Community treatment orders: Are they useful?

Abstract

SummaryIn the wake of the deinstitutionalisation of mental health services, community treatment orders (CTOs) have been introduced in around 75 jurisdictions worldwide. They make it a legal requirement for patients to adhere to treatment plans outside of hospital. To date, about 60 CTO outcome studies have been conducted. All studies with a methodology strong enough to infer causality conclude that CTOs do not have the intended effect of preventing relapse and reducing hospital admissions. Despite this, CTOs are still debated, possibly reflecting different attitudes to the role of evidence-based practice in community psychiatry. There are clinical, ethical, legal, economic and professional reasons why the current use of CTOs should be reconsidered.Learning Objectives• Gain an overview of the development and use of CTOs in the UK and internationally• Get up-to-date information about the evidence base for CTO effectiveness and the relative contributions of different levels of evidence• Appreciate the nature of the current controversy around the use of CTOs and become familiar with the factors in the ongoing debate about their future

Compulsory community treatment to reduce readmission to hospital and increase engagement with community care in people with mental illness: a systematic review and meta-analysis

“…1 The introduction of CCT in England and Wales, the USA, Australia, the Netherlands, Sweden, Spain, and parts of Canada 1 , 2 has triggered substantial debate about whether such measures reduce so-called revolving door use of inpatient services enough to justify the associated restriction of patient liberty. 3 In England and Wales, CCT makes patients who are discharged from compulsory inpatient care subject to hospital recall if they do not comply with conditions that can include maintaining contact with services. 3 , 4 CCT can also require adherence to conditions including taking medication, abstaining from illicit drugs, and attending outpatient appointments.…”

“… 3 In England and Wales, CCT makes patients who are discharged from compulsory inpatient care subject to hospital recall if they do not comply with conditions that can include maintaining contact with services. 3 , 4 CCT can also require adherence to conditions including taking medication, abstaining from illicit drugs, and attending outpatient appointments. 5 CCT can also impose requirements on service providers to make care available.…”

“…Arguments for CCT concentrate on its less restrictive nature compared with admission to hospital, 1 , 3 , 7 and its potential to prevent relapses and readmissions. 8 However, evidence supporting these benefits is inconclusive and CCT could risk replacement of engagement and building therapeutic alliance with unjustified control and threat, while ignoring underlying reasons for non-adherence 7 , 9 —eg, the need for better community services or increased engagement of service users in decision making.…”

“… 8 However, evidence supporting these benefits is inconclusive and CCT could risk replacement of engagement and building therapeutic alliance with unjustified control and threat, while ignoring underlying reasons for non-adherence 7 , 9 —eg, the need for better community services or increased engagement of service users in decision making. 3 , 10 Furthermore, restriction of liberty of adults who might have capacity for decision making and who have broken no laws has been questioned by both service users and health-care professionals. 8 , 11 However, some studies have reported preference among patients for CCT if the alternative is admission to hospital, 12 and carers also support use of CCT.…”

Use of community treatment orders and their outcomes: an observational study

“…In response, clinicians, researchers and government bodies have called for its use to be reconsidered. 17,18 Obviously, such calls also have resonance in the light of ever increasing demands for financial efficiency in health service delivery. There is, therefore, a clear need for new research on CTOs.…”