Compulsory community treatment orders (CTOs) alone do not reduce admissions to psychiatric hospital

Compulsory CTOs remove from psychiatric patients the right to choose whether or not to continue to receive their treatment once they are discharged from hospital. At the moment, mental health law in England and Wales is closest to that in Australia and New Zealand, where compulsory CTOs are in operation. The UK government is expected to include in its new Mental Health Bill the recommendation that similar orders are introduced in England and Wales.

There is, however, controversy about whether compulsory CTOs for psychiatric patients reduce hospital admission rates. This is the first study to evaluate them using an epidemiological sampling frame and survival analysis of three linked databases of health service use, involuntary treatment and forensic history.

It compared the readmission rate of patients receiving compulsory community treatment with that of two control groups: one matched on demographic characteristics, diagnosis, past psychiatric history and treatment setting; and the other consecutive controls matched on date of discharge from in-patient care.

265 compulsory CTO cases were matched with 265 controls and 224 consecutive controls. It was found that the compulsory CTO group had a significantly higher readmission rate: 72% v. 65% and 59% for the matched and consecutive controls.

CTO placement, aboriginal ethnicity, younger age, personality disorder and previous health service use were all associated with increased admission rates.

The authors of the study conclude that compulsory CTOs alone do not reduce admission rates. One interpretation of their findings is that increased surveillance of patients given CTOs ensured that they were admitted if they deteriorated, which might in the long run lead to shorter periods of admission. But previous research showed that having a CTO did not reduce the length of time spent in hospital over the next 12 months.

Some research suggests that compulsory community treatment has to be maintained for at least 180 days, and combined with at least seven out-patient contacts a month, to reduce admission rates. Further studies are needed to establish whether it is intensity of treatment or its compulsory nature that may affect outcome. Further research may also determine whether there are particular types of patient, or legislative frameworks, that give the best outcomes.

The authors conclude that health service planners, clinicians, patients and carers should question the rationale for CTOs and advocate more effective treatments.

Dr. Tony Zigmond, vice-president of the RCPsych and a consultant psychiatrist in Leeds, commented, "This research from Australia, along with other studies, looks at whether compulsory CTOs achieve certain objectives. The evidence from this paper, in line with previous research, is that CTOs are ineffective in reducing admissions to hospital."

"Furthermore, there is the ethical issue of whether CTOs are fair. Should any person who is capable of making a decision about their treatment be forced to accept medical treatment they don't want solely to benefit their health? We don't force patients with heart disease, for instance, to take medication and change their lifestyle (although this would reduce their need for medical services), so why should be force those with depression to do so?"

"Psychiatric patients who present clear serious risks to others (as do patients with open tuberculosis who refuse treatment or those with untreated epilepsy who insist on driving) require other provision to protect the public."

"The UK government is still proposing such legislation in the draft Mental Health Bill. The Royal College of Psychiatrists believes that patients in the community should only be given without their consent if they lack the capacity to make a decision for themselves."

For further information on the paper, Impact of compulsory community treatment on admission rates, contact Prof. Stephen Kisely. Tel: +1 902 473 7356. E-mail: [email protected]

Dr. Tony Zigmond. Tel: 0113 305 6428. E-mail: [email protected].