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Community treatment orders: Are they useful?

  • Jorun Rugkåsa and Tom Burns

In the wake of the deinstitutionalisation of mental health services, community treatment orders (CTOs) have been introduced in around 75 jurisdictions worldwide. They make it a legal requirement for patients to adhere to treatment plans outside of hospital. To date, about 60 CTO outcome studies have been conducted. All studies with a methodology strong enough to infer causality conclude that CTOs do not have the intended effect of preventing relapse and reducing hospital admissions. Despite this, CTOs are still debated, possibly reflecting different attitudes to the role of evidence-based practice in community psychiatry. There are clinical, ethical, legal, economic and professional reasons why the current use of CTOs should be reconsidered.

Learning Objectives

• Gain an overview of the development and use of CTOs in the UK and internationally

• Get up-to-date information about the evidence base for CTO effectiveness and the relative contributions of different levels of evidence

• Appreciate the nature of the current controversy around the use of CTOs and become familiar with the factors in the ongoing debate about their future

Corresponding author
Correspondence Professor Jorun Rugkåsa, Health Services Research Unit, Akershus University Hospital, 1478 Lørenskog, Norway. Email:
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Declaration of Interest

J.R. and T.B. were the manager and principal investigator respectively of the OCTET trial

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Burns, T (2007) Hospitalisation as an outcome measure in schizophrenia. British Journal of Psychiatry, 191 (suppl 50): s3741.
Burns, T, Rugkåsa, J, Molodynski, A, et al (2013) Community treatment orders for patients with psychosis (OCTET): a randomised controlled trial. Lancet, 381: 1627–33.
Burns, T (2014) Assisted outpatient treatment services and the influence of compulsory treatment. American Journal of Psychiatry, 171: 228.
Burns, T, Yeeles, K, Koshiaris, C, et al (2015) Effect of increased compulsion on readmission to hospital or disengagement from community services for patients with psychosis: follow-up of a cohort from the OCTET trial. Lancet Psychiatry, 2: 881–90.
Canvin, K, Rugkåsa, J, Sinclair, J, et al (2014) Patient, psychiatrist and family carer experiences of community treatment orders: qualitative study. Social Psychiatry and Psychiatric Epidemiology, 49: 1873–82.
Care Quality Commission (2011) Monitoring the Mental Health Act in 2010/11. The Care Quality Commission's Annual Report on the Exercise of its Function in Keeping under Review the Operation the Mental Health Act 1983. Care Quality Commission.
Castells-Aulet, L, Hernández-Viadel, M, Asensio-Pascual, P, et al (2013) Involuntary out-patient commitment: 2-year follow-up. Psychiatrist, 37: 60–4.
Castells-Aulet, L, Hernández-Viadel, M, Jiménez-Martos, J, et al (2015) Impact of involuntary out-patient commitment on reducing hospital services: 2-year follow-up. BJPsych Bulletin, 39: 196–9.
Churchill, R, Owen, G, Singh, S, et al (2007) International Experiences of Using Community Treatment Orders. Institute of Psychiatry.
Dawson, J (2005) Community Treatment Orders: International Comparisons. Otago University.
Dawson, J (2016) Doubts about the clinical effectiveness of community treatment orders. Canadian Journal of Psychiatry, 61: 46.
DeRidder, R, Molodynski, A, Manning, C, et al (2015) Community treatment orders in the UK 5 years on: a repeat national survey of psychiatrists. BJPsych Bulletin, 40: 119–23.
Dye, S, Dannaram, S, Loynes, B, et al (2012) Supervised community treatment: 2-year follow-up study in Suffolk. Psychiatrist, 36: 298302.
Evans, R, Makala, J, Humphreys, M, et al (2010) Supervised community treatment in Birmingham and Solihull: first 6 months. Psychiatrist, 34: 330–3.
Geller, J (2006) The evolution of outpatient commitment in the USA: from conundrum to quagmire. International Journal of Law and Psychiatry, 29: 234–48.
Geller, J (2013) Community treatment orders for patients with psychosis. Lancet, 382: 502.
Health and Social Care Information Centre (2015) Inpatients Formally Detained in Hospitals Under the Mental Health Act 1983 and Patients Subject to Supervised Community Treatment, England – 2014–2015, Annual Figures. HSCIC.
Heun, R, Dave, S, Rowlands, P (2016) Little evidence for community treatment orders: a battle fought with heavy weapons. BJPsych Bulletin, 40: 115–8.
House of Commons Health Committee (2013) Post-Legislative Scrutiny of the Mental Health Act 2007: First Report of Session 2013–14. Report, together with Formal Minutes, Oral and Written Evidence (HC 584). TSO (The Stationery Office).
Kisely, S, Campbell, LA (2006) Community treatment orders for psychiatric patients: the emperor with no clothes. Canadian Journal of Psychiatry, 51: 683.
Kisely, S, Campbell, LA, Scott, A, et al (2007) Randomized and non-randomized evidence for the effect of compulsory community and involuntary out-patient treatment on health service use: systematic review and meta-analysis. Psychological Medicine, 37: 314.
Kisely, S (2014a) Randomised controlled evidence for the effectiveness of community treatment orders: an update of a Cochrane systematic review. Australian and New Zealand Journal of Psychiatry, 48: 110–1.
Kisely, S, Hall, K (2014b) An updated meta-analysis of randomized controlled evidence for the effectiveness of community treatment orders. Canadian Journal of Psychiatry, 59: 561–4.
