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Cossu G, Kalcev G, Sancassiani F, Primavera D, Gyppaz D, Zreik T, Carta MG. The long-term adherence following the end of Community Treatment Order: A systematic review. Acta Psychiatr Scand 2024; 150:78-90. [PMID: 38796307 DOI: 10.1111/acps.13709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 04/16/2024] [Accepted: 05/10/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND The community treatment order (CTO) is designed to deliver mental healthcare in the community and has been introduced in around 75 jurisdictions worldwide. It constitutes a legal obligation in which individuals with severe mental illness must adhere to out-of-hospital treatment plans. Despite intense criticism and the debated nature of published evidence, it has emerged as a clinical and policy response to frequent hospital readmissions and to enhance adherence in cases where there is refusal of pharmacological treatments. This systematic review outlines findings on CTO long-term adherence, after mandatory outpatient treatment has ended, in studies that include people with psychiatric disorders. METHOD Following PRISMA guidelines, we performed a review of published articles from PubMed, PsycINFO, EMBASE, and CINAHL up to January 15, 2023. We included studies that assessed adherence after CTO ends. The study is registered with PROSPERO number CRD42022360879. RESULTS Six independent studies analyzing the main indicators of long adherence: engagement with services and medication adherence, were included. The average methodological quality of the studies included is fair. Long-term adherence was assessed over a period ranging from 11 to 28 months. Only two studies reported a statistically significant improvement. Regarding the remaining studies, no positive correlation was observed, except for certain subgroup samples, while in one study, medication adherence decreased. CONCLUSION Scientific evidence supporting the hypothesis that CTO has a positive role on long-term adherence post-obligation is currently not sufficient. Given the importance of modern recovery-oriented approaches and the coercive nature of compulsory outpatient treatment, it is necessary that future studies ensure the role of CTO in effectively promoting adherence.
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Affiliation(s)
- Giulia Cossu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Goce Kalcev
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Federica Sancassiani
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Diego Primavera
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Davide Gyppaz
- Department of Neuroscience, University of Turin, Turin, Italy
| | | | - Mauro Giovanni Carta
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
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Segal SP. Protecting Health and Safety with Needed-Treatment: the Effectiveness of Outpatient Commitment. Psychiatr Q 2022; 93:55-79. [PMID: 33404994 PMCID: PMC8257759 DOI: 10.1007/s11126-020-09876-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2020] [Indexed: 11/30/2022]
Abstract
Outpatient civil commitment (OCC) requires the provision of needed-treatment, as a less restrictive alternative (LRA) to psychiatric-hospitalization in order to protect against imminent-threats to health and safety associated with severe mental illness (SMI). OCC-reviews aggregating all studies report inconsistent outcomes and interpret such as intervention failure. This review, considering those studies whose outcome criteria are consistent with the provisions of OCC-law, seeks to determine OCC-effectiveness in meeting its legislated objectives. This review incorporated studies from previous systematic-reviews, used their search methodology, and added investigations through August 2020. Selected OCC-studies evaluated samples of all eligible patients in a jurisdiction. Their outcome-measures were threats to health or safety or the receipt of needed-treatment exclusive of post-OCC-assignment- hospitalization, the latter being the OCC-default for providing needed-treatment in the absence of an LRA and dependent on bed-availability. A study's evidence-quality was evaluated with the Berkeley Evidence Ranking and the New Castle Ottawa systems. Thirty-nine OCC-outcome-studies in six-outcome-areas directly addressed OCC-statute objectives: 21 considered imminent threats to health and safety, 10 compliance with providing needed-treatment, and 8 conformity to the LRA-standard. With the top evidence-rank equal to one, the studies M = 2.55. OCC-assignment was associated with reducing mortality-risk, increasing access to acute-medical-care, and reducing risks of violence and victimization. It enabled reaching these objectives as a LRA to hospitalization and facilitated the use of community-services by individuals refusing such assistance when outside of OCC-supervision. OCC's appears to enable recovery by reducing potentially life-altering health and safety risks associated with SMI.
