes. Later trials of assertive outreach in the UK have replicated that finding, suggesting that it produces no better outcomes than ‘standard’ community mental health teams. Is there a consistent pattern emerging here? What does this tell us about the role of coercion within mental health services?

Perhaps the findings of this study, and others preceding it which also focused on assertive approaches to the provision of care, indicate that attention needs to be paid to developing more supportive approaches to care rather than compulsion. As we are exploring in the Connecting People study, it is possibly more effective to support people to develop their networks which can support their recovery rather than focus on coercive measures to control them.

It was interesting to note that another important study was published in The Lancet today. The CRIMSON study of joint crisis plans aimed to explore the extent to which they avoided the need for future intervention under the MHA. An earlier randomised controlled trial had found that they improved outcomes and reduced incidence of use of the MHA. This larger ‘definitive’ trial, however, found that they made no difference. The lack of difference between the groups was explained by the authors to be a result of a lack of full implementation of the joint crisis plans in the study sites. A similar argument had been made about the failure of assertive outreach to improve outcomes – it was not implemented in the same way it had been in the US where studies have found it to reduce re-hospitalisation.

These two papers provide several points for reflection:

  • Can care be provided in less coercive ways and produce the same outcomes?
  • To what extent can the focus of interventions in mental health services move away from compulsion to support?
  • How can models of care or interventions be implemented consistently to maximise their effectiveness?
  • To what extent should Approved Mental Health Professionals change their practice when responding to requests for a CTO?
  • If social workers were to design their own randomised controlled trial, what would they evaluate?

Please let me know your thoughts about this.

2 thoughts on “Community Treatment Orders don’t work

  1. brendan blair says:

    this research begs several questions. it makes signifciant claims chiefly regarding the failures of CTOs. in my view, it is flawed in two important areas. firstly it says nothing about the qualitative experience of users subject to CTOs. secondly by comparing 17 leave with CTOs it is flawed in respect of assuming that section 17 leave can be used in an open ended manner, where the intention of CTOs is in part at least to provide a clear legal framework regarding what is permissible and what is not with regard to enforcing treatment. the idea that CTOs are more coercive than section 17 leave is wrong. the prolonged extended use of section 17 leave is dubious both legally and morally. the author is making assumptions that CTOs are coercive when my practice experience is that CTOs provide clear safeguards, are used in general only when necessary to provide a framework for managing people with a history of repeated admissions,who are likely to benefit from a legal framework to help develop their compliance with their care plan. the author, by ignoring the experience of individuals in favour of a quantative approach, is missing the negotaited aspect of CTOs and that the ways in which the discretionary conditions are negotiated, and how the order is internalised or experienced by the service user.
    a final piint: the authors cant be bothered to get the AMHP name correct. Approved Mental Health Practitioner?

  2. Thanks for your comments, Brendan. I understand that they have conducted a qualitative evaluation too so I will write about that too when it’s published.

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