This strange republic of the good: Community treatment orders and their conditions

Mental Health Act ◽

Treatment Order ◽

The Community Treatment Order (CTO) was introduced by the Mental Health Act 2007, and from the start, it was controversial. There is evidence that even the principle of community compulsion was opposed by a majority of psychiatrists, and it was said that many would resign rather than implement CTOs. Happily, that prediction has not been realised. In fact, it seems that many psychiatrists, and more than one Approved Mental Health Professional (AMHP), have seized upon CTOs with something approaching alacrity.

Does legislative change affect the use and duration of compulsory treatment orders?

Australian & New Zealand Journal of Psychiatry ◽

10.1177/0004867418812683 ◽

2018 ◽

Vol 53 (5) ◽

pp. 433-440 ◽

Author(s):

Ruth Vine ◽

Holly Tibble ◽

Jane Pirkis ◽

Fiona Judd ◽

Matthew J Spittal

Keyword(s):

Mental Health ◽

Legal Status ◽

Subsequent Treatment ◽

Community Treatment ◽

Service Utilisation ◽

Mental Health Act ◽

The Difference ◽

Treatment Order ◽

Objective: Victoria, Australia, introduced reformed mental health legislation in 2014. The Act was based on a policy platform of recovery-oriented services, supported decision-making and minimisation of the use and duration of compulsory orders. This paper compares service utilisation and legal status after being on a community treatment order under the Mental Health Act 1986 (Vic) with that under the Mental Health Act 2014 (Vic). Methods: We obtained two distinct data sets of persons who had been on a community treatment order for at least 3 months and their subsequent treatment episodes over 2 years under the Mental Health Act and/or as an inpatient for the periods 2008–2010 (Mental Health Act 1986) and 2014–2016 (Mental Health Act 2014). The two sets were compared to assess the difference in use, duration and odds of having a further admission over 2 years. We also considered the mode of discharge – whether by the treating psychiatrist, external body or through expiry. Results: Compared with the Mental Health Act 1986, under the Mental Health Act 2014, index community treatment orders were shorter (mean 227 days compared with 335 days); there was a reduction in the mean number of community treatment orders in the 2 years following the index discharge − 1.1 compared with 1.5 (incidence rate ratio (IRR) = 0.71, 95% confidence interval = [0.63, 0.80]) – and a 51% reduction in days on an order over 2 years. There was a reduction in the number of subsequent orders for those whose order expired or was revoked by the psychiatrist under the Mental Health Act 2014 compared to those under the Mental Health Act 1986. The number of orders which were varied to an inpatient order by the authorised psychiatrist was notably greater under the Mental Health Act 2014. Conclusion: The reformed Mental Health Act has been successful in its intent to reduce the use and duration of compulsory orders in the community. The apparent increase in return to inpatient orders raises questions regarding the intensity and effectiveness of community treatment and context of service delivery.

Community Treatment Orders

International Journal of Mental Health and Capacity Law ◽

10.19164/ijmhcl.v1i16.211 ◽

2014 ◽

Vol 1 (16) ◽

pp. 149

Author(s):

Kris Gledhill

Keyword(s):

Mental Health ◽

Revolving Door ◽

Community Treatment ◽

Patient Treatment ◽

England And Wales ◽

Mental Health Act ◽

Heated Debate ◽

Policy Objectives ◽

Treatment Order ◽

<p>A community treatment order is now a well-established feature of various common law jurisdictions in North America and Australasia, and in other countries. Its introduction into England and Wales was a central part of the government’s drawn out reform of the Mental Health Act 1983, and it attracted heated debate as part of the Parliamentary process, both in the exchanges between Parliamentarians and the evidence and briefings filed by interested parties. A CTO provision was introduced with a speedier gestation period in Scotland. But there is no single form of “community treatment order”; and there may also be different policy objectives. What is usually central is the desire to provide a regime for patients who are assessed as being able to function in the community so long as they accept medication but who may disengage from treatment and relapse to the extent that they require in-patient treatment: the description “revolving door” is often attached to such patients and was during the course of the debates.</p><p>The first question to be explored is whether what emerged in the Mental Health Act 2007 is much different from what already exists in relation to such patients: if it is and it allows community treatment which was previously not available, the further question is whether that is a good thing in light of the experience of other jurisdictions that have CTO regimes. If it is not, there are two further questions: firstly, why has something called a CTO been introduced if it does not amount to a change of substance; and secondly, is it a missed opportunity in light of the information from other jurisdictions – in other words, would a substantive change provide benefits which England and Wales is now missing?</p>

