Effectiveness of Community Treatment Orders: The International Evidence

Psychotropic implant can be a new hope in psychiatry

Non-adherence to oral psychotropic medications is common in patients with severe mental illness (SMI). This substantially limits the effectiveness of treatment and results in higher rates of relapse, rehospitalization, suicide, early mortality and disability in SMI. This is a major concern for professionals, caregivers and policy makers. The pharmacological, psychological, psychosocial models and interventions have been there since last few decades to address non-adherence. These have not made major changes in treatment adherence and outcome of SMI. Hence new powerful, long acting and novel psychotropic implant can be developed and could soon revolutionize the treatment in psychiatry.

Patients on outpatient commitment orders in Northern Norway

BACKGROUND

In recent years, an increasing number of countries have introduced outpatient commitment orders (OC), which imply that patients can be subject to compulsory follow-up and treatment while living in the community. However, few studies on how OC is practised have been published.

METHOD

Retrospective case register study based on medical files of all patients receiving an OC order in 2008-2012. We used a pre/post design, recording the use of inpatient services three years before and three years after for those patients who received their first ever OC order in 2008 and 2009.

RESULTS

A total of 345 OC orders applying to 286 persons were identified in the study period 2008-2012. Incidence and prevalence rates were relatively stable, but decreased during the last years of the study period. For all the 54 patients receiving their first ever OC order in 2008 and 2009, need for treatment was the reason for imposing OC, and all received psychotropic medication. The number of inpatient admissions and inpatient days was greater, while the number of days for each admission was lower three years after the OC order than three years before. The first ever OC lasted under a year for 76% of the patients. Receiving depot medication and follow-up by psychiatrists predicted longer OC durations than such treatment and care by psychologists. Only nine patients were not hospitalized during the three-year follow-up after the first ever OC order.

CONCLUSION

Patients on first ever OC orders in Northern Norway used inpatient services more after OC orders than before. Further studies are needed to explore whether increased use of inpatient services by OC patients is beneficial or a failure of OC.

What does being on a community treatment orders entail? A 3-year follow-up of the OCTET CTO cohort

PURPOSE

Community Treatment Orders lack evidence of effectiveness. Very little is known about how they are used in practice and over time in terms of what it obliges patients to do and the judicial threshold for remaining on an order.

AIMS

To investigate CTO implementation in England in terms of the use of specified conditions, and judicial hearings; whether these change over time, and; the level of continued coercion.

METHOD

36-month observational prospective study of patients on CTO in the OCTET follow-up study.

RESULTS

The number of CTO conditions remained stable over time but consolidated around medication adherence and remaining in contact with services. Ten percent of Mental Health Tribunal Hearings and only 1 percent of Hospital Managers Hearings resulted in discharge. Twenty-seven percent of patients experienced more than one CTO episode and eighteen percent remained under compulsion until the end of follow-up.

CONCLUSIONS

CTOs seem to be used primarily to oblige patients to take medication and stay in contact with services. There is agreement between clinical and legal judgements about their appropriateness and threshold for use. A pattern of continuous coercion for a significant group of patients raises concerns. If CTOs are to be continued to be imposed, their use should be carefully monitored with further cohort studies with long-term follow-up.

Notes on the use of randomised controlled trials to evaluate complex interventions: Community treatment orders as an illustrative case

Over the past seven decades, randomised controlled trials (RCTs) have revolutionised clinical research and achieved a gold standard status. However, extending their use to evaluate complex interventions is problematic. In this paper we will demonstrate that complex intervention RCTs violate the necessary premises that govern the RCTs logic and underpin their rigour. The lack of blinding, heterogeneity of participants, as well as poor treatment standardisation and difficulty of controlling for confounders, which characterise complex intervention RCTs, can potentially be profoundly detrimental to their integrity. Proponents of this approach argue that matching "real world" circumstances, while maintaining the randomised design, enhances external validity. We counter this argument by pointing out that an inverted U relation exists between internal and external validity, and thus relaxing the experimental conditions beyond a certain threshold can potentially paradoxically render the RCT externally invalid, i.e. its results cannot be used anywhere. We shall illustrate the inappropriate use of RCTs to evaluate community treatment orders and propose an alternative epistemic model that is based on mechanistic reasoning and Cartwright's capacity concept.

Recall of patients on community treatment orders over three years in the OCTET CTO cohort

BACKGROUND

Randomised studies consistently show that Community Treatment Orders (CTOs) do not have the intended effect of preventing relapse and readmissions of patients with severe and enduring mental illness. Critics suggest this in part can be explained by RCTs studying newly introduced CTO regimes and that patients therefore were not brought back to hospital for short-term observations ('recall') as frequently as intended. Our purpose was (i) to test the hypothesis that CTO practice as regards recall of patients to hospital in England and Wales was as rigorous under the OCTET trial period as in current routine use and (ii) to investigate the reasons for and outcomes of recalls and whether this changed over time.

METHOD

Thirty six-month observational prospective study of 198 patients in the OCTET Follow-up Study.

RESULTS

Forty percent of patients were recalled, 19 % more than once. This is in line with current national use. Deterioration in clinical condition was the most common reason for recalls (49 %), and 68 % of recalls resulted in revocation of the order (i.e., retention in hospital under compulsion). This pattern remained stable over time.

CONCLUSION

The use of recall cannot explain why RCTs have not confirmed any benefits from CTOs, and their continued use should be reconsidered.

TRIAL REGISTRATION

The OCTET Trial was retrospectively registered on 12 November 2009 ( ISRCTN73110773 ).