The Psychiatric Bulletin has devoted an entire issue to the topic of CTOs (Community Treatment Orders), so I thought it would be an opportune time to discuss what they are, and the various arguments for and against them.
I’ll discuss three possible conclusions about CTOs:
- They’re good (they work)
- They’re bad (they don’t work)
- They’re ugly (they’re a breach of human rights)
What are CTOs?
CTOs, or Community Treatment Orders, are “community sections”.
If you’ve been in hospital under Section 3 of the Mental Health Act and are well enough to be discharged home, your consultant psychiatrist might decide to put you on a CTO instead of let you go completely. They need the agreement of an AMHP (usually a social worker) to do this.
In simple terms, being on a CTO means that you’re free to do as you wish, as long as you keep to the conditions of the CTO. There are two mandatory conditions – you have to turn up at the end of your CTO to be reassessed, and you have to turn up to see a “second opinion” doctor if you don’t agree with your treatment plan – but your consultant can add any number of additional conditions if they feel it’s necessary to keep you well. Conditions like “avoid drugs” and “turn up to my clinic” are common.
Here’s the kicker – if you don’t keep to the conditions of the CTO, your consultant can recall you to hospital (force you to come back) if it’s in the interests of your health, your safety or the protection of others. In this respect, being on a CTO is quite like being parole.
You can’t be treated (i.e. injected) against your will in the community – that can only happen in the hospital after you’ve been recalled.
A CTO initially last 6 months, but it can be reviewed and extended as many times as your consultant likes, as long as an AMHP still agrees and the patient doesn’t win a tribunal.
You can find the exact legal criteria for CTOs here.
Why do we have CTOs?
We’ve had CTOs since 2008. Large parts of the rest of the world already had them in some form, including numerous states of the USA, Australia, New Zealand and Israel.
The idea to bring them to the UK was raised as early as 1988 by the Royal College of Psychiatrists, though fierce opposition and political stagnation delayed their arrival.
The aim was to keep “revolving door” patients out of hospital – the type of patient who disengages with their care team, stops their medication, relapses, gets admitted, gets better with treatment, gets discharged and then starts the whole cycle all over again, often many times a year. Apparently these patients are demographically similar in every place that uses CTOs – they have psychotic illnesses and tend to be male, black and use drugs.
Ultimately, CTOs were meant to free up lots of beds for other patients and to keep difficult-to-manage patients well.
Initially, the government estimated we’d only use CTOs on a few hundred patients a year, but since their inception in 2008 we’ve used over 14,000. Roughly 4,000 of those patients have been recalled to hospital and roughly 4,000 have had their CTOs discontinued. Only 5% of patients who appeal to a tribunal win their case.
Are they GOOD or BAD?
Whether CTOs work or not has been hotly debated. The key reviews of the research were written by Churchill in 2007 and Maughan in 2013.
The first point to make is that the effects of CTOs are very difficult to study scientifically – different countries have differently worded laws, with different intents, so it’s not always possible to directly apply evidence from one place to another. It’s also very hard to tease apart the effects of CTOs from the effects of other interventions that often come with them, like extra support.
A good example of how unintentionally misleading research about CTOs can be is this recent study. The researchers followed 37 patients and compared how long they spent in hospital before and after being put onto their CTOs. Low and behold, the average number of days they spent in hospital per year dropped from 133 to just 11. Admission rates per year fell from 3.3 per year to 0.3 year – a tasty 91%. It appears to be a miracle.
But it isn’t – when the patients were put onto their CTOs, they got a lot of extra care from the specialist team, which would have strongly influenced their likelihood of improvement regardless of their CTO. And people are prone to getting better anyway (“regression to the mean”).
You need to compare groups of patients whose care is identical except for the CTOs to get a valid result. When this has been done, the outcomes are clear – CTOs don’t work. Many studies have actually shown that being on a CTO makes it more likely that you’ll be admitted because you’re being watched more closely.
All three randomised controlled trials – the most reliable type of trial – support this assertion. Before 2013, the only two studies of this type, performed in North Carolina and New York, were poorly designed and of debatable usefulness, but still failed to report any benefit from being on a CTO.
