Community Treatment
Orders:
What do we know about
how they work?
Dr. Jorun Rugkåsa
Health Services Research Unit,
Akershus University Hospital, Norway
and
Social Psychiatry Group
Department of Psychiatry, University of Oxford
jorun.rugkasa@ahus.no
Overview of presentation
•
Where do CTOs exist
and how do they
vary?
• International data
•
What do we know
about CTO
effectiveness?
• International evidence
and systematic
reviews
•
How are CTOs used in
England & Wales over
the first 4 years?
• NHS data and survey
of psychiatrists’ views
and experiences
Where do CTOs exist and how
do they vary?
Community treatment orders
Canada
Europe: Sweden, Scotland,
England &Wales, Norway, Israel,
some Swiss Cantons
Australia
USA (most states)
New Zealand
• Legal regimes allowing compulsory community supervision
exist in ~70 jurisditions
• Legal regimes vary, but overall, patients are obliged to adhere to
treatment. Rapid recall
• ’Outpatient committment’, ’Mandated Outpatient Treatment’,
’Community Treatment Orders’, ’Supervised Community
Treatment’, ’TUD’
1980s
1990s
2005
2008
1961
2001
OCT introduced in most
north american states
CTOs in Autralia and NZ
Scotland
England & Wales; Sweden
}
NORWAY
TUD allowed in Norway
TUD may be initiated from the
community
Some
research
conducted
CTO discourse vs
type of welfare state
Country
type
Sweden
Norway
England/
Wales
New York
SocialSocialdemocratic democratic Liberal
Liberal
Controversy
Some
No
Yes
Yes
Proceeded by
high profile
killings
Yes
No
Yes
Yes
Evidence
Agreement
No
Disagreement
Disagreement
Ideology
Integration
Treatment
Protection
Protection
Control
Broad
Broad
Risk
Risk
Patient rights
Positive
Positive
Negative
Negative
Role in
CTO
discourse
Adapted from: Sjöström et al., 2011
Issues that vary
between CTO legislations
• Whether CTOs may be introduced from the
community or from involuntary hospitalisation
• How they are linked to treatment/medication
• The threshold for compulsion
• Whether patients must have history of
– Hospitalisation
– Non-adherence
• Rationale
– Control risk
– Provide alternative less restrictive than hospital
Variation in use of CTO
Between countries (in
order of frequency)
• Australia and NZ
• England & Wales,
Scotland
• North America
• In most (but not all)
states there is a year on
year increase
(Lawton- Smith, 2005)
• No reliable figures for
Norway
Within countries
• Marked regional
differences in many
countries (including
Norway)
• Could be due to differing
views among clinicians
(Dawson 1995)
• Might mean clinicans’
practice remains beyond
the control of legislators
(Sjöström, 2011)
International evidence for
CTO effectiveness
Three key reviews of CTO
evidence published → 2005
• Narrative Review: Dawson, J. (2005). Community
treatment orders: International comparisons. Dunedin, New
Zealand: University of Otago.
• Systematic Review: Churchill, R., Owen, G., Hotopf, M.
& Singh, S. (2007). International experiences of using
community treatment orders. London: Department of Health
and Institute of Psychiatry, King’s College London.
• Cochrane Review: Kisely, S., Campbell, L. A. &
Preston, N. (2005). Compulsory community and
involuntary outpatient treatment for patients with severe
mental health disorders. Cochrane database of systematic reviews,
issue 3.
Types of studies
• Descriptive studies
• Experimental studies
• Experiential studies
Descriptive studies
Show remarkable consistent practice across
jurisdictions:
– Majority of patients are isolated, male, middleaged, schizophrenia, self-neglecting and
lacking insight
– High use of depot medication
– Evidence of overuse
– Evidence of increased level of overall
coercion
Current evidence on CTOs:
Experimental studies
• 2 case control studies
– Western Australia and Canada
– CTOs not shown to lead to better outcomes
• Only two RCTs to date
– Both in the US
– No difference in primary outcome (readmission) in
either study
North Carolina secondary analyses
(Swartz et al, 1999)
• 57% reduction in means admissions, occupancy down 20 days (all)
• 73% reduction in means admissions, occupancy down 28 days
(schizophrenia)
Experiential studies
• Some good qualitative studies (though
difficult to generalise across countries)
– Doctors hold largely positive views
– Families find them helpful
– Patients are ambivalent
• This literature is largely descriptive; little
theorising around the issues
Clinicians’ views of CTOs
– More positive than patients
– Yet law is insufficient to manage nonadherence
– CTO involves tough choices, need to
accept the role of the bad guy
– CTOs are helping therapeutic
relationships
– Administratively burdensome
– CTOs is a long term treatment form
(O’Reilly et al 2006)
Family’s views of CTOs
– More positive than patients
– CTOs provide support for patients
– Grateful for police involvement but concerned
about criminalisation of patient
– Caregiving burden becomes more shared
– But, family take the brunt of the burden when
CTOs fail
– Cumbersome administration weaken the
efficiency of CTOs
– CTOs need to be sustained
(O’Reilly et al 2006)
Patients’ views of CTOs
– CTOs are coercive and appeals are futile
– A contest of will and difficult to accept
– Maintained for too long
– Medication has side effects
– Reluctant acceptance and recognition of a
need for structure
– Provide security and more freedom than
hospitalisation
– Doesn’t adversely affect therapeutic
relationships (some variation here)
– Some wish to remain on orders
(O’Reilly et al 2006)
Patients’ ambivalence
• It was like a prison sentence. I could not go
hunting in the forest with my sons. My psychiatrist
was a fascist. The injections impair my alertness
and energy. They took away my gun licence.
