First Do No Harm

Sometimes people tell me that treatments like antipsychotic medication and ECT are unethical because they can have side effects. The Hippocratic adage “First Do No Harm” gets quoted as proof that no treatment that could harm someone should ever be prescribed.

And that would be fine, except that’s not what the old saying really means. Doctors would be in a tricky spot if it were. Every single treatment ever given to a patient has held the potential to cause harm – chemotherapy is a horrendous assault on a person; any operation could be terminal. Even taking a blood sample can cause bruising.

In reality, “First Do No Harm” (or “Primum Non Nocere”) is more complicated, and in fact, Hippocrates never even said it. The earliest known attribution is to medieval doctor Thomas Sydenham (1624-89) in an 1860 book by Thomas Inman.

In modern times we associate the famous saying with the two ethical principles of non-maleficence (avoiding harm) and beneficence (doing good). The two principles constantly hang in a delicate balance as we try to decide just how much to treat someone, knowing that every treatment we give has inherent risks. Sometimes it might even turn out that doing nothing is best, if all the available treatments are known to be ineffective or the condition is known to be self-limiting.

So a more authentic interpretation of the phrase might actually be “make sure you consciously try to do more good than harm”, though that wouldn’t look so good in Latin.

This balance between trying to do good and risking harm is no less important in psychiatry than anywhere else. It’s also where the real ethical criticism of some of our treatments can be found – we sometimes get the balance wrong, giving too little thought to risks when we chase improvements. Antipsychotics can be prescribed for too long and in high doses; admissions under the Mental Health Act can drag on long past the point of overall benefit. Thousands of people are given antidepressants for sadness that will pass naturally.

I can understand how this happens. The future is hard to predict; we can never really be sure how well a treatment will work or which side effects will show up. Turning incomplete information into good decisions is not something the permanently biased human brain does well, so we often do something rather than nothing simply because it feels like we’re helping.

But another medical ethical principle could help us out – autonomy. The right of the patient to make decisions for themselves if at all possible is, I think, the most overriding right in medicine. If we involved patients more often in making decisions about their care, by explaining the potential risks and rewards of each option, the best course of action might become obvious. Some would be immediately keen on taking the risk, for others they might have strong personal reasons against it. We could share in the success when things go well and share the responsibility when things go badly.

So “First Do No Harm” doesn’t mean what many people think it does, but perhaps we could still improve on it.

How about “First, Discuss The Harms”?

Maudsley Debate #50: “CBT for psychosis has been oversold”

I live-tweeted from the 50th Maudsley debate, “CBT for psychosis has been oversold”, earlier tonight. You can read my storify of the event here.

That’s a wrap: Medfest 2014 comes to a close

The 30th and final Medfest film event of 2014 took place last week. I had the privilege of being this year’s national lead, and wanted to take this opportunity to review the festival and to thank everyone.

Medfest is an annual series of evening events held at medical schools across the UK each spring. It’s funded by the Royal College of Psychiatrists and organised by trainee psychiatrists. A programme of medically-themed short films, clips and animations are shown and discussed with panels of distinguished names from psychiatry and related disciplines, with the aim of getting medical students interested in mental health.

Through our theme for the year, the catchy yet mysterious “Medicine from Cradle to Grave”, we aimed to show how film portrays medicine impacting upon the lives of people of all ages.

Our poster, for the third consecutive year, was designed by the marvellous David Shillinglaw.

finalposterMF2

Gradually, we found trainee psychiatrists and medical students all over the country who were interested in organising an event in their local medical school. Though we weren’t able to host an event everywhere, our final total of 30 events was an exponential increase on the previous years of 9, 16 and then 21 events. We also found no shortage of amazing pannellists, with the likes of Claire Gerada, Norman Lamb MP, David Nutt, Simon Wessely and Raj Persaud more than happy to give up their time to chat about how the various clips affected them.

