Compulsory treatment orders for mental illness need reviewing

Community Treatment Orders (CTOs) have been controversial since their introduction in the UK in 2008. An Oxford University study has now found they do not alter the likelihood of patients being hospitalised again, compared with an older and less restrictive type of supervised discharge called Section 17 leave.

'This is the largest randomised trial of CTOs, and we did not find any evidence that they achieve their intended purpose of reducing readmission in so-called "revolving door" patients with a diagnosis of psychosis,' says Professor Tom Burns of the Department of Psychiatry at Oxford University, who led the study.

He says: 'The evidence is now strong that the use of CTOs does not confer early patient benefits despite substantial curtailment of individual freedoms. Their current high usage should be urgently reviewed.'

The findings are published in the medical journal The Lancet.

CTOs were introduced for psychiatric patients that are often repeatedly involuntarily hospitalised, leading to the idea of 'revolving door syndrome'. This group of patients are likely to have diagnoses of bipolar disorder or schizophrenia, are often men, lead unstable lives, and experience social exclusion and unemployment. 

 The measure was intended to address growing rates of involuntary hospital admissions due to mental ill health in the UK. CTOs allow clinicians and mental health practitioners to monitor a patient’s condition when leaving hospital after an involuntary admission, with the aim of providing a period of stability when relapse is considered likely.

Currently, around 4,000 people annually are made subject to a CTO in the UK, with perhaps 10,000 people on a CTO at any point.

Similar legislation has also been introduced in the USA, Australasia, some parts of Canada, and several other European countries.

However, several mental health organisations have expressed concerns that CTOs are an unacceptable infringement on patients' civil liberties, as they allow specific conditions to be imposed on the patient, and that there is insufficient evidence to show that they are effective.

CTOs can include requirements that the patient takes certain medication, attends regular assessments, or lives in a certain place. If a patient breaks any of these conditions, the responsible clinician has the ability to recall them to hospital for up to 72 hours without formally readmitting them.

This is unlike the older provision of Section 17 leave, a period of leave from a hospital’s inpatient unit which, if it goes well, is followed by discharge and voluntary treatment. 

The OCTET study looked at whether 166 patients on CTOs experienced fewer hospital admissions compared with 167 patients released under Section 17 leave.

The Oxford University researchers found that the number of patients readmitted to hospital over 12 months did not differ between the groups. Just over a third (36%) of patients in each group were readmitted at some point.

Nor were there any significant differences in the time to readmission, or the number or duration of hospital admissions. The use of CTOs was not found to affect any of the patients' clinical or social outcomes.

But there was a great difference in the length of compulsory supervision of patients. Although the patients received equivalent levels of clinical contact, the patients on CTOs received compulsory treatment for an average of around 6 months. Those in the Section 17 group received compulsory treatment for an average of just over a week.

Professor Sonia Johnson of University College London, who was not involved in the study, comments in the Lancet: 'A strong respect for civil liberties is imperative for professionals entrusted with coercive powers, and arguments that CTOs infringe human rights seem persuasive if benefits cannot be shown.'