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Affiliation(s)
- Steven P Segal
- University of Melbourne, Melbourne, Australia. .,Mental Health and Social Welfare Research Group, School of Social Welfare, University of California, 120 Haviland Hall (MC #7400), Berkeley, CA, 94720-7400, USA.
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Segal SP. The utility of outpatient civil commitment: Investigating the evidence. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2020; 70:101565. [PMID: 32482302 PMCID: PMC7394121 DOI: 10.1016/j.ijlp.2020.101565] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 04/20/2020] [Accepted: 04/21/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Outpatient civil commitment (OCC), community treatment orders (CTOs) in European and Commonwealth nations, require the provision of needed-treatment to protect against imminent threats to health and safety. OCC-reviews aggregating all studies report inconsistent outcomes. This review, searches for consistency in OCC-outcomes by evaluating studies based on mental health system characteristics, measurement, and design principles. METHODS All previously reviewed OCC-studies and more recent investigations were grouped by their outcome-measures' relationship to OCC statute objectives. A study's evidence-quality ranking was assessed. Hospital and service-utilization outcomes were grouped by whether they represented treatment provision, patient outcome, or the conflation of both. RESULTS OCC-studies including direct health and safety outcomes found OCC associated with reduced mortality-risk, increased access to acute medical care, and reduced violence and victimization risks. Studies considering treatment-provision, found OCC associated with improved medication and service compliance. If coupled with assertive community treatment (ACT) or aggressive case management OCC was associated with enhanced ACT success in reducing hospitalization need. When outpatient-services were limited, OCC facilitated rapid return to hospital for needed-treatment and increased hospital utilization in the absence of a less restrictive alternative. OCC-studies measuring "total hospital days", "prevention of hospitalization", and "readmissions" report negative and/or no difference findings because they erroneously conflate their intervention (provision of needed treatment) and outcome. CONCLUSIONS This investigation finds replicated beneficial associations between OCC and direct measures of imminent harm indicating reductions in threats to health and safety. It also finds support for OCC as a less restrictive alternative to inpatient care.
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Affiliation(s)
- Steven P Segal
- Professor, University of Melbourne, Australia; Professor of the Graduate Division and Director of the Mental Health and Social Welfare Research Group, University of California, Berkeley, USA.
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Barkhuizen W, Cullen AE, Shetty H, Pritchard M, Stewart R, McGuire P, Patel R. Community treatment orders and associations with readmission rates and duration of psychiatric hospital admission: a controlled electronic case register study. BMJ Open 2020; 10:e035121. [PMID: 32139493 PMCID: PMC7059496 DOI: 10.1136/bmjopen-2019-035121] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 11/26/2019] [Accepted: 12/04/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Limited evidence is available regarding the effect of community treatment orders (CTOs) on mortality and readmission to psychiatric hospital. We compared clinical outcomes between patients placed on CTOs to a control group of patients discharged to voluntary community mental healthcare. DESIGN AND SETTING An observational study using deidentified electronic health record data from inpatients receiving mental healthcare in South London using the Clinical Record Interactive Search (CRIS) system. Data from patients discharged between November 2008 and May 2014 from compulsory inpatient treatment under the Mental Health Act were analysed. PARTICIPANTS 830 participants discharged on a CTO (mean age 40 years; 63% male) and 3659 control participants discharged without a CTO (mean age 42 years; 53% male). OUTCOME MEASURES The number of days spent in the community until readmission, the number of days spent in inpatient care in the 2 years prior to and the 2 years following the index admission and mortality. RESULTS The mean duration of a CTO was 3.2 years. Patients receiving care from forensic psychiatry services were five times more likely and patients receiving a long-acting injectable antipsychotic were twice as likely to be placed on a CTO. There was a significant association between CTO receipt and readmission in adjusted models (HR: 1.60, 95% CI 1.42 to 1.80, p<0.001). Compared with controls, patients on a CTO spent 17.3 additional days (95% CI 4.0 to 30.6, p=0.011) in a psychiatric hospital in the 2 years following index admission and had a lower mortality rate (HR: 0.66, 95% CI 0.50 to 0.88, p=0.004). CONCLUSIONS Many patients spent longer on CTOs than initially anticipated by policymakers. Those on CTOs are readmitted sooner, spend more time in hospital and have a lower mortality rate. These findings merit consideration in future amendments to the UK Mental Health Act.
