Community Treatment Orders associated with increased readmission risk and longer hospital stay

Reviewed by James Ives, M.Psych. (Editor)Mar 5 2020

In the first large, observational study with a control group in England and Wales, research funded by the NIHR Maudsley Biomedical Research Centre has found that Community Treatment Orders (CTOs) are associated with an increased risk of readmission as well as increased time spent in psychiatric hospitals, contrary to results from previous uncontrolled studies. Researchers suggest that these findings should be considered in future reforms to the UK Mental Health Act.

CTOs were introduced in England and Wales under the 2007 amendment to the Mental Health Act (1983). They are a legal order for compulsory monitoring and treatment of people discharged from psychiatric hospitals with serious mental disorders within a community care setting. They also allow quicker readmission to hospital, if necessary, following suspected relapse. Their use has exceeded initial expectation and 5,000 are now used in England each year on average.

Researchers compared 830 patients who were discharged on a CTO with 3,659 patients discharged to voluntary community mental healthcare. Results showed that in the two years following discharge from psychiatric hospital, patients on CTOs spent, on average, 17.3 additional days in hospital and had a 60% greater rate of readmission compared to patients receiving voluntary care. The study also found that the average CTO lasted three years, more than four times longer than initial government projections of nine months.

These findings are contrary to previous uncontrolled observational studies carried out in the UK and Wales, some of which reported a reduction in readmission rates in patients on CTOs. However, the addition of a control group of patients discharged without a CTO in this study allowed researchers to compare outcomes more robustly than in previous studies.

These results could be due to the tendency for patients with CTOs to have historic relapses and severe symptoms, or due to the ease of readmission through the CTO pathway.

Lead author Dr Rashmi Patel, MRC UKRI Health Data Research UK Fellow at the Institute of Psychiatry, Psychology & Neuroscience at King's College London, said:

Community Treatment Orders were designed to prevent relapse and readmission to hospital for people with serious mental illnesses. In fact, our study suggests that they have the opposite effect, with people on CTOs being more likely to be readmitted and spending longer in hospital. In light of these findings, we need to think carefully about what role (if any) CTOs should play in providing care to people with serious mental illnesses".

Co-author Dr Alexis Cullen, Research Fellow at the Institute of Psychiatry, Psychology & Neuroscience at King's College London added:

While we cannot establish a causal effect of CTOs on readmission rates, our findings concur with smaller randomized controlled trials from the UK in showing that readmission rates are not reduced. Importantly, our inclusion of patients treated in forensic psychiatric settings (who have been excluded from previous studies) means that our sample is more reflective of the patients who typically receive these treatments."

Researchers used the Clinical Record Interactive Search (CRIS) system which has access to over 400,000 anonymized electronic health records from the South London and Maudsley NHS Foundation Trust. Records available from patients who were discharged between 2008 and 2014 under the Mental Health Act were analyzed.

The findings have been published today (5 March 2020) in BMJ Open.