Kisely, S (2015) Are there any situations where community treatment orders are effective? Australian and New Zealand Journal of Psychiatry, 50: 381–2.
Lawton-Smith, S (2005) A Question of Numbers: The Potential Impact of Community-Based Treatment Orders in England and Wales. The King's Fund.
Lepping, P, Malik, M (2013) Community treatment orders: current practice and a framework to aid clinicians. Psychiatrist, 37: 54–7.
Light, E, Kerridge, I, Ryan, C, et al (2012) Community treatment orders in Australia: rates and patterns of use. Australasian Psychiatry, 20: 478–82.
Maughan, D, Molodynski, A, Rugkåsa, J, et al (2014) A systematic review of the effect of community treatment orders on service use. Social Psychiatry and Psychiatric Epidemiology, 49: 651–63.
McKie, RJ (2014) Factors associated with the use of community treatment orders. Psychiatric Bulletin, 38: 139.
Mental Health Alliance (2005) Towards a Better Mental Health Act: The Mental Health Alliance Policy Agenda. The Mental Health Alliance.
Mental Health Taskforce (2016) The Five Year Forward View for Mental Health. A Report from the Independent Mental Health Taskforce to the NHS in England. Mental Health Taskforce.
Mental Welfare Commission for Scotland (2015) Mental Health Act Monitoring 2014/15. MWCS.
Morrissey, JP, Desmarais, SL, Domino, ME (2014) Outpatient commitment and its alternatives: questions yet to be answered. Psychiatric Services, 65: 812–5.
Munetz, MR, Galon, PA, Frese, FJ (2003) The ethics of mandatory community treatment. Journal of the American Academy of Psychiatry and the Law Online, 31: 173–83.
Mustafa, FA (2015a) Non-consent bias in OCTET. Lancet Psychiatry, 2: e33.
Mustafa, FA (2015b) Why clinicians still use community treatment orders. Acta Psychiatrica Scandinavica, 132: 309–10.
O'Donoghue, B, Brophy, L, Owens, N, et al (2016) Rate of community treatment orders and readmission orders following reconfiguration of community mental health services. Australasian Psychiatry, 24: 278–81.
Rawala, M, Gupta, S (2014) Use of community treatment orders in an inner-London assertive outreach service. Psychiatric Bulletin, 38: 13–8.
Ridley, J, Hunter, S, Rosengard, A (2010) Partners in care? Views and experiences of carers from a cohort study of the early implementation of the Mental Health (Care & Treatment) (Scotland) Act 2003. Health & Social Care in the Community, 18: 474–82.
Riley, H, Hoyer, G, Lorem, GF (2014) “When coercion moves into your home”: a qualitative study of patient experiences with outpatient commitment in Norway. Health & Social Care in the Community, 22: 506–14.
Royal College of Psychiatrists (1993) Community Supervision Orders (Council Report CR18). Royal College of Psychiatrists (original withdrawn: available on request from ).
Rugkåsa, J, Vazquez Montes, M, Bennett, C, et al (2015) Community treatment orders: clinical and social outcomes, and a subgroup analysis from the OCTET RCT. Acta Psychiatrica Scandinavica, 131: 321–9.
Rugkåsa, J (2016a) Family carers and coercion in the community. In Coercion in Community Mental Health Care: International Perspectives (eds Molodynski, A, Rugkåsa, J, Burns, T): 161–78. Oxford University Press.
Rugkåsa, J (2016b) Effectiveness of community treatment orders: the international evidence. Canadian Journal of Psychiatry, 61: 1524.
Rugkåsa, J, Yeeles, K, Koshiaris, C, et al (2017) What does being on a community treatment order entail? A 3-year follow-up of the OCTET CTO cohort. Social Psychiatry and Psychiatric Epidemiology, 52: 465–72.
Sjöström, S, Zetterberg, L, Markström, U (2011) Why community compulsion became the solution: reforming mental health law in Sweden. International Journal of Law and Psychiatry, 34: 419–28.
Smith, M, Branton, T, Cardno, A (2014) Is the bark worse than the bite? Additional conditions used within community treatment orders. Psychiatric Bulletin, 38: 912.
Snow, N, Austin, W (2009) Community treatment orders: the ethical balancing act in community mental health. Journal of Psychiatric and Mental Health Nursing, 16: 177–86.
Steadman, HJ, Gounis, K, Dennis, D, et al (2001) Assessing the New York City involuntary outpatient commitment pilot program. Psychiatric Services, 52: 330–36.
Stroud, J, Banks, L, Doughty, K (2015) Community treatment orders: Learning from experiences of service users, practitioners and nearest relatives. Journal of Mental Health, 24: 8892.
Swanson, JW, Swartz, MS (2014) Why the evidence for outpatient commitment is good enough. Psychiatric Services, 65: 808–11.
Swartz, M, Swanson, JW, Wagner, H, et al (1999) Can involuntary outpatient commitment reduce hospital recidivism? Findings from a randomized trial with severely mentally ill individuals. American Journal of Psychiatry, 156: 1968–75.
Swartz, MS, Swanson, JW, Wagner, HR, et al (2003) Assessment of four stakeholder groups' preferences concerning outpatient commitment for persons with schizophrenia. American Journal of Psychiatry, 160: 1139–46.
Swartz, MS, Swanson, JW (2004) Involuntary outpatient commitment, community treatment orders, and assisted outpatient treatment: what's in the data? Canadian Journal of Psychiatry, 49: 585–91.
Szmukler, G (2015) Is there a place for community treatment orders after the OCTET study? Acta Psychiatrica Scandinavica, 131: 330–2.
Taylor, M, Macpherson, M, Macleod, C, Lyons, D (2015) Community treatment orders and reduced time in hospital: a nationwide study, 2007–2012. BJPsych Bulletin, 40: 124–6.
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Community treatment orders: Are they useful?

  • Jorun Rugkåsa and Tom Burns
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