Then came one of the most important mental health papers of the year – the OCTET trial. Professor Tom Burns and his team in Oxford randomised 336 patients to receive either a CTO or a short period of day leave from hospital before discharge. A year later, they checked up on how the patients did. It was the best study design they could manage under the legal circumstances, and the results were astonishing – there was no difference at all between the two groups in terms of admissions, wellness, time spent in hospital or social functioning. Literally zero change.
Though the study has been criticised, usually on the grounds that the sample of patients and clinicians who took part in the trial was biased, it’s hard to argue against such an emphatic result when the only contradictory evidence is your own gut feeling that CTOs appear to work.
As we know, you can’t judge if an intervention works just by looking at ground level. Humans just aren’t capable of making accurate inferences in that way.
Why are they BAD?
So why don’t CTOs work? I have my theories.
If you conceptualise CTOs as a threat – “if you don’t do as I say, we’ll bring you back to hospital” – there are various reasons why that threat might not be effective.
- The threat is ignored. The type of patients who end up on CTOs aren’t usually the ones who follow the instructions of their doctor to the letter.
- The threat is a bluff. Even when a patient ignores their doctor and breaks the conditions of their CTO, their doctor doesn’t recall them. They stay well for a while, and aren’t a risk to themselves or anyone else, so the doctor doesn’t think it would be a good idea to drag them back to hospital kicking and screaming. Eventually they do relapse, usually quickly, and are brought into hospital in the state they would have been in without a CTO.
- The threat is hard to carry out. With services as stretched as they are, it’s difficult enough to organise admission for someone who is really unwell, let alone someone who has refused to take their medication and needs to have it given under force, even though they’re still well.
- The treatment doesn’t work anyway. The type of patient who ends up on a CTO, who is very difficult to keep well, isn’t usually going to have an amazing response to medication even if they are coerced into taking it. They tend to relapse anyway, whatever we do.
Are they UGLY?
Some groups have stated that even if we were sure that CTOs reduced admissions and kept patients really well, it would be wrong to use them as they infringe human rights.
In February 2013 the UN Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment, Juan E. Méndez, released a report detailing how some developing countries were discriminating against people with mental health problems, resulting in their abuse.
Though some have argued that CTOs do not amount to the same level of “diminishing human dignity” as the laws of these developing countries, it seems that the opinion is just a shade of grey; a matter of interpretation. It shouldn’t be this way.
Though research suggests that the opinions of patients on CTOs is mixed – some like the extra care and structure, others dislike the coercion – I think the emphasis on paternalism is a very unhelpful step for psychiatry.
As I’ve discussed in a blog before, our Mental Health Act doesn’t allow for the possibility that a patient might be able to make sound decisions about their own life. It assumes they won’t be able to, and hands that power to doctors.
If a patient with a physical health problem, like diabetes or asthma, has the capacity to make a decision about their own care, then that decision is respected – even if it’s unwise and might lead to them becoming very unwell. We have no right to force capable people with diabetes to come back into hospital if they stop taking their insulin, even though we might drastically reduce the rates of illness that way.
But if the patient has a mental illness, for some reason we can force them, even if they’re utterly capable of considering the situation for themselves. I recognise that mental illness predisposes slightly more readily to violence that most physical illnesses – but this is just another risk that the patient has to demonstrate they can weigh up to be deemed capable of making their own decisions.
A large proportion of patients on CTOs – I’m not sure how many exactly – will be chronically too unwell to be able to make reasonable decisions about their care, so being on a CTO is less of an infringement for them, but this is simply fortunate, and not an excuse for ultimately abusive legislation.
Where from here?
The water is muddy. The research on CTOs appears to state that they don’t work, but it’s hard to be certain because it’s a tough area to study scientifically. Even if they do reduce relapse and readmission rates, in the eyes of many, CTOs represent a blatant infringement of human rights.
The possibility of CTOs being abolished, even in the face of robust scientific evidence of their ineffectiveness, is slim – unless our government is instructed by a higher power. That outcome seems unlikely too.
The best we can do for now is to keep investigating, keep discussing, keep raising the lack of evidence.
CTOs are a law, but they’re also a treatment. For any treatment, a lack of evidence of effectiveness should make us sceptical and cautious.