Community Treatment Orders
Prof Peter Lepping
Consultant Psychiatrist/Associate Medical Director (BCULHB) and
Visiting Professor (Glyndŵr University)
Dr Masood Malik
Consultant Psychiatrist (BCULHB)
CTOs
Introduced as part of 2007 amendments to
1983 MHA
Place conditions on patients that may
cover any aspect of someone’s health and
social care
To “ensure that the patient receives
medical treatment for [his or her] mental
disorder, prevent a risk of harm to the
patient’s health or safety, or protect other
people”
Purpose
to allow suitable patients to be safely
treated in the community rather than under
detention in hospital, and to provide a way
to help prevent relapse and any harm to
the patient or to others. It is intended to
help patients maintain stable mental health
outside hospital and to promote recovery.
(Code of Practice, England, 2008)
to address the specific problem of
‘revolving door’ patients. (DoH, 2007)
used where treating clinician believes that
the patient is “well enough to leave hospital
but is concerned that [the patient] may not
continue with treatment, or may need to be
admitted to hospital again at short notice
for more treatment” (DoH, 2008)
Unequivocally intended to facilitate
treatment in community and prevent
relapse
Does not authorise forced treatment, but
can facilitate it
Allows for patient to be recalled to hospital
(f.ex. to give depot medication)
Extended trial leave with conditions
Germany
France
Belgium
Luxemburg
Portugal
Israel
Forced or covert community
treatment
Spain (some cities)
USA (some federal states): judicial
decision, varying provisions and
consequences of non-compliance
Australia: judicial decision and forced
treatment
New Zealand and Canada
Since 2009 (Wales)
CTOs often fail (one third need recall)
Wide regional variations
Wide range of conditions
Rationale for conditions often not clearly
documented
Conditions often non-specific, e.g.
compliance with care plan
25% of conditions aimed at containing risk,
not compliance (Psychiatric policing?)
Problems
In Britain, rapid increase in use, which is far higher
than envisaged (29% increase in 2011)
Recall possible without breach of conditions
Judging when conditions have been breached
Use to control risk, not compliance
All 3 serious incidents occurred when conditions
were used for risk management (North Wales
audit)
Authoritarian and ethically questionable
Compatible with recovery?
Determining when to end a CTO can be very
difficult as success proves continued usefulness
Welsh audit, conditions
Make available for extension*
SOAD*
Appointment with care team*
Take medication
Appointments with psychiatrist
Reside at address
Allow access to team
Attend drug counselling, provide UDS
Refrain from drugs and alcohol
Allow nursing care support
Attend day service, leisure, education
Noncompliance leading to recall
Attend blood tests
Restricted home visits to family
Family to contact services
Stop driving
Adverse directive
Check Mail
Compliance with care plan
100%
100%
100%
98%
72%
46%
24%
20%
18%
16%
12%
10%
8%
4%
4%
2%
2%
2%
2%
SMART framework
Accept depot
See care team
SPECIFIC
To accept depot
antipsychotic every 2
weeks
To see key worker
twice a week
MEASURABLE
The dose will be
confirmed and
specified in care plan
Engagement will be
recorded with regard to
specific behaviour
ACHIEVABLE
Mental health and
side-effects will be
monitored by CPN
Difficulties will be
discussed and steps
taken to resolve
REALISTIC
Date, time and venue
fixed prior to each
Date, time and venue
will be fixed prior to
visits
depot
TIMEFRAMED
Treatment plan will be
reviewed every three
months in clinic
Treatment plan will be
reviewed every three
months in clinic
Recent Lancet article, Burns
We tested whether CTOs reduce admissions compared
with use of Section 17 leave
Methods: RCT, diagnosis of psychosis, aged 18–65
years, who were deemed suitable for supervised
outpatient care by their clinicians. Patients were
randomly assigned (1:1 ratio) to be discharged from
hospital either on CTO or Section 17 leave.
Results: 333 patients (166 in the CTO group and 167 in
Section 17 group). At 12 months, readmission did not
differ between groups (36% in both groups).
Interpretation: In well coordinated mental health
services the imposition of compulsory supervision does
not reduce rate of readmission of psychotic patients. We
found no support in terms of any reduction in overall
hospital admission to justify the significant curtailment
of patients’ personal liberty.
Conclusion
CTOs are problematic, especially
when used to control risk
A more rigorous approach to
conditions and plans might enhance
compliance and outcome
References
Lepping P, Malik M. Community treatment
orders: current practice and a framework to
aid clinicians, The Psychiatrist (2013) 37:
54-57
Burns T, Rugkåsa J, Molodynski A,
Dawson J, Yeeles K, Vazquez-Montes M,
Voysey M, Sinclair J, Priebe S. Community
treatment orders for patients with
psychosis (OCTET): a randomised
controlled trial. Lancet. 2013 Mar 25
Thank you very much