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Affiliation(s)
- Wikus Barkhuizen
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Alexis E Cullen
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Hitesh Shetty
- NIHR Maudsley Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, UK
| | - Megan Pritchard
- NIHR Maudsley Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, UK
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Robert Stewart
- NIHR Maudsley Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, UK
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Philip McGuire
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- NIHR Maudsley Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, UK
| | - Rashmi Patel
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- NIHR Maudsley Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, UK
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Barnett P, Matthews H, Lloyd-Evans B, Mackay E, Pilling S, Johnson S. Compulsory community treatment to reduce readmission to hospital and increase engagement with community care in people with mental illness: a systematic review and meta-analysis. Lancet Psychiatry 2018; 5:1013-1022. [PMID: 30391280 PMCID: PMC6251967 DOI: 10.1016/s2215-0366(18)30382-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 09/07/2018] [Accepted: 09/17/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Compulsory community treatment (CCT) aims to reduce hospital readmissions among people with mental illness. However, research examining the usefulness of CCT is inconclusive. We aimed to assess the effectiveness of CCT in reducing readmission and length of stay in hospital and increasing community service use and treatment adherence. METHODS For this systematic review and meta-analysis, we searched three databases (PsycINFO, MEDLINE and Embase) for quantitative studies on CCT published in English between Jan 1, 1806, and Jan 4, 2018. We included both randomised and non-randomised designs that compared CCT with no CCT, and pre-post designs that compared patients before and after CCT. Studies were eligible if they had been peer-reviewed, if 50% or more of patients had severe mental illness, and if CCT was the intervention. Trials in which CCT was used in response to a criminal offence were excluded. We extracted data on study characteristics and length of follow-up, patient-level data on diagnosis, age, sex, race, and admission history, and outcomes of interest (readmission to hospital, inpatient bed-days, community service use, and treatment adherence) for meta-analysis, for which we extracted summary estimates. We used a random-effects model to compare disparate outcome measures and convert effect size statistics into standardised mean differences. This systematic review is registered with PROSPERO, number CRD42018086232. FINDINGS Of 1931 studies identified, 41 (2%) met inclusion criteria and had sufficient data for analysis. Before and after CCT comparisons showed significant large effects on readmission to hospital (standardised mean difference 0·80, 95% CI 0·53-1·08; I2=94·74), use of community services (0·83, 0·46-1·21; I2=87·26), and treatment adherence (2·12, 1·69-2·55; I2=0), and a medium effect on inpatient bed-days (0·66, 0·46-0·85; I2=94·12). Contemporaneous controlled comparison studies (randomised and non-randomised) showed no significant effect on readmission, inpatient bed-days, or treatment adherence, but a moderate effect on use of community services (0·38, 0·19-0·58; I2=96·92). A high degree of variability in study quality was found, with observational study ratings ranging from three to nine. Bias most frequently centred on poor comparability between CCT and control participants. INTERPRETATION We found no consistent evidence that CCT reduces readmission or length of inpatient stay, although it might have some benefit in enforcing use of outpatient treatment or increasing service provision, or both. Future research should focus on why some people do not engage with treatment offered and on enhancing quality of the community care available. Shortcomings of this study include high levels of variability between studies and variation in study quality. FUNDING National Institute for Health Research.
