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Outcomes of Community Treatment Orders

Ann Hiller is an experienced AMHP in Kent. She completed the MSc in Mental Health Social Work with Children & Adults at the Institute of Psychiatry, King’s College London,  in 2011. For her dissertation she conducted a study exploring an observation she made as a practitioner that shorter inpatient stays lead to more frequent readmissions. Her findings have been written up into a paper which is currently under review, so we’ll share more when it comes out the other side.

Bitten by the research bug, I’m really pleased that Ann is now starting a part-time PhD in social work with me at the University of York. She writes here about her research topic:

The research area for my PhD is Community Treatment Orders (CTOs) pertaining to part II of the Mental Health Act (1983 as amended 2007). Whilst used internationally since the 1980s CTOs were only introduced in England and Wales in November 2008.

My interest was initially stimulated by a practice observation that recalling patients to hospital was often delayed due to a lack of inpatient beds (it is necessary to identify the hospital on the recall documentation). Subsequent exploration of literature led me to conclude that it is necessary to ascertain who CTOs are being applied to and what outcomes they provide in order to prevent CTOs becoming normal practice rather than being identified for the minority of  ‘revolving door’ patients they were intended for.

CTOs provide the authority to set conditions regarding the treatment of people with a severe mental health problem within a community setting and also provide a mechanism by which the patient can be recalled back to hospital should they breach their treatment conditions or their mental health deteriorates. Such recalls are valid for up to 72 hours and should a longer inpatient stay be required the CTO can be revoked, at which point the patient is again placed under a s3 treatment order.

A systematic review of international literature (Churchill et al 2007) was equivocal about whether CTOs were favourable or detrimental to patients. Similarly, they reported the absence of robust evidence regarding the positive or negative effects on key outcomes such as hospital readmission, length of hospital stay, improved medication compliance or patients’ quality of life.

A preliminary database search showed very little research evidence from within the UK. Jethwa and Galappathie (2008) suggested that CTOs were being brought in without sufficient evidence to support such legislation in the UK. They referred to CTOs being a means to improve public protection whilst identifying that between 1999 and 2003 only a fifth of homicides were committed by those having contact with mental health services in the year prior to the offence. However, non-compliance with medication was reported as a related factor to such incidences (Zito Trust 1997, The University of Manchester 2006).

Literature pertaining to two UK NHS Trusts (Mlik 2009; Evans et al 2010)  indicates that further research is needed to identify outcomes such as reduction in admission rates, CTO numbers, duration, recall and revocations.

Studies also raise concern as to whether CTOs are ethically justified or whether they breach the patients Human Rights under Articles 3 and 5. It has been proposed that mental health services should respect patients decisions and not force them to comply with treatment but rather to be available to support them during times of relapse (Moncreiff and Smyth 1999; McIvor 1998).

Studies have identified that situational circumstances (Mgutshini 2010), and social and relationship problems (Chakraborty and Aryiku, 2008) precipitate relapse and that psychosocial support reduces readmission by 20% (Silva 2009). Bridgett and Polak (2003) highlight that a relapse can be equally attributed to a social cause as a medical one and, therefore, the need to understand social systems in order to identify strengths and support the user through their crisis. Moncreiff and Smyth (1999) raise concerns that CTOs will result in an increased focus on drug treatment and force compliance on those who would previously have declined citing intolerable side-effects.

Whilst CTOs may be considered a ‘least restrictive’ option in that patients will reside within their community and, therefore reduce the risk of social exclusion and stigma that is associated with long inpatient stays (Jones 2008), this is offset by the threat of recall to hospital should they decline to comply with their drug treatment.

The UK Government had anticipated 450 CTOs within England and Wales (Dunning 2009) but the NHS Information Centre identified that by 31st March 2009 1755 such orders had been made. The Care Quality Commission (2011) reported a 29% increase in CTOs and noted that only 41% had been discharged between 2008 and 2011.


Bridgett, C. and Polak, P. (2003) Social systems intervention and crisis resolution. Part 1: Assessment, Advances in Psychiatric Treatment, 9, 424-431.

Care Quality Commission (2011) Monitoring the Mental Health Act

Chakraborty, N., and Aryiku, C. (2008) Reasons for rapid readmission to general adult psychiatry wards. Progress in Neurology and Psychiatry, 12 (5) 14-18

Churchill R, Owen G, Hotopf M, Singh S (2007). International Experiences of Using Community Treatment Orders. London: Department of Health and Institute of Psychiatry, King’s College London.

Dunning, J (2009) Mental health order levels far outstrip government expectations, Community Care

Jethwa, K., Galappathie, N. (2008)  Community treatment orders, British Medical Journal,  337: a613

Jones, R. (2006) Mental Health Act Manual, 11th Ed. London: Sweet & Maxwell

Malik, M (2009) Qualitative outcome for community treatment orders, The Psychiatrist, 33, 437-438

Mgutshini, T. (2010) Risk factors for psychiatric re-hospitalization: An exploration, International Journal of Mental Health Nursing, 19, 257-267.

Moncrieff, J and Smyth, M (1999) Community treatment orders – a bridge too far? Pychiatric Bulletin, 23, 644-646

NHS Information Centre (2009) In-patients formally detained in hospitals under the Mental Health Act 1983 and patients subject to supervised community treatment: 1998-99 to 2008-9

Silva, N.C., Bassani, D.G. and Palazzo, LS. (2009) A case-Control Study of Factors Associated with Multiple Psychiatric Readmissions, Psychiatric Services, 60, 6, 786-791.

The University of Manchester (2006) Avoidable Deaths: Five year report of the national confidential inquiry into suicide and homicide by people with a mental illness

Zito Trust (1997) Learning the lessons

If you are interested in finding out more about the research Ann will be conducting, please use the contact form on this blog to contact her. She will be posting updates here in due course.

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