Coercion in mental health: a trial of the effectiveness of community treatment orders and an investigation of informal coercion in community mental health care

Programme Grants for Applied Research ◽

10.3310/pgfar04210 ◽

2016 ◽

Vol 4 (21) ◽

pp. 1-354 ◽

Author(s):

Tom Burns ◽

Jorun Rugkåsa ◽

Ksenija Yeeles ◽

Jocelyn Catty

Keyword(s):

Mental Health ◽

Community Mental Health ◽

Primary Outcome ◽

Research Programme ◽

Community Treatment ◽

Informal Coercion ◽

Treatment Order ◽

BackgroundCoercion comprisesformal coercionorcompulsion[treatment under a section of the Mental Health Act (MHA)] andinformal coercion(a range of treatment pressures, includingleverage). Community compulsion was introduced in England and Wales as community treatment orders (CTOs) in 2008, despite equivocal evidence of effectiveness. Little is known about the nature and operation of informal coercion.DesignThe programme comprised three studies, with associated substudies: Oxford Community Treatment Order Evaluation Trial (OCTET) – a study of CTOs comprising a randomised controlled trial comparing treatment on CTO to voluntary treatment via Section 17 Leave (leave of absence during treatment under section of the MHA), with 12-month follow-up, an economic evaluation, a qualitative study, an ethical analysis, the development of a new measure of capabilities and a detailed legal analysis of the trial design; OCTET Follow-up Study – a follow-up at 36 months; and Use of Leverage Tools to Improve Adherence in community Mental Health care (ULTIMA) – a study of informal coercion comprising a quantitative cross-sectional study of leverage, a qualitative study of patient and professional perceptions, and an ethical analysis.ParticipantsParticipants in the OCTET Study were 336 patients with psychosis diagnoses, currently admitted involuntarily and considered for ongoing community treatment under supervision. Participants in the ULTIMA Study were 417 patients from Assertive Outreach Teams, Community Mental Health Teams and substance misuse services.OutcomesThe OCTET Trial primary outcome was psychiatric readmission. Other outcomes included measures of hospitalisation, a range of clinical and social measures, and a newly developed measure of capabilities – the Oxford Capabilities Questionnaire – Mental Health. For the follow-up study, the primary outcome was the level of disengagement during the 36 months.ResultsCommunity treatment order use did not reduce the rate of readmission [(59 (36%) of 166 patients in the CTO group vs. 60 (36%) of 167 patients in the non-CTO group; adjusted relative risk 1.0 (95% CI 0.75 to 1.33)] or any other outcome. There were no differences for any subgroups. There was no evidence that it might be cost-effective. Qualitative work suggested that CTOs’ (perceived) focus on medication adherence may influence how they are experienced. No general ethical justification was found for the use of a CTO regime. At 36-month follow-up, only 19 patients (6% of 329 patients) were no longer in regular contact with services. Longer duration of compulsion was associated with longer time to disengagement (p = 0.023) and fewer periods of discontinuity (p < 0.001). There was no difference in readmission outcomes over 36 months. Patients with longer CTO duration spent fewer nights in hospital. One-third (35%) of the ULTIMA sample reported lifetime experiences of leverage, lower than in the USA (51%), but patterns of leverage experience were similar. Reporting leverage made little difference to patients’ perceived coercion. Patients’ experiences of pressure were wide-ranging and pervasive, and perceived to come from family, friends and themselves, as well as professionals. Professionals were committed to patient-centred approaches, but felt obliged to assert authority when patients relapsed. We propose a five-step framework for determining the ethical status of offers by mental health professionals and give detailed guidance for professionals about how to exercise leverage.ConclusionsCommunity Treatment Orders do not deliver clinical or social functioning benefits for patients. In the absence of further trials, moves should be made to restrict or stop their use. Informal coercion is widespread and takes different forms.Trial registrationCurrent Controlled Trials ISRCTN73110773.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