We were lucky enough to find some wonderful films, which together formed a vibrant, varied programme:

Our first section, the health of children, was led by Shane Koyczan’s animated spoken-word poem To This Day, a viscerally eloquent tour through the hell of being bullied and the lifelong after-effects. The poem touched many audience members personally, but equally, some panels found that it tried too hard, or was even unnecessarily scary or defeatist.

To this day

We also compared two clips on Polio. The 1946 public education film His Fighting Chance, narrated by Eleanor Roosevelt and a real child of its time, was contrasted with the slick computer generated imagery of a commercial from the Bill and Melinda Gates Foundation called Polio’s Last Percent. There were so many ways to compare the films – social attitudes, film making techniques, medical progress – it was a fertile ground for discussion. Overall, though audiences enjoyed watching both films they also remarked that they felt equally disingenuous, covering up aspects of the truth for different aims (morale and money).

Polio                             Polio2

In the second section, the heath of adults, we compared two more films. In a brave gamble we decided to include Dr Easy, a science fiction short about a robot doctor dealing with a mental health crisis. The dystopian tale and its unsettling ending left many an audience member torn – did they feel comfortable with liking the film in spite of its artificiality, and could they accept what it had to say about our own, supposedly uniquely human, communication skills?

In direct contrast, we showed a collection of clips from the recent Channel 4 series Bedlam. Lloyd, a man recently diagnosed with schizophrenia, was shown coming to terms with his diagnosis and the image of madness that he assumed society would now have of him. The audience comments on this film were far more widely appreciative, but also sometimes pessimistic – is this all good mental health care can really achieve?

   Dr Easy                Bedlam

In our final section, health in old age, we showed two more short films back to back. Irene, the story of a 92 year old Scottish lady suffering with Alzheimer dementia preparing for a week in respite care, was shot by her granddaughter director Lindsay Goodall. It was compelling, heart warming and truly brought out the personality of the titular character as she resiliently lived her life. Flatline, in a directly opposing style, was a brash American short film showing two pioneering heart surgeons recount their implantation of the first prosthetic heart into a human. Though no less captivating, audiences noticed that it lacked a rich narrative of the patient – something Irene did fantastically.

Other areas of discussion including whether Irene could give informed consent to be filmed (which Linday Goodall herself, as a pannellist in Edinburgh, assured us that she could), the increasing demonisation of the unavoidable process of death, and the need to consider a sick person in a social context.

Irene                     Flatline

Packed into around 2 hours, the programme was quite a challenge to co-ordinate and I’m sure many a local lead will have been glad when the time came to hand out the feedback forms and get started on the cheese and wine.

As reports came back to us from up and down the country, it was clear that thankfully, our hard work had paid off.  Films were hated and loved, but the pattern of attitudes varied across each event. We’d split people’s opinions, made them think and got them talking about mental heath.

Overall, the feedback we had was highly positive, which is very rewarding. It appears that well over 1000 medical students attended, and they seemed genuinely more attuned to mental health and more likely to consider it as a career as a result. You can read far more articulate reviews than mine by Desmond O’Neill in his BMJ blog and Anna Taylor in her Bristol University Psychiatry Society blog. We were also the cover feature of the most recent edition of Junior Dr magazine.

Clearly, the job of leading the whole festival was far too much for one person, certainly for me. The first thing I did after being given the role was to advertise for willing (naïve) helpers, and I need to thank them profusely – I was lucky enough to find an amazing group of committee members, and I owe them a huge debt of gratitude for all their hard work.

Alex Blackman, under the nominal title of secretary, was a firm hand on the tiller of our website and co-ordinated the distribution of posters and DVDs with effortless precision.

Daniel Meek and Duke Nzekwue, as my co-leads, took a substantial amount of stress off my hands by liaising with a proportion of the local leads, and they also found extra sponsorship.

Louise Murphy, along with Helen Hutchings, organised a phenomenal art exhibition at the Royal College. It was the first time we’d branched out into art, and Louise and Helen took hold of our theme for the year brilliantly by displaying work from patients of all ages.

