Community treatment orders 'don't reduce psychiatric...

"'Psychiatric Asbos' were an error says key advisor," The Independent reports. The news comes from new research examining the effectiveness of community treatment orders (CTOs), a legal measure that allows mental health teams to impose compulsory supervision on a patient after they have been discharged from an involuntary stay in hospital.

Patients may also be ordered to meet other requirements, such as taking medication or living in a specified place, or be faced with readmission to hospital. For this reason, CTOs are controversial as they restrict patients' personal liberty.

This well-designed piece of research on patients in England found that CTOs were no better at stopping people with psychosis from being readmitted to hospital care than another type of legal measure that allows patients short periods of leave from psychiatric hospital care.

The study also found that CTOs did not reduce the length of time patients stayed in hospital, the severity of their symptoms, or how they coped in society.

The lead researcher on this trial, who The Independent reports originally advised the government on CTOs, was quoted as saying, "We were all a bit stunned by the result, but it was very clear data and we got a crystal clear result. So I've had to change my mind. I think sadly – because I've supported them for 20-odd years – the evidence is staring us in the face that CTOs don't work."

It is not yet clear whether changes to the legislation will be made on the basis of this single – but seemingly important – piece of research.

Where did the story come from?

This study was carried out by researchers from the University of Oxford and other research centres in the UK, Norway and New Zealand. It was funded by the UK National Institute for Health Research and was published in the peer-reviewed medical journal The Lancet.

The Independent covered the research briefly and accurately, with most of the article focusing on the social and political context in which CTOs were introduced and are being used.

However, The Independent chose to refer to them as 'psychiatric Asbos' in their headline, a rather unkind and pejorative label that suggests people receiving psychiatric care have in some way broken the law or shown antisocial behaviour towards other people, which is not necessarily the case. People receiving these orders have a mental illness that needs treatment, and a key aim of the CTOs is to protect their own health and safety.

What kind of research was this?

This was a randomised controlled trial (RCT) that tested the effect of community treatment orders (CTOs) on how often people with psychotic disorders were readmitted to psychiatric hospital care.

CTOs were introduced in England and Wales in 2008. Before their introduction, section 17 legislation allowed patients to leave hospital for periods of hours or days – and occasionally weeks – while being subject to recall.

This allowed the stability of a patient's recovery to be assessed, and patients could be readmitted if needed without additional legal processes. These section 17 rules were retained after CTOs were introduced. People treated under section 17 rules acted as controls in this study.

CTOs did not have universal support when they were introduced, with some professional and patient groups resisting their implementation. This was partly because of concerns about patients' civil liberties and partly because of the lack of research evidence about their effects.

Two randomised control trials from the USA did not show a difference in overall readmission rates with CTOs, although one of the studies suggested there may be benefits for patients with sustained CTOs (more than 180 days) and regular clinical contact.

This study aimed to look at whether CTOs reduce admissions in the UK when both the CTO and control group have the same levels of clinical contact, but different lengths of compulsory supervision. An RCT is the best way of determining whether different treatment options have different effects.

What did the research involve?

The researchers recruited adults aged 18-65 years who were detained for inpatient treatment for psychosis in England between 2008 and 2011. To be eligible, patients had to be able to give informed consent and be considered suitable for supervised outpatient care by the clinical team in charge of their care. The 336 consenting participants were randomly allocated to be discharged to a form of mandatory outpatient care – either a CTO or section 17 leave.

The researchers' main specified outcome was whether the patient was admitted to hospital during the year after they were randomised to either a CTO or section 17 care. They also assessed clinical and social functioning using established scales.

Three of the participants were not included in the final analyses: one withdrew from the CTO group on day one of the study, and two were excluded from the section 17 group as they did not meet the study criteria (one was already on a CTO and one had been on section 17 for too long).

The researchers compared outcomes in the two groups. They took into account the patients' gender, whether or not they had a diagnosis of schizophrenia, and how long they had their psychosis for.

What were the basic results?

The researchers found that readmissions did not differ between the CTO and section 17 groups. Just over a third of patients in both groups (36%) were readmitted in the year after randomisation.

There was also no statistically significant difference between the groups in:

total length of all psychiatric hospitalisations
average number of readmissions
number of patients with multiple readmissions
time to first readmission
clinical functioning
social functioning

The researchers found that the CTO group had more days under their initial randomised compulsory supervision (average 170.1 days versus 45.5 days in the section 17 group), and also more total days with compulsory supervision during follow-up (average 241.4 days versus 134.6 days in the section 17 group).

The researchers say that excluding patients whose care did not follow the study's protocol (42 in the CTO group and 46 in the section 17 group) did not affect the findings of the trial.

How did the researchers interpret the results?

The researchers concluded that, "In well-co-ordinated mental health services, the imposition of compulsory supervision does not reduce the rate of readmission of psychotic patients."

They say that these results do not support a justification of the "significant curtailment of patients' personal liberty" imposed by community treatment orders, and suggest that "their current high usage should be urgently reviewed".

Conclusion

This study of community treatment orders (CTOs) in patients with psychosis is reported as being the largest of its kind. Its findings support those of two previous trials, which also found no benefit from CTOs in reducing readmissions.

The researchers note that their trial had some issues to consider, and limitations:

Legally, once the patients were randomised the clinicians had to make all subsequent clinical decisions independently of their randomisation. This meant that the clinicians could not be encouraged to continue with the patients' randomised supervision option.
During the study, most mental health services were reorganised, meaning that the care of the participants passed to psychiatrists who were not familiar with the trial and may have differed in their opinions on the management of the patients' care.
As with all RCTs, the participants needed to agree to be involved. The patients' families were also consulted in this study, and some families had strong feelings about which supervision option their relative should receive. Excluding these patients may mean that the sample is not representative of everyone normally seen by doctors in this scenario.

The study also did not assess all possible outcomes that might be affected by the CTO – for example, it did not assess to what extent people took their prescribed medication. However, it did assess clinical and social functioning, which could potentially indicate if a person was not taking their medication.

Overall, this study does not support the theory that CTOs can cut readmission in people with psychosis. It highlights the importance of testing the effects of complex interventions using robust randomised controlled trials, where possible, to ensure they provide the benefits that they are thought to.