Guardianship – a case for wider use

Psychiatric Bulletin ◽

10.1192/pb.17.5.276 ◽

1993 ◽

Vol 17 (5) ◽

pp. 276-278 ◽

Author(s):

R. L. Symonds

Keyword(s):

Mental Health ◽

Royal College ◽

Community Care ◽

Community Treatment ◽

Care Programme ◽

Mental Health Act ◽

The Future ◽

Treatment Order ◽

Few psychiatrists have had much experience of guardianship (Section 7, Mental Health Act, 1983). The two cases described have been successful and suggest wider use of this section. It seems apposite in view of the Royal College of Psychiatrists' advice on discharge of patients from hospital, and discussion on a community treatment order; the continuing drive to community care, as codified in the ‘Care Programme Approach’; and the need in the future to treat increasingly disturbed individuals in the community as envisaged in the Reed report.

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

Health Services and Delivery Research ◽

10.3310/hsdr08090 ◽

2020 ◽

Vol 8 (9) ◽

pp. 1-76

Author(s):

Scott Weich ◽

Craig Duncan ◽

Liz Twigg ◽

Orla McBride ◽

Helen Parsons ◽

...

Keyword(s):

Mental Health ◽

Mental Health Services ◽

Health Services ◽

Local Area ◽

Community Treatment ◽

Data Set ◽

Local Areas ◽

Treatment Order ◽

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.

Community treatment orders – principles and attitudes

The Psychiatrist ◽

10.1192/pb.bp.112.040170 ◽

2013 ◽

Vol 37 (2) ◽

pp. 58-59 ◽

Cited By ~ 1

Author(s):

Vimal Kumar Sharma

Keyword(s):

Community Treatment ◽

Successful Implementation ◽

Care Providers ◽

Expected Number ◽

The Past ◽

Number Of Patients ◽

Patient Groups ◽

Treatment Order ◽

SummaryThe community treatment order (CTO) was implemented in 2008 as part of the 2007 amendments to the Mental Health Act 1983. Initially, health professionals and patient groups were sceptical about the successful implementation of CTOs. However, as more than the expected number of patients has been subjected to CTOs in the past 3 years in England and Wales, the professionals' views are shifting in favour of CTOs. More needs to be done to improve the approach and attitude of care providers so that CTOs are used in the most appropriate and effective way for the patients.

Community treatment orders: Current evidence and the implications

The British Journal of Psychiatry ◽

10.1192/bjp.bp.113.133900 ◽

2013 ◽

Vol 203 (6) ◽

pp. 406-408 ◽

Cited By ~ 18

Author(s):

Jorun Rugkåsa ◽

John Dawson

Keyword(s):

Controlled Trial ◽

Revolving Door ◽

Community Treatment ◽

Current Evidence ◽

Case Control Studies ◽

Evaluation Trial ◽

Randomised Controlled ◽

Treatment Order ◽

SummaryCommunity treatment orders (CTOs) have been widely introduced to address the problems faced by ‘revolving door’ patients. A number of case–control studies have been conducted but show conflicting results concerning the effectiveness of CTOs. The Oxford Community Treatment Order Evaluation Trial (OCTET) is the third randomised controlled trial (RCT) to show that CTOs do not reduce rates of readmission over 12 months, despite restricting patients' autonomy. This evidence gives pause for thought about current CTO practice. Further high-quality RCTs may settle the contentious debate about effectiveness.

Impact of introducing capacity-based mental health legislation on the use of community treatment orders in Norway: case registry study

BJPsych Open ◽

10.1192/bjo.2021.1073 ◽

2022 ◽

Vol 8 (1) ◽

Author(s):

Georg Høyer ◽

Olav Nyttingnes ◽

Jorun Rugkåsa ◽

Ekaterina Sharashova ◽

Tone Breines Simonsen ◽

...