Kat Levick was our music lead, lending a hand to the team at the National Student Psychiatry Conference in organising their Medfest:Music night, and also putting together a night of medically-related music on a boat on the Thames too.

Karina Beinerte, our international lead, scoured the globe for potential host cities outside of the UK, and came up trumps with Canberra, Melbourne and Riga. Next year we’re looking good for Canada and more of Europe too, which is very exciting.

I also need to thank everyone who helped out at local events, everyone who sat on a panel, and of course, everyone who turned up to an event. I’m also grateful to The Royal College of Psychiatrists for funding the events, and I hope they agree that they’ll make their money back in terms of improved recruitment!

Medfest will be back for another round of mental health-inspired film, art and music in 2015. We don’t know the theme yet, we don’t even know who’ll be taking charge of it, but one thing is for sure – it’ll be bigger, brighter and better than ever. Lights, camera, action.

Continuity of Care: Why we need to build services around therapeutic relationships

This month’s British Journal of Psychiatry includes a lovely qualitative study by Bilderbeck et al on how patients experience being assessed for a mood disorder.

I think we can learn so much more from a good qualitative study than we ever could from a study on genetics or a drug RCT, both as professionals and as mere members of the human endeavour, so it was great to see a high-impact journal publishing the paper.

One of the recurring themes that Bilderbeck et al identified in their interviews with patients really leapt off the page at me. As well as wanting an explanation for their feelings, wanting to feel listened to and involved, the patients wanted consistent and continuous care. 

In short, the patients wanted to meet the same doctor each time they attended. In the trade we call this continuity of care.

Continuity of care

Bilderbeck et al noticed that patients felt more comfortable and able to discuss sensitive, personal events if they’d met the doctor before. Conversely, if the doctor they were meeting was new, they felt more anxious and were generally less able to use the relationship to heal:

‘There’s never any consistency. It really bothered me… Virtually a different doctor every time I went back… it’s just like going back to a stranger and I don’t really, it’s not helping me at all.’ 

In fact, one quote illustrates how seeing a new doctor at each visit can be nothing more than a waste of time, like a clinical Groundhog Day:

‘I’d like to see the same doctor all the time. See one, than have to explain myself again and again and again.’

 

Widespread problem 

This is by no means a chance finding in a small group of participants. A lack of continuity is raised again and again by patients who feel let down by the system.

This is because getting to know a mental health professional, and letting them get to know you back, is the most powerful treatment we have. The therapeutic bond formed between the professional and the patient is taught to be worth more than the effect of any tablet, and responsible for the majority of the effect of any talking therapy.

In most other medical specialities, meeting a patient for the first time and taking a history (asking them all about their main problem, past problems, personal life and family history) is largely nothing more than a simple transfer of information. The patient gives the doctors facts about his life and current state, and the doctor uses these facts to decide on a treatment. If the same doctor turns up again the next time then that’s nice, and saves a bit of time, but if a different doctor turns up they can just read the notes the carry on fairly easily where the previous doctor left off.

In mental health, however, talking to a patient about their problems for the first time is more than just an exercise in gathering facts. It is the foundation for a lasting and potentially healing relationship, built on the trust that the patient’s disclosures imply. It isn’t always easy but it’s the first part of recovery.

Later meetings between the professional and the patient continue this healing – building on the previous meetings and delving deeper and wider into the problems, with growing nuance and understanding. To meet a different doctor at this point would be, in a way, to restart the largest aspect of the whole healing process and risk the patient feeling rejected.

What’s more, a doctor who already knows you is far less likely to make a mistake, like misdiagnosing you or sectioning you when you’re actually no worse than you usually are.

Stifling continuity

Often a lack of continuity is unavoidable – doctors have to take it in turns to cover the hospital at night, for example – but often we build services in such a way that continuity is stifled from the start.

