Lisa is a 42 year-old woman. She has had a difficult life. She has experienced multiple traumas and has at times struggled with her emotions. Lisa has a few close family members and a small social circle, though she does at times feel a bit oppressed by them. In 2010 Lisa contracted HIV. She has been treated medically and was stable for some time, however in 2013 she started to deteriorate. She was seen by a psychologist as well as by medics. After a further twelve months she had had enough of interventions and decided she wanted to live the remainder of her life in her own way. Her family and friends objected as they could see she would rapidly deteriorate. However with support from professionals, Lisa utilised the Mental Capacity Act (MCA) to set some advanced directives. She was found to be capable of making these decisions under the MCA, and was legally allowed to refuse further intervention. Lisa did indeed deteriorate, and died a few months later in her own home with her family and friends around her.
Every so often I come across an article on Community Treatment Orders (CTOs). Usually the view expressed is critical and it always produces a stab of disquiet. More on the bad feelings in a second, but before that, it’s worth just establishing what we’re talking about. The norm that people with mental health problems can be given treatment against their will and detained in hospital is well established. In the United Kingdom the Mental Health Act 2007 extended this principle by allowing people such compulsory treatment at home (i.e. without admission). The twinge of unease comes because I, in the face of a good deal of criticism from colleagues, thought this change was a good idea.
Let’s leave aside whether such compulsory powers are right or wrong. Feelings run high but there is no sense in which the abandonment of enforced treatment is on the table. Let’s also leave aside the idea of confining compulsory treatment to cases where people lack the capacity to consent. Unlike physical health (where any of us has a right to refuse treatment unless we lack capacity) the UK the Mental Health Act allows treatment on the basis of mental illness While there are powerful arguments that this situation is unjust, these have struggled to gain traction. Here I want to focus on the narrower question of whether, in a world were compulsion is established, CTOs have been helpful.
The rationale behind CTOs (introduced in 2008) was to facilitate compulsory treatment and to avoid the potentially distressing and dislocating effects of an admission to hospital. At the time I was spending my working life in acute mental health wards and the downsides of being in hospital (forced or otherwise) were regularly right in front of me. Because of this, the alternative of delivering treatment at home rather than in hospital struck me as, if not exactly good, then potentially better than the status quo. However, even after six years it’s clear that uncertainty persists as to whether CTOs are worth retaining.
Assessments of similar provisions across the world have been inconclusive. A range of methodologies have been employed and much of the work is either descriptive or involves comparing admissions before and after the introduction of CTOs. This was the kind of rationale used in a Guardian article arguing that an increase in compulsory admissions between 2008-09 and 2011-12 was proof enough of failure. It is of course, unclear just how many hospitalisations there would have been in 2011-12 without CTOs, so perhaps treating such figures as decisive is overdoing it. A third kind of evidence has been somewhat sparse: controlled trials. These are studies where people have been randomly allocated either to treatment involving CTOs or to treatment without them, At the time of the introduction of CTOs in the UK there were only two such studies (details here and here). Both of these suggested that allocation to CTO or non-CTO- based conditions had little observable effect on hospital admissions. The results were slightly ambiguous though as one of the studies did find that, for people subject to longer-term CTOs, there were fewer hospital admissions.
More recently, in this month’s Psychiatric Bulletin CTOs receive detailed consideration in five articles. This series of pieces features a contribution from researchers on The Oxford Community Treatment Order Trial (OCTET). This project is the largest controlled thus far involving 333 people. For detailed results see here and here. The short version of their findings is that the hope that I, and others, had of a reduction in hospital admissions with CTOs has not been borne out. Both admission rates and length of stay were essentially indistinguishable.
Is the case closed then? Well maybe not quite. In the face of the OCTET evidence, other contributors make three points. Firstly, it is argued that, while OCTET hasn’t shown a reduction in hospital admissions, there may be other indices by which CTOs might be considered helpful. Though you may hear the creak of moving goalposts, there is some merit in this. Readmissions may not necessarily be seen as a treatment failure, something I’ve argued myself in the past. There are cases where a move to hospital (say to try and forestall an intensifying crisis) might be helpful. Indices such as frequency of clinical contact and rates of preventable physical illness are areas where CTOs seem to produce positive effects. Secondly, one potential limitation of the OCTET trial, which lumps together a large and diverse group, is that it does not focus precisely enough on specific sub-groups who may benefit. For example those on CTOs for a protracted time period (as suggested in the study mentioned above). A third point (and one that is likely to raise hackles) is the proposal that the OCTET trial may partly be affected by the participation of clinicians who are lukewarm towards, or outright negative about CTOs. This may affect the appropriateness with which they have been used in the trial. In other words not a fair test. I suspect responses are on their way.
So where are we left? Critics say that OCTET and other controlled trials show that CTOs have failed to meet their intended purposes and should be given the boot. Those taking a more circumspect line argue that the very few controlled trials are insufficient to allow a final decision to be taken and that further work (and perhaps a wider range of outcome measures) is needed: especially to establish more precisely if particular groups benefit. One thing I’m struck by is that inconclusive evidence is seen as a reason to continue with CTOs rather than to abandon, or suspend, them. True, practice in healthcare ultimately must often make policy before the evidence is in. Otherwise innovations would never occur. Nonetheless, the evidence in favour of CTOs, though, has been far less convincing than I (and I suspect many others) expected. Compulsory powers are not insignificant in their effect on people. Could it be time for a pause?