Keyword(s):

Mental Health ◽

Incidence Rates ◽

Community Treatment ◽

Prevalence Rates ◽

Retrospective Case ◽

Case Register ◽

Mental Health Act ◽

Catchment Areas ◽

Involuntary Care

Background In 2017, a capacity-based criterion was added to the Norwegian Mental Health Act, stating that those with capacity to consent to treatment cannot be subjected to involuntary care unless there is risk to themselves or others. This was expected to reduce incidence and prevalence rates, and the duration of episodes of involuntary care, in particular regarding community treatment orders (CTOs). Aims The aim was to investigate whether the capacity-based criterion had the expected impact on the use of CTOs. Method This retrospective case register study included two catchment areas serving 16% of the Norwegian population (aged ≥18). In total, 760 patients subject to 921 CTOs between 1 January 2015 and 31 December 2019 were included to compare the use of CTOs 2 years before and 2 years after the legal reform. Results CTO incidence rates and duration did not change after the reform, whereas prevalence rates were significantly reduced. This was explained by a sharp increase in termination of CTOs in the year of the reform, after which it reduced and settled on a slightly higher leven than before the reform. We found an unexpected significant increase in the use of involuntary treatment orders for patients on CTOs after the reform. Conclusions The expected impact on CTO use of introducing a capacity-based criterion in the Norwegian Mental Health Act was not confirmed by our study. Given the existing challenges related to defining and assessing decision-making capacity, studies examining the validity of capacity assessments and their impact on the use of coercion in clinical practice are urgently needed.

Community treatment order legislation in the Commonwealth

10.1093/med/9780198788065.003.0003 ◽

2016 ◽

Author(s):

John Dawson

Keyword(s):

Outpatient Treatment ◽

Community Care ◽

Common Law ◽

Community Treatment ◽

Treatment Plans ◽

The Uk ◽

Treatment Order ◽

This chapter provides an overview of legislation governing the use of community treatment orders (CTOs)—that authorize compulsory outpatient treatment—in the UK, Canada, Australia, and New Zealand. It focuses particularly on the cluster of powers that CTOs confer on community mental health teams, permitting them to continue supervising a person’s outpatient care. It covers the criteria, procedures, and structure of authority for a CTO, the conditions such an order can impose on a person’s community care, the role of statutory treatment plans, and the powers available to enforce the outpatient treatment regime, especially the power of recall to hospital—analysing and comparing the subtly different regimes enacted in these Commonwealth nations that share a common law tradition.

Community treatment orders and associations with readmission rates and duration of psychiatric hospital admission: a controlled electronic case register study

BMJ Open ◽

10.1136/bmjopen-2019-035121 ◽

2020 ◽

Vol 10 (3) ◽

pp. e035121 ◽

Author(s):

Wikus Barkhuizen ◽

Alexis E Cullen ◽

Hitesh Shetty ◽

Megan Pritchard ◽

Robert Stewart ◽

...

Keyword(s):

Mental Health ◽

Mortality Rate ◽

Psychiatric Hospital ◽

Mental Healthcare ◽

Index Admission ◽

Community Treatment ◽

Lower Mortality ◽

Electronic Health Record Data ◽

Mental Health Act

ObjectivesLimited evidence is available regarding the effect of community treatment orders (CTOs) on mortality and readmission to psychiatric hospital. We compared clinical outcomes between patients placed on CTOs to a control group of patients discharged to voluntary community mental healthcare.Design and settingAn observational study using deidentified electronic health record data from inpatients receiving mental healthcare in South London using the Clinical Record Interactive Search (CRIS) system. Data from patients discharged between November 2008 and May 2014 from compulsory inpatient treatment under the Mental Health Act were analysed.Participants830 participants discharged on a CTO (mean age 40 years; 63% male) and 3659 control participants discharged without a CTO (mean age 42 years; 53% male).Outcome measuresThe number of days spent in the community until readmission, the number of days spent in inpatient care in the 2 years prior to and the 2 years following the index admission and mortality.ResultsThe mean duration of a CTO was 3.2 years. Patients receiving care from forensic psychiatry services were five times more likely and patients receiving a long-acting injectable antipsychotic were twice as likely to be placed on a CTO. There was a significant association between CTO receipt and readmission in adjusted models (HR: 1.60, 95% CI 1.42 to 1.80, p<0.001). Compared with controls, patients on a CTO spent 17.3 additional days (95% CI 4.0 to 30.6, p=0.011) in a psychiatric hospital in the 2 years following index admission and had a lower mortality rate (HR: 0.66, 95% CI 0.50 to 0.88, p=0.004).ConclusionsMany patients spent longer on CTOs than initially anticipated by policymakers. Those on CTOs are readmitted sooner, spend more time in hospital and have a lower mortality rate. These findings merit consideration in future amendments to the UK Mental Health Act.