We’ve brought in Triage wards, to which patients are admitted for a few days before either being discharged or admitted to a longer stay ward. Triage wards have their own team of doctors and nurses, with whom patients somehow have to miraculously form a relationship in just a few days, when seriously unwell, before being moved on to tell their story again elsewhere.

If the patient is admitted to a longer stay ward, the chances are that their consultant won’t be the same consultant that they see in the community. These days, consultants are moving towards solely doing either inpatient or outpatient work for the sake of “specialisation”. Therefore, another person to tell your story to.

Even on discharge, you might not end up under the care of your old consultant. Depending on your diagnosis you might end up under an Early Intervention team, or any number of other crisis resolution or brief treatment teams. They might be specialists, but they’re not mind readers – it’s time to tell your story again. 

And don’t forget that you might have to see a Home Treatment Team in the meantime (tell your story) and even a separate Drug and Alcohol team, because your own team can’t deal with that (tell your story).

Of course, you might not see any of these teams – they might all be burnt out and hideously understaffed because getting to know new patients all the time is hard work. Treating patients you know can be thoroughly fulfilling, and building on those relationships can make your job worthwhile, but a constant turnover of new and subsequently worrying cases can be enough to wear anyone out.

Where from here? 

So how do we bring continuity of care back to the forefront of psychiatric practice?

Sometimes it’s easy. We need to make sure that when a patient is re-referred to a service, someone who already knows them takes their case again. If a patient is readmitted to hospital, they need to go back to the ward where the staff know them best. It sounds obvious but so often, it doesn’t happen.

Of course, this also means keeping enough beds open so patients don’t need to be transferred hundreds of miles away when they need an admission, and paying for enough staff to be available to cater for all the patients on a long term basis.

But how do we ensure continuity past the obvious?

For me, the first step seems to be proving that it’s important. That means more qualitative studies on patient experience in high-quality journals. In general, we need to listen to what patients feel is important more often – we need to judge quality of care not just by abstract outcome markers like “readmission rate”, “medication adherence” and “employment” but by what patients think about how much we helped.

Ideally, we need to prove that continuity of care is somehow cost effective too. This is certainly true, but also certainly difficult to demonstrate. If different doctors see the same patient three times, they’ll each repeat a lot of the work, generally take longer and make more mistakes – all costing time and money.

Next, we need to use that evidence to design services with continuity in mind. Ideas could include:

  • switching consultant posts back to a mix of community and inpatient work
  • cutting down on unnecessary or unproven specialist teams
  • developing service policies on continuity on an individual and service level
  • turning Triage wards back into longer stay wards, or linking them better with the patient’s long term consultant
  • being more flexible about keeping a patient under a team’s care when they change GP or move house

Continuity of care is at the core of every positive change we make in mental health and we need to protect it at all costs. As always, I’m eager to hear your thoughts.

Knots

I’ve been reflecting on times when I’ve felt trapped during conversations with patients and their families.

Times when whatever I seemed to say, I tangled myself further into an endlessly looping web of discursive constriction.

I was reminded of R.D. Laing’s book Knots, which is a gleefully brusque collection of various traps of thinking.

Here are some of my own examples.

This one is from my time on the medical wards:

Patient’s family: “We don’t agree with your diagnosis. Do some more tests”

Me: “Did you have any specific alternative diagnoses or additional tests in mind?”

Patient’s family: “Don’t ask us. You’re the doctor!”

 

If I try to assert my medical opinion I get shot down, but if I try to divest it I get shot down too. An infinite regress of rejection.

A second example, this time from early in my career in psychiatry:

Patient seen in A+E: “Admit me or I’ll kill myself”

Me [after lengthy consultation]: “Ok, let’s admit you”

Patient: “No. I won’t come into hospital”

 

I had no idea what to do. The opening statement felt more like a threat than a presenting symptom. The patient appeared to have turned up in A+E specifically to pose me a choice and then categorically turn both self-imposed options down. It was checkmate, I was lost.

