The RCPsych Article of the Month for September is ‘Impact of diagnosis on outcomes for compulsory treatment orders in New Zealand’ and the blog is written by author Ben Beaglehole published in BJPsych Open.

Psychiatrists use Compulsory Community Treatment Orders (CTOs) to enforce treatment in the community even when active symptoms of severe mental illness may not be present. A key goal of CTO use is to prevent psychiatric admissions. This degree of control over the lives of mental health patients should not be taken lightly.  But there have only been three Randomised Controlled Trials examining the effectiveness of CTOs and each have methodological limitations. Typically, only a small percentage of real-world patients are eligible for clinical trials. We suspect that this percentage lessens further when compulsory treatment is considered. We wanted to study all patients placed on CTOs in New Zealand.  We therefore decided to use routinely collected health data to report key clinical outcomes for all patients placed on CTOs over a ten-year period. We compared periods during which patients were on CTOs with periods when they were off CTOs.

We reported that periods on CTOs were associated with less frequent admissions and less admission days/annum for patients with Psychotic Disorders compared to non-CTO periods. In other words, the treatment provided during CTOs appeared to serve a useful purpose by keeping patients with Psychotic Disorders in the community and preventing admissions. However, the opposite occurred for patients with other diagnoses such as Bipolar Disorders, Depression, and Personality Disorders. These patients had more frequent admissions and spent longer in hospital during CTOs compared to non-CTO periods. This occurred despite much higher rates of care and medication (including injectable antipsychotics) when on CTOs.   

Our research raises the question: Should CTOs be used for non-Psychotic Disorder patients? We believe that decision-making about CTOs is too complex for a blanket determination. However, we hope that psychiatrists using CTOs consider the associations we report in our paper and ask whether the likely outcomes on CTOs justify coercive treatment. We think that our research could provide a useful basis for conversations between psychiatrists, family members, and patients. The conversations could include asking whether injectable antipsychotic treatments are justified if admissions are more frequent during CTOs than non-CTO periods.

We suggest other researchers undertake similar work examining if there are distinct diagnostic outcome signatures associated with CTOs. Future research by our team will report mortality rates on and off-CTOs to shed further light on key outcomes associated with compulsory community treatment. Rather than view CTOs as a necessary intervention or an unnecessary human rights violation we believe a more nuanced understanding is required and that diagnosis is a key influencer of CTO outcomes.

Coercive care in psychiatry has clinical, legal, policy, and human rights implications.  It is important that the different components of coercive care are periodically researched and reviewed to maximize clinical benefit and minimize any human rights abuses. BJPsych Open is planning a thematic series on “Human rights based mental health care: New Developments.” Thus it is most fitting that the article of the month for BJPsych Open is “Impact of diagnosis on outcomes for compulsory treatment orders in New Zealand [BJPsych Open 2022; 8(5):e145].” The authors reviewed the New Zealand Department of Health databases from 2009-2018; during that 10-year period, there were 14,726 patients placed on Community Treatment Orders (CTOs). A unique finding was that admission rates decreased for psychotic disorders but increased for bipolar disorders, major depressive disorders, dementia disorders, and personality disorders. 

Further, higher rates of medications were noted for all groups on CTOs. The authors appropriately concluded “that here are specific outcome signatures associated with CTOs for different disorders and knowledge of these can improve understanding and clinical practice in this area.” Thought the authors acknowledge study limitations, this paper is an important step in addressing the meaning and outcome of CTOs. The authors recommend similar studies in other countries legislating CTOs and BJPsych Open welcomes submission of these further studies. 

Kenneth Kaufman,
BJPsych Open Editor in Chief