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Affiliation(s)
- Phoebe Barnett
- Centre for Outcomes Research and Effectiveness, Department of Clinical Educational and Health Psychology, University College London, London, UK; NIHR Policy Research Unit, University College London, London, UK.
| | - Hannah Matthews
- Centre for Outcomes Research and Effectiveness, Department of Clinical Educational and Health Psychology, University College London, London, UK; NIHR Policy Research Unit, University College London, London, UK
| | | | - Euan Mackay
- Centre for Outcomes Research and Effectiveness, Department of Clinical Educational and Health Psychology, University College London, London, UK; NIHR Policy Research Unit, University College London, London, UK
| | - Stephen Pilling
- Centre for Outcomes Research and Effectiveness, Department of Clinical Educational and Health Psychology, University College London, London, UK; NIHR Policy Research Unit, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK
| | - Sonia Johnson
- NIHR Policy Research Unit, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK
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Bennett DM, Bailey AC, Forrest AD. Community treatment orders in England: review of usage from national data. BJPsych Bull 2018; 42:218. [PMID: 30345071 PMCID: PMC6189978 DOI: 10.1192/bjb.2018.65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Daniel M Bennett
- Consultant Forensic Psychiatrist, Associate Postgraduate Dean, University of Aberdeen, NHS Grampian;
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Gupta S, Akyuz EU, Baldwin T, Curtis D. Community treatment orders in England: review of usage from national data. BJPsych Bull 2018; 42:119-122. [PMID: 29681252 PMCID: PMC6048733 DOI: 10.1192/bjb.2017.33] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
UNLABELLED Aims and methodCommunity treatment orders (CTOs) have been in used in England and Wales since November 2008; however, their effectiveness has been debated widely, as has the question of which methodology is appropriate to investigate them. This paper uses national data to explore the use of CTOs in England. RESULTS About 5500 patients are subject to CTOs at any one time. Each year, ~4500 patients are made subject to a CTO each year and ~2500 are fully discharged, usually by the responsible clinician; fewer than half of CTO patients are recalled, and two-thirds of recalls end in revocation. The low rate of CTO discharges by mental health tribunals (below 5%) suggests that they are not used inappropriately.Clinical implicationsThe introduction of CTOs in England has coincided with a reduction in psychiatric service provision due to the economic downturn. Pressures on services might be even more severe if patients currently subject to CTOs instead needed to be detained as in-patients.Declaration of interestNone.
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Abstract
SummaryIn the wake of the deinstitutionalisation of mental health services, community treatment orders (CTOs) have been introduced in around 75 jurisdictions worldwide. They make it a legal requirement for patients to adhere to treatment plans outside of hospital. To date, about 60 CTO outcome studies have been conducted. All studies with a methodology strong enough to infer causality conclude that CTOs do not have the intended effect of preventing relapse and reducing hospital admissions. Despite this, CTOs are still debated, possibly reflecting different attitudes to the role of evidence-based practice in community psychiatry. There are clinical, ethical, legal, economic and professional reasons why the current use of CTOs should be reconsidered.Learning Objectives• Gain an overview of the development and use of CTOs in the UK and internationally• Get up-to-date information about the evidence base for CTO effectiveness and the relative contributions of different levels of evidence• Appreciate the nature of the current controversy around the use of CTOs and become familiar with the factors in the ongoing debate about their future
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Vergunst F, Rugkåsa J, Koshiaris C, Simon J, Burns T. Community treatment orders and social outcomes for patients with psychosis: a 48-month follow-up study. Soc Psychiatry Psychiatr Epidemiol 2017; 52:1375-1384. [PMID: 28900690 DOI: 10.1007/s00127-017-1442-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 08/31/2017] [Indexed: 11/24/2022]
Abstract
PURPOSE Community treatment orders (CTOs) are widely used internationally despite a lack of evidence supporting their effectiveness. Most effectiveness studies are relatively short (12-months or less) and focus on clinical symptoms and service data, while a little attention is given to patients' social outcomes and broader welfare. We tested the association between the duration of CTO intervention and patients' long-term social outcomes. METHODS A sub-sample (n = 114) of community-based patients from the Oxford Community Treatment Order Evaluation Trial (OCTET) were interviewed 48 months after randomisation. Multivariate regression models were used to examine the association between the duration of the CTO intervention and social outcomes as measured by the social network schedule, Objective Social Outcomes Index, Euro-Qol EQ-5D-3L (EQ-5D), and Oxford Capabilities Questionnaire for Mental Health. RESULTS No significant association was found between the duration of CTO intervention and social network size (IRR = 0.996, p = .63), objective social outcomes (B = -0.003, p = .77), health-related quality of life (B = 0.001, p = .77), and capabilities (B = 0.046, p = .41). There were no between-group differences in social outcomes when outcomes were stratified by original arm of randomisation. Patients had a mean of 10.2 (SD = 5.9) contacts in their social networks, 42% of whom were relatives. CONCLUSIONS CTO duration was not associated with improvements in patients' social outcomes even over the long term. This study adds to growing concerns about CTO effectiveness and the justification for their continued use.