Both examples can be boiled down to “I want you to help, but I won’t let you help”.

So how do we untangle these knots?

As I have now learnt – from insightful senior colleagues and patients themselves – the key to escape is to recognise why you’re stuck. And talk about it.

What lies beneath the tangle? Defense? Confusion? Weaponry?

The first example is a double bind ­­- damned if you do, damned if you don’t. The fix is to either do or don’t but explain why you’re not damned for it. In the example given above, we explained the diagnosis again as a team – giving the option of disagreement but making it clear that we were firm in our convictions.

The second example, as well as being a double bind of sorts, is also a false choice ­– there were other options available, like the patient not being admitted but not killing themselves. Fostering some responsibility in the patient and getting them to work with us, not against us was the key to progress in that situation.

I don’t exactly look forward to more knots, but unbinding myself, or watching others unbind me, is an education.

Categorically Ill: My argument in favour of the diagnosis of mental illnesses

This is the viewpoint I gave at the debate on mental health diagnosis, “Categorically Ill”, at the Science Museum today.

It’s quite strange, quite sad I think, that after decades of anti-stigma campaigns, work by charities like Mind, so many confessions of mental illness and progressive government policies, that some people still doubt mental illness even exists. But I am very proud to defend it tonight. I don’t have the years of research experience that the other speakers have; all I have are years spent with patients and my own time as a patient. I hope that will be enough to convince you that I’m worth listening to tonight. I want to start by defining mental illness. Some people think that only your body can be ill, not your mind. But mind and body are two sides of the same coin- the mind is the product of the brain.

Image

Mental illnesses are simply illnesses which involve the brain, but show themselves in a form we think of as “the mind”, like distressing thoughts, feelings and behaviours. Some are caused by brain diseases, like dementia. Some are caused by the outside world interacting with an initially fairly healthy brain, like alcohol addiction. Some are a mix of small brain changes and outside stress, like psychotic disorders.

But despite the fact that the brain is always involved in some way, we don’t just send all our patients to neurology – because we know that the mind deserves its own speciality – one that respects psychological and social factors, not just biological. Having this concept of mental illness is helpful for the same reasons having a concept of any kind of illness is helpful. It helps patients discover that they are not alone, that their suffering is not a private, unique torment, but that it has a name, and other people have been through it before. It allows them to learn about their difficulties and help themselves. Using the word illness, not just “problems”, ensures that society treats people with mental illnesses with the respect they deserve; not just lazy, peculiar, and malingering.

Calling someone ill, or giving someone a label, doesn’t removes the unique meaning of their experiences, if you do it in the right way. If any of you have felt dehumanised by receiving a mental health diagnosis, it was the fault of the person who gave it to you, not the fault of the label. I listen to my patients, get to know them as individuals, hear their stories and their opinions on what they think might help  – that’s why I went into psychiatry not neurology – but I also say to them, hey, your symptoms also fall into a group we see quite a lot – and there’s a whole load of research on that.

By recognising that certain symptoms often occur together, like flashbacks, being on edge and feeling numb and by giving this syndrome a name, in this instance PTSD, we can do research into causes, and treatments that might work. Sometimes we even find a cure. We learn from these patterns we see in people – we don’t have to start from square one with everyone that comes through the door.

So mental illness is a useful concept. But is it a valid one – are mental illnesses real? Of course they are. Some mental illness or disorders are quite plainly real. Dementia, addiction, severe autism and learning difficulties are all expressed through the mind, and therefore listed in those evil “psychiatric bibles” – but no one would argue that they didn’t exist.

But as soon as something is found to have a solid cause in the brain, it tends to get called “neurology”, so the heat can be kept focussed on psychiatry, on disorders for which a biological focus is less clear cut.

