The ethics and effectiveness of Community treatment orders (CTOs) has always been a subject of intense international debate. The first UK-based scientific trial evaluating its effectiveness finds that CTOs fail to cut hospital readmission rates in mental health patients; they rather curtail patients' liberty.
A community treatment order allows an eligible patient with psychosis to leave the hospital and get treated in the community. Patients are however required to accept clinical monitoring and allow rapid recall for assessment. Doctors and approved mental health professionals are granted powers to impose strict supervised community treatment on mental health patients. This system has been widely introduced in the USA, Australia, some Canadian provinces, the UK, and several other European countries. This aimed at reducing the involuntary hospitalisation of patients with mental illness.
AdvertisementSevere opposition always followed the system of CTOs, because in a sense, patients discharged under CTOs had a 'restricted' version of liberty. Discharge under CTOs could happen only after getting the approval of a responsible clinician (usually a psychiatrist) and an approved mental health professional. Only those patients who comply with certain conditions would be allowed to stay in the community. Patients who fail to comply would be recalled to the hospital.
There was no experimental evidence to prove the superiority of CTOs over the existing provision for "leave of absence" under Section 17. Section 17 allows a patient to leave hospital for some hours or days, or even exceptionally weeks, while still subject to recall. This was a means to assess recovery before granting voluntary status. Section 17 may be viewed as an older and "less restrictive" form of supervised community treatment.
A UK-based randomised controlled trial compared the outcomes of patients discharged under CTOs with patients discharged under section 17 leave. Researchers postulated that discharge under CTOs would be associated with a lower rate of readmission than those discharged on the pre-existing Section 17 leave of absence. The proposition proved this wrong.
The imposition of compulsory supervision failed to reduce the rate of readmission of psychotic patients. No evidence that could justify 'the significant curtailment of patients' personal liberty' could be obtained from the trial. In light of findings from this trial, the age-old debate over ethics and effectiveness of use of Community Treatment Orders are once again active.
The trials conducted are however not fool proof, but implications of this report need careful consideration.
Reference: Community treatment orders for patients with psychosis (OCTET): a randomised controlled trial; Tom Burns et al; The Lancet 2013.