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Affiliation(s)
- Francis Vergunst
- Research Unit On Children's Psychosocial Maladjustment, University of Montreal, 3175 Chemin de la Côte Ste-Catherine, Montreal, H3T 1C5, Canada. .,Department of Psychiatry, University of Oxford, Oxford, UK.
| | - Jorun Rugkåsa
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway.,Centre for Care Research, University College of Southeast Norway, Notodden, Norway
| | | | - Judit Simon
- Department of Health Economics, Centre for Public Health, Medical University of Vienna, Vienna, Austria.,Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Tom Burns
- Department of Psychiatry, University of Oxford, Oxford, UK
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What does being on a community treatment orders entail? A 3-year follow-up of the OCTET CTO cohort. Soc Psychiatry Psychiatr Epidemiol 2017; 52:465-472. [PMID: 27816998 DOI: 10.1007/s00127-016-1304-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 10/24/2016] [Indexed: 10/20/2022]
Abstract
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.
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Rugkåsa J. Effectiveness of Community Treatment Orders: The International Evidence. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2016; 61:15-24. [PMID: 27582449 PMCID: PMC4756604 DOI: 10.1177/0706743715620415] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Community treatment orders (CTOs) exist in more than 75 jurisdictions worldwide. This review outlines findings from the international literature on CTO effectiveness. METHOD The article draws on 2 comprehensive systematic reviews of the literature published before 2013, then uses the same search terms to identify studies published between 2013 and 2015. The focus is on what the literature as a whole tells us about CTO effectiveness, with particular emphasis on the strength and weaknesses of different methodologies. RESULTS The results from more than 50 nonrandomized studies show mixed results. Some show benefits from CTOs while others show none on the most frequently reported outcomes of readmission, time in hospital, and community service use. Results from the 3 existing randomized controlled trials (RCTs) show no effect of CTOs on a wider range of outcome measures except that patients on CTOs are less likely than controls to be a victim of crime. Patients on CTOs are, however, likely to have their liberty restricted for significantly longer periods of time. Meta-analyses pooling patient data from RCTs and high quality nonrandomized studies also find no evidence of patient benefit, and systematic reviews come to the same conclusion. CONCLUSION There is no evidence of patient benefit from current CTO outcome studies. This casts doubt over the usefulness and ethics of CTOs. To remove uncertainty, future research must be designed as RCTs.
