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

Abstract

Background Community treatment orders are widely used in England. It is unclear whether their use varies between patients, places and services, or if they are associated with better patient outcomes. Objectives To examine variation in the use of community treatment orders and their associations with patient outcomes and health-care costs. Design Secondary analysis using multilevel statistical modelling. Setting England, including 61 NHS mental health provider trusts. Participants A total of 69,832 patients eligible to be subject to a community treatment order. Main outcome measures Use of community treatment orders and time subject to community treatment order; re-admission and total time in hospital after the start of a community treatment order; and mortality. Data sources The primary data source was the Mental Health Services Data Set. Mental Health Services Data Set data were linked to mortality records and local area deprivation statistics for England. Results There was significant variation in community treatment order use between patients, provider trusts and local areas. Most variation arose from substantially different practice in a small number of providers. Community treatment order patients were more likely to be in the ‘severe psychotic’ care cluster grouping, male or black. There was also significant variation between service providers and local areas in the time patients remained on community treatment orders. Although slightly more community treatment order patients were re-admitted than non-community treatment order patients during the study period (36.9% vs. 35.6%), there was no significant difference in time to first re-admission (around 32 months on average for both). There was some evidence that the rate of re-admission differed between community treatment order and non-community treatment order patients according to care cluster grouping. Community treatment order patients spent 7.5 days longer, on average, in admission than non-community treatment order patients over the study period. This difference remained when other patient and local area characteristics were taken into account. There was no evidence of significant variation between service providers in the effect of community treatment order on total time in admission. Community treatment order patients were less likely to die than non-community treatment order patients, after taking account of other patient and local area characteristics (odds ratio 0.69, 95% credible interval 0.60 to 0.81). Limitations Confounding by indication and potential bias arising from missing data within the Mental Health Services Data Set. Data quality issues precluded inclusion of patients who were subject to community treatment orders more than once. Conclusions Community treatment order use varied between patients, provider trusts and local areas. Community treatment order use was not associated with shorter time to re-admission or reduced time in hospital to a statistically significant degree. We found no evidence that the effectiveness of community treatment orders varied to a significant degree between provider trusts, nor that community treatment orders were associated with reduced mental health treatment costs. Our findings support the view that community treatment orders in England are not effective in reducing future admissions or time spent in hospital. We provide preliminary evidence of an association between community treatment order use and reduced rate of death. Future work These findings need to be replicated among patients who are subject to community treatment order more than once. The association between community treatment order use and reduced mortality requires further investigation. Study registration The study was approved by the University of Warwick’s Biomedical and Scientific Research Ethics Committee (REGO-2015-1623). Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 9. See the NIHR Journals Library website for further project information.

Suicide rates among patients subject to community treatment orders in England during 2009–2018

“…13,14 Other studies in England have reported patients on a CTO had more hospital readmissions and spent longer in in-patient care compared with those not on a CTO. 15,16 Despite the sparse evidence on whether CTOs reduce bed use and improve treatment response, they are used extensively in many countries and are often initiated to potentially reduce the risk of self-harm and suicide after discharge.…”

Readmission after discharge from acute mental healthcare among 231 988 people in England: cohort study exploring predictors of readmission including availability of acute day units in local areas

“…There have been several changes in the English mental healthcare system since that time, including decreases in the number of acute beds available and increased use of community treatment orders. 14,22 The MHMDS has large amounts of missing clinical data regarding diagnoses, and because of the nature of the administrative data we could not include a range of individual variables which might explain people's mental health vulnerability to relapse after they were discharged, for example, social support, employment, housing, individual-level deprivation, and receipt of community care and support for mental health. We also had no information regarding the pharmacological treatments people were receiving.…”

“…In the NHS, clinicians allocate care clusters for individuals on their mental health caseload. We categorised people into three groups based on other work using this data-set, 14 namely non-psychosis, psychosis and severe psychosis (see Supplementary Table 1 available at ).…”

Hospitais de Custódia e Tratamento Psiquiátrico no sistema prisional: a morte social decretada?

“…Na Itália, país considerado modelo para o Brasil na Reforma Psiquiátrica, os HCTPs já foram extintos e foram criadas as Residências para Execução das Medidas de Segurança 23 . Seguindo outra possibilidade de tratamento, na Inglaterra e no País de Gales existem as chamadas Ordens de Tratamento Comunitário Supervisionado, que obrigam os pacientes pós-alta a cumprir as condições especificadas por seus médicos, sob a possibilidade de um retorno compulsório ao hospital para nova internação 24 . Em contraposição, os Artigos 12 e 14 da Convenção internacional sobre os direitos das pessoas com deficiência tratam, respectivamente, do "Reconhecimento igual perante a lei" e da "Liberdade e segurança da pessoa" e fornecem subsídios para avançarmos ainda mais nessa discussão 25 .…”