Community treatment orders: state of the evidence.

Legislation to allow for the compulsory supervision and treatment of mentally disordered individuals outside hospital has become a feature of several health care systems over the past 30 years. Various terms are used, most frequently mandated outpatient care or community treatment orders (CTOs), which is the term that will be used here. Community treatment orders have been widely introduced in most American states, across Australia and New Zealand and, more recently, in some Canadian Provinces and European countries, with the England and Wales introducing them in 2007. Several Asian legislatures are currently considering their introduction. The powers of CTOs are generally similar despite often very different descriptions and legal structures. The CTOs provide a legal framework that obliges patients to maintain contact with their clinical team and to take prescribed medication. A power of recall exists if patients fail to meet the terms of their CTO, but none of the legislations allow for physical force to be used outside hospital, indeed all specifically prohibit it. Clearly defined regular monitoring by an independent body and second opinions are features of most regimens. Most CTOs are imposed at the point of discharge after a compulsory admission, although most legislations allow for them to be imposed without such an admission (so-called 'preventative' CTOs), but the UK CTO can only be imposed on a legally detained patient (so-called 'least restrictive' CTO). In considering whether to introduce legislation for CTOs, the potential clinical benefits to patients and their families have to be weighed against the undoubted curtailment of liberty in an already marginalised and stigmatised patient group. This editorial will restrict itself to the clinical evidence, which has been excellently summarised in 2 major reviews. (1,2) There is certainly no shortage of publications; Churchill et al's review (1) contains 72 studies. Despite this, there is considerable controversy. The evidence can be broadly divided into 3 groups of studies: (1) descriptive and stakeholder trials; (2) database studies; and (3) randomised controlled trials. Descriptive and Stakeholder Trials Descriptive and stakeholder trials are well covered in the reviews by Churchill et al (1) and Dawson. (2) New Zealand and the US dominate in this early literature. In summary, these reviews show that the clinical features of patients subject to CTOs are reassuringly similar across different jurisdictions. Patients are more often men, with about 10 years of psychotic illness (around 80% were schizophrenia in all studies), generally with poor insight, isolated, and at risk of self-neglect. These patients are rarely considered a risk to others. These studies find that carers are generally positive about CTOs. Patients are less positive, but not universally critical, sometimes reporting a sense of security from them and a relief not to be regularly readmitted. Staff, even in legislations where there was initial fierce resistance, rapidly form very favourable opinions and consider them indispensable. Rates of use rise rapidly and reliance on depot medication increases. Many of these early studies claim a reduction in hospital admission based either on a before-and-after or a matched cohort design. Database Studies There are 2 significant databases where the association of CTOs with outcomes have been extensively explored. The largest is the Victoria State Database in Australia with data on 16,216 CTOs, and the other is the New York State Database with 3576 CTOs to draw on. There are several publications from each database using a range of methods, of which the commonest is a controlled before-and-after comparison. In these studies, the rates and duration of admissions for a fixed period before and after the imposition of a CTO were compared with a sample (generally much larger) matched at the very least for age, sex, and diagnosis. …

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