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Affiliation(s)
- Jorun Rugkåsa
- Health Services Research Unit, Akershus University Hospital, Social Psychiatry Group, Lørenskog, Norway Department of Psychiatry, University of Oxford, Oxford, United Kingdom
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Burns T, Yeeles K, Koshiaris C, Vazquez-Montes M, Molodynski A, Puntis S, Vergunst F, Forrest A, Mitchell A, Burns K, Rugkåsa J. Effect of increased compulsion on readmission to hospital or disengagement from community services for patients with psychosis: follow-up of a cohort from the OCTET trial. Lancet Psychiatry 2015; 2:881-90. [PMID: 26362496 DOI: 10.1016/s2215-0366(15)00231-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 04/11/2015] [Accepted: 05/08/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND Community treatment orders (CTOs) have not been shown in randomised trials to reduce readmission to hospital in patients with psychosis, but these trials have been short (11-12 months). We previously investigated the effect of CTOs on readmission rates over 12 months in a randomised trial (OCTET). Here, we present follow-up data for a cohort of individuals recruited to our original trial to examine the long-term effect of CTOs on readmissions and the risk of patients disengaging from mental health services temporarily or enduringly. METHODS For OCTET, an open-label, parallel, randomised controlled trial, we recruited patients aged 18-65 years involuntarily admitted to mental health hospitals in 32 trusts in England, with a diagnosis of psychosis and deemed suitable for CTOs by their clinicians. Between Nov 10, 2008, and Feb 22, 2011, we recruited and randomly assigned 336 eligible patients (1:1) to be discharged on either a CTO (n=167) or to voluntary status via Section 17 leave (control group; n=169). For the analysis presented in this report, we assessed data at 36 months for 330 of these patients. We tested rates of readmission to hospital, time to first readmission, number of readmissions, and duration of readmission in patients assigned to CTO versus those assigned to control, and in all patients with CTO experience at any time in the 36 months versus those without. We also tested whether duration of CTO affected readmission outcomes in patients with CTO experience. We examined discontinuation (≥60 days between clinical contacts) and disengagement from services (no clinical contact for ≥90 days with no return to contact) in the whole cohort. OCTET is registered with isrctn.com, number ISRCTN73110773. FINDINGS We obtained data for 330 patients in the relevant period between Nov 10, 2008 and Feb 22, 2014 (36 months after the last patient was randomly assigned to OCTET). We identified no difference between the randomised groups in the numbers of patients readmitted (100 [61%] of 165 CTOs vs 113 [68%] of 165 controls; relative risk 0·88 [95% CI 0·75-1·03]), number of readmissions (mean 2·4 readmissions [SD 1·91] vs 2·2 [1·43]; incident density ratio [IDR] 0·97 [95% CI 0·76-1·24]), duration of readmissions (median 117·5 days [IQR 63-303] vs 139·5 days [63·0-309·5]; IDR 0·84 [95% CI 0·51-1·38]), or time to first readmission (median 601·0 days [95% CI 387·0-777·0] vs 420·0 days [352·0-548·0]; hazard ratio [HR] 0·81 [95% CI 0·62-1·06]). The CTO experience group had significantly more readmissions than the group without (IDR 1·39 [95% CI 1·07-1·79]) and we noted no significant difference between groups in readmission rates, duration of readmission, or time to first readmission. We did not identify a linear relationship between readmission outcomes and duration of CTO. 19 (6%) patients disengaged from services (12 [7%] of 165 CTOs vs 7 [4%] of 165 controls). Longer duration of compulsion was associated with later disengagement (HR 0·946 [95% CI 0·90-0·99, p=0·023). 187 (57%) experienced no discontinuities, and we noted no significant difference between the CTO and control groups for time to disengagement or number of discontinuities. Levels of discontinuity were associated with compulsion (IDR 0·973 [95% CI 0·96-0·99, p<0·0001]. We identified no effect of baseline characteristics on the associations between compulsion and disengagement. INTERPRETATION We identified no evidence that increased compulsion leads to improved readmission outcomes or to disengagement from services in patients with psychosis over 36 months. The level of persisting clinical follow-up was much higher than expected, irrespective of CTO status, and could partly account for the absence of CTO effect. The findings from our 36-month follow-up support our original findings that CTOs do not provide patient benefits, and the continued high level of their use should be reviewed. FUNDING National Institute for Health Research.
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Affiliation(s)
- Tom Burns
- Department of Psychiatry, University of Oxford, Oxford, UK.
| | - Ksenija Yeeles
- Department of Psychiatry, University of Oxford, Oxford, UK
| | | | - Maria Vazquez-Montes
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK; Centre for Statistics in Medicine, Botnar Research Centre, University of Oxford, Oxford, UK; National Institute for Health Research, Oxford Biomedical Research Centre Research Fellow, The Churchill Hospital, Oxford, UK
| | | | - Stephen Puntis
- Department of Psychiatry, University of Oxford, Oxford, UK
| | | | - Alexandra Forrest
- Department of Psychiatry, University of Oxford, Oxford, UK; Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Amy Mitchell
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Kiki Burns
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Jorun Rugkåsa
- Department of Psychiatry, University of Oxford, Oxford, UK; Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
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Burns T, Rugkåsa J, Molodynski A. In defence of OCTET. Lancet Psychiatry 2015; 2:375-376. [PMID: 26360267 DOI: 10.1016/s2215-0366(15)00120-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 03/13/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Tom Burns
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, OX3 7ZX, UK.
