{"id":142,"date":"2014-01-17T15:17:00","date_gmt":"2014-01-17T15:17:00","guid":{"rendered":"https:\/\/blogs.canterbury.ac.uk\/discursive\/2014\/01\/17\/is-it-time-to-call-time-on-community-treatment-orders\/"},"modified":"2015-11-10T13:36:39","modified_gmt":"2015-11-10T13:36:39","slug":"is-it-time-to-call-time-on-community-treatment-orders","status":"publish","type":"post","link":"https:\/\/blogs.canterbury.ac.uk\/discursive\/is-it-time-to-call-time-on-community-treatment-orders\/","title":{"rendered":"Is it time to call time on Community Treatment Orders?"},"content":{"rendered":"

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\u2019s worth just establishing what we\u2019re talking about. The norm that people with mental health problems can be given treatment against their will and detained in hospital is well established.\u00a0 In the United Kingdom the\u00a0Mental Health Act 2007<\/a> 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.<\/p>\n

Let\u2019s 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\u2019s also leave aside the idea of confining compulsory treatment to cases where people lack the capacity\u00a0<\/i>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 \u00a0\u00a0mental illness While there are\u00a0powerful arguments<\/span><\/a>\u00a0that this situation is unjust, these have\u00a0struggled<\/span><\/a>\u00a0to gain traction.\u00a0 Here I want to focus on the narrower question of whether, in a world were compulsion is established, CTOs have been helpful.<\/p>\n

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.\u00a0 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.\u00a0 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\u2019s clear that uncertainty persists as to whether CTOs are worth retaining.<\/p>\n

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\u00a0before and after the introduction of CTOs. This was the kind of rationale used in\u00a0a Guardian article<\/a>\u00a0arguing 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\u00a0here<\/a>\u00a0and\u00a0here<\/a>). 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\u00a0one of the studies<\/a>\u00a0did find that, for people subject to longer-term CTOs, there were fewer hospital admissions.<\/p>\n

More recently, in this month\u2019s\u00a0Psychiatric Bulletin<\/a>\u00a0CTOs receive detailed consideration in five articles. This series of pieces features a contribution from researchers on\u00a0The Oxford Community Treatment Order Trial (OCTET)<\/a>. This project is the largest controlled thus far involving 333 people. For detailed results see\u00a0here<\/a>\u00a0and here<\/a>. 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.<\/p>\n

Is the case closed then? Well maybe not quite.\u00a0In the face of the OCTET evidence, other contributors make three points. Firstly, it is argued that, while OCTET hasn\u2019t shown a reduction in hospital admissions, there may be other indices by which CTOs might be considered helpful<\/a>. 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\u2019ve\u00a0argued myself<\/a>\u00a0in 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\u00a0proposal<\/a>\u00a0that 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.<\/p>\n

So where are we left?\u00a0Critics<\/a>\u00a0say 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\u2019m 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.\u00a0 Compulsory powers are not insignificant in their effect on people. Could it be time for a pause?<\/p>\n

By\u00a0John McGowan<\/a><\/i><\/div>\n","protected":false},"excerpt":{"rendered":"

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 […]<\/p>\n","protected":false},"author":5457,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[657],"tags":[314,10,6,146],"class_list":["post-142","post","type-post","status-publish","format-standard","hentry","category-comment","tag-community-treatment-orders","tag-john-mcgowan-author","tag-mental-health","tag-the-mental-health-act"],"acf":[],"aioseo_notices":[],"authorName":"John McGowan","featuredImage":false,"postExcerpt":"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 […]","_links":{"self":[{"href":"https:\/\/blogs.canterbury.ac.uk\/discursive\/wp-json\/wp\/v2\/posts\/142","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.canterbury.ac.uk\/discursive\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.canterbury.ac.uk\/discursive\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.canterbury.ac.uk\/discursive\/wp-json\/wp\/v2\/users\/5457"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.canterbury.ac.uk\/discursive\/wp-json\/wp\/v2\/comments?post=142"}],"version-history":[{"count":0,"href":"https:\/\/blogs.canterbury.ac.uk\/discursive\/wp-json\/wp\/v2\/posts\/142\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.canterbury.ac.uk\/discursive\/wp-json\/wp\/v2\/media?parent=142"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.canterbury.ac.uk\/discursive\/wp-json\/wp\/v2\/categories?post=142"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.canterbury.ac.uk\/discursive\/wp-json\/wp\/v2\/tags?post=142"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}