Some say, well, you’ve had years to find a simple cause or test for these disorders, things like depression, and you haven’t done it. So depression can’t be a real illness! But medicine doesn’t work like that. We don’t suddenly decide that the symptoms don’t add up to an illness just because we haven’t found a cause or a test yet – because the symptoms are still there. We don’t even have a good idea what causes migraines yet, we certainly don’t have a test, but no one will be telling people with headaches that sorry, no clear cause yet and no test, so no illness. So we won’t stop calling things like OCD and bipolar disorder illnesses. Our patients deserve better than that.

A lot of people think that no two psychiatrists will agree on a diagnosis, that there is no reliability, but the reality in very different. Here are some correlation co-efficients – the closer to 1.0 the number is, the more psychiatrists agree on the diagnosis. Anywhere near 0.7 is pretty damn good. Mostly ok.

Autistic Spectrum Disorder 0.69
PTSD 0.67
ADHD 0.61
Bipolar Disorder 0.56
Borderline Personality Disorder 0.54
Schizophrenia 0.46

Surely physical health problems all score 1 though? I’m afraid not. Here are the scores for a few physical conditions.

Atherosclerotic stroke 0.60
Lung cancer under a microscope 0.57
Osteoarthritis on X ray 0.51-0.68
Reflux using endoscopy 0.56
Heart attack using blood test and ECG 0.52
Smaller stroke 0.20

You see, people think that physical health is perfectly scientific, that patients fall into neat, valid little boxes, that there are tests that give yes/no answers for every condition. Anyone who tells you these things has not worked in general medicine. Sure, some patients fall easily into boxes; big heart attacks, massive strokes, overwhelming chest infections…but most patients have a collection of small problems, all in the ill/not ill grey area, which add up. This is why when our elderly relatives are admitted to hospital, the doctors tell us things like “maybe a small stroke” or “a small heart attack but we’ll treat him for an infection just in case”. It’s nonsense to say that big hearts attacks aren’t real because lots of people have small ones…we just have to be wary that illness isn’t a precise concept anywhere in medicine – psychiatry is not alone in this.

Every speciality changes its classification of illnesses every few years, as we learn more about illnesses, but only psychiatry gets abuse for doing so. How high your blood pressure has to be to be high changes every 5 minutes, we used to have bronchitis and emphysema but now we have COPD, the stages and groups of cancers changes every few years. Making categories more accurate is important and I look forward to seeing them improve with time.

Let’s be clear on another thing – psychiatry is not “growing out of control”, “medicalising normal emotions” – you only need to read the headlines about the shameful ways our services are being cut to see that. Mental health is being suffocated, and our patients with it, because it is seen as less deserving because some people are still willing to get up on stage and tell you that they don’t believe mental illness even exists.

Tonight, you have to vote whichever way you believe is best for the people who suffer from mental illness. The choice is your own, but you have to understand what voting against mental illness would mean. It would mean saying to the young woman with a BMI of 12, who thinks she is fat, that she doesn’t have a condition ­– anorexia has a 10% death rate, by the way. It would mean saying to the man who has scrubbed the skin off his hands to try to get rid of intrusive, plaguing thoughts, that he doesn’t have a disorder, just a problem with living. It would mean saying to a man whose muscles are rigid, who hasn’t eaten or drunk in days and who is mentally unconnected with the outside world, who soils himself and would die of dehydration without intensive nursing – a state I might call catatonia - you aren’t ill. It would mean telling Stephen Fry, and other public figures who have revealed their histories, that they might think they have bipolar disorder but actually it doesn’t exist; it would mean looking all your friends and family who’ve had a mental illness in the eye and telling them that their diagnoses were nonsense and they weren’t really ill, they shouldn’t have seen their doctor for that, they shouldn’t have been allowed health insurance or sick leave or medication or treatment for that, that they were just sad, obsessed, stressed or weak.  

One short step away from get over it. I thought we’d moved past all that.

Thank you.

Community Treatment Orders: Good, Bad or Ugly?

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.

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