| | - Jorun Rugkåsa
- Health Services Research Unit, Akershus University Hospital, 1478 Lørenskog, Norway
| | - Andrew Molodynski
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, OX3 7ZX, UK
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Rawala M, Gupta S. Use of community treatment orders in an inner-London assertive outreach service. PSYCHIATRIC BULLETIN 2014; 38:13-8. [PMID: 25237484 PMCID: PMC4067843 DOI: 10.1192/pb.bp.112.042184] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Revised: 04/15/2013] [Accepted: 04/29/2013] [Indexed: 11/23/2022]
Abstract
Aims and method To compare admission rates and bed occupancy before and after the introduction of community treatment orders (CTOs) in 37 assertive outreach service patients. The effect of CTOs on treatment adherence and illicit drug use were also evaluated. The views of patients and care coordinators were obtained through a focus group. Results When CTOs were introduced, admission rates fell from 3.3 to 0.3 per year and average bed occupancy declined from 133.2 to 10.8 days per year. Treatment adherence improved from 4 (10.8%) to 31 (83.7%) patients, and an objective reduction in substance misuse was observed in 25 (67.5%) patients. Whereas patients expressed ambivalence towards CTOs, their care coordinators generally had a more positive view. Clinical implications The decline in hospital usage following the introduction of CTOs is encouraging and could reflect improved adherence and engagement through intensive case management, leading to a reduction in readmissions. However, further studies need to look at quality of life, cost-effectiveness and the impact on patients.
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Patel MX, Matonhodze J, Baig MK, Taylor D, Szmukler G, David AS. Naturalistic outcomes of community treatment orders: antipsychotic long-acting injections versus oral medication. J Psychopharmacol 2013; 27:629-37. [PMID: 23676196 DOI: 10.1177/0269881113486717] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Community treatment orders (CTOs) are initiated to compel the patient in the community to take part in a management plan, of which medication is often a part. CTOs were introduced in 2008, in England and Wales. We evaluated naturalistic outcomes of CTOs, according to the antipsychotic formulation prescribed at CTO initiation. METHODS A cohort study with prospective consecutive sampling and 1-year follow-up was conducted in a large mental health trust in South London. Measures included: demographics, psychotropics and CTO outcomes. Comparison groups were long-acting injection (LAI) versus oral formulations only, for the primary outcomes of time to CTO cessation in days and time to first hospital admission in days, whilst the CTO remained active. RESULTS For the 188 included patients, the CTO ceased within 1 year, either due to revocation (22.3%), discharge (28.1%) or lapse (19.7%). The CTO was renewed at 6 months for 92 (48.9%) patients, and then 56 (29.8%) were renewed again at 12 months. The antipsychotic formulation at CTO initiation was more likely to be LAI (60.6%) than oral (39.4%). Time to CTO cessation was longer for LAI than oral (median 251 versus 182 days, p = 0.030). A total of 54 patients experienced at least one admission; there was no difference between groups by drug formulation (oral 28.4% versus LAI 28.9%, p = 0.933). The mean time to first admission was 147.1 days and did not differ by formulation. CONCLUSIONS CTO duration was longer for those prescribed an antipsychotic LAI at CTO initiation, although the time to first admission and number of admissions did not differ between groups. CTOs not only compel treatment, but bind services to the patient, resulting in more intensive follow up. Whether enhanced treatment, via oral or LAI and enabled by the CTO, translates into improved clinical outcomes is yet to be determined.
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Affiliation(s)
- Maxine X Patel
- Institute of Psychiatry, King's College London, London, UK.
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