• It brought me back into society as a normal dad. It
lifted the burden of monitoring from my wife. It
saved my marriage. It’s good but there’s
handcuffs on it.
(Gibbs, Dawson et al 2005)
Coercion changes social status
• Loss of credible identity
• Changes to self image and presentation to
others
• Loss of autonomy
• Feeling forced to “play the game”
• Loss of trust in clinicians
(Gault 2009)
Temporal issues
• “Thank-you-theory”: Patients are in retrospect
grateful for coercive treatment
• Little support for thank-you theory in the North
Carolina RCT: most view CTO ambivalently and
with little gratitude
• However, those with good clinical outcome had
more positive appraisal of CTO
• Questions raised:
– At what point does the patient express “real” attitude?
– Does patients’ acceptance of force justify coercion?
– We need a better understanding of patients as
“moral agents”
(Swartz et al 2003)
2005: the CTO evidence base
is relatively weak
• Systematic review of 72 published articles:
‘there is very little evidence to suggest that CTOs
are associated with any positive outcomes’
Churchill et al., 2007
• Cochrane review of 2x RCTs:
– 85 CTOs required to prevent one admission
– 238 CTOs to prevent one arrest
– Further RCTs urgently needed
‘they provide no significant evidence that CTOs
affect health-service use, costs or forensic contacts.’
Kinsley et al., 2005
22
2005: the CTO evidence base
is relatively weak
– Early studies show reduction in readmission,
but mostly poorly controlled; not conclusive
– Later studies show more inconsistency re
outcomes
– Generalisibility issues
• Discrepant methodologies
• Different cultural/social settings
– Uncertainty opens for different interpretations
– All three reviews concluded RCT level
evidence is needed
CTO use in England,
2008-2011
CTO use to date
• A 20 year debate produced strong opinions for
and against CTOs
• Govt’s guestimate for first year was ~400, but
more than 4,000 were applied for
• To date 10,000+ CTOs have been applied for
• On 31st March 2011:
– 4,291 people were subject to a CTO
– 41.2% of CTOs have ended
– 64% of CTO recalls result in revocation
25
CTOs: Total numbers, 2008-2011
Number of CTOs, recalls revocations and
discharges, by year
2008/09 2009/10 2010/11
CTOs
recall
discharge
revocation
2,134
207
33
143
4,103
1,207
1,010
779
Source: NHS Information Centre, 2011
http://www.ic.nhs.uk/
Total
3,834 10,071
1,601 3,025
1,167 2,210
1,018 1,940
Decrease in new CTOs of 6.6%
from 2009/10 to 2010/11
Number of CTOs made and ended, by year
Source: NHS Information Centre, 2011
http://www.ic.nhs.uk/
27
The number of people on CTOs
increased 29% from 2009/10 to 2010/11
Patients on CTOs at 31 March 2011 by gender
Source: NHS Information Centre, 2011
http://www.ic.nhs.uk/
28
Continuing slight increase in
hospital detentions
“In combination with the numbers of people on CTOs at
31st March 2011, it is apparent that increasing numbers of
people are being subject to restrictions under the
Mental Health Act.”
NHS Information Centre, 2011, p. 19
29
How do patients get on a CTO?
Source: CQC (2010). Monitoring the use of the MHA in 2009/10
NB: N= 208
Who are subject to a CTO?
Source: CQC (2010). Monitoring the use of the MHA in 2009/10
NB: N= 208
CTOs and type of medication
Source: CQC (2010). Monitoring
the use of the MHA in 2009/10
NB: N= 193 (15 missing)
Early indications
• Pattern of CTO use seems to mirror the experience
from other jurisdictions
– Gender, diagnosis, medication usage, increased overall
coercion
• Early figures indicate varied practice
– Great variation in use between NHS Trusts (N, and
compared with use of formal admission)
– Some RCs have not used any CTOs, some have
used 20+
• Does the much higher number of CTOS than
expected reflect
– “defensive practice”
– early perception of CTOs being effective?
Clinicians’ views about CTOs
79
% Respondents 80
Crawford's UK
survey 2000
(n=1171)
70
60
50
40
60
Molodynski UK
survey 2010
(n=558)
46
35
30
20
10
18
9
1920
12
Dawson NZ survey ,
2005 (n=284)
0
Prefer system Prefer system
with CTO/in
without
favour
CTO/against
Unsure
Manning et al, 2011
34
Conclusions
• They are spreading
across the Western,
industrialised world.
• Some variation, but in
general obliges patients
to adhere
•
Where do CTOs exist
and how do they
vary?
•
How are CTOs used in
England & Wales over
• Just like anywhere else
the first 4 years?
•
What do we know
about CTO
effectiveness?
• Not terribly much as
there is no rigorous RCT
(to be continued…)