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OCTET does not demonstrate a lack of effectiveness for community treatment orders

  • David Curtis (a1)
Summary

In the Oxford Community Treatment Order Evaluation Trial (OCTET), patients were randomised either to be made subject to a community treatment order (CTO) or to be managed with Section 17 leave and discharge. No differences in outcome between the two groups were observed. Here it is argued that the patients studied were not those who might have benefited from a CTO and that the psychiatrists involved were unlikely to have used the provisions of a CTO assertively. Consideration of the lengths of time for which both Section 17 leave and CTOs were used supports the notion that CTOs were not used appropriately for a group of patients who might have benefited from them. Hence the results of this study should not be taken to provide any evidence as to the effectiveness or otherwise of CTOs.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Declaration of interest

None.

Footnotes
References
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1 Burns, T, Rugkåsa, J, Molodynski, A, Dawson, J, Yeeles, K, Vazquez-Montes, M, et al. Community treatment orders for patients with psychosis (OCTET): a randomised controlled trial. Lancet 2013; 381: 1627–33.
2 Johnson, S. Can we reverse the rising tide of compulsory admissions? Lancet 2013; 381: 1603–4.
3 Geller, J. Community treatment orders for patients with psychosis. Lancet 2013; 382: 502.
4 Naudet, F, El Sanharawi, M. Community treatment orders for patients with psychosis. Lancet 2013; 382: 501–2.
5 Nakhost, A, Perry, JC, Simpson, AI. Community treatment orders for patients with psychosis. Lancet 2013; 382: 501.
6 McCutcheon, R. Community treatment orders for patients with psychosis. Lancet 2013; 382: 501.
7 Burns, T, Rugkåsa, J, Molodynski, A. Community treatment orders for patients with psychosis – Authors' reply. Lancet 2013; 382: 502–3.
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BJPsych Bulletin
  • ISSN: 2053-4868
  • EISSN: 2053-4876
  • URL: /core/journals/bjpsych-bulletin
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OCTET does not demonstrate a lack of effectiveness for community treatment orders

  • David Curtis (a1)
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eLetters

Factors associated with the use of community treatment orders

Rachel J. McKie, ST5 Psychiatrist
18 March 2014

In his article Curtis (1) highlights one of the limitations of the OCTET study (2), in that patients selected for randomisation may not have been suitable for CTO placement in the first place. In his conclusions hesuggests there may be a small subgroup of patients for whom CTOs are enormously beneficial. Perhaps clinicians need more clarity of the characteristics of the 'revolving door' patient in order to better assess suitability for Supervised Community Treatment.

Most clinicians will have a personal construct of the epidemiologicaland clinical characteristics of 'revolving door' patients, although this may not be explicitly defined. There is no consistency in the literature as to the definition of 'revolving door', and previous research in the UK has shown predictors of readmission are varied and not consistently replicated across studies. Research carried out when the practice of 'long leash' Section 17 leave was widespread showed that those placed on extended leave had a history of more frequent compulsory admissions, increased recent dangerousness to others, and decreased compliance with their outpatient follow-up prior to admission (3).

A case control study was conducted at Leeds Partnerships NHS Foundation Trust in 2010, and approved by the local research and development department as a service evaluation. The aim was to compare characteristics of patients placed on CTOs and those discharged from Section 3, to elicit which factors were associated with CTO placement. Allpatients placed on a CTO between November 2008 and February 2010 were included as cases, and controls were randomly selected from patients who had been detained under Section 3 of the Mental Health Act, but whose Section was rescinded within the same week that the CTO was commenced. A ratio of two controls for each case increased the power of the study. This amounted to 56 cases and 112 controls. Characteristics chosen for analysis were those for which previous research had suggested may be of importance and where collection was feasible. The characteristics of the patients placed on CTOs were broadly similar to those recruited into OCTET.

Analysing variables individually, patients on CTOs were significantlymore likely (P<0.05) to be single, have a principal diagnosis of schizophrenia, a history of violence, a higher number of previous admissions, a history of criminal conviction and a higher number of convictions within the past year. On logistic regression analysis, patients on CTOs were significantly more likely to have a principal diagnosis of schizophrenia and a higher number of previous admissions.

There remains the outstanding question as to whom the elusive group of patients are for which CTOs are effective, if indeed this group exists.This study provides insight into the demographic and historical factors that are influencing clinicians' decisions to implement CTOs. There is noproof so far that CTOs are effective in their aims. Perhaps we need to look again at who are the truly 'revolving door' patients and take this objective evidence into consideration at the point of deciding whether to initiate supervised community treatment.

References:

1.Curtis, D. OCTET does not demonstrate a lack of effectiveness forcommunity treatment orders. Psychiatric Bulletin 2014; 38: 36-39.

2.Burns T, Racks J, Molodynski A, Dawson J, Yeeles K, Vazques-Montes M, et al. Community treatment orders for patients with psychosis (OCTET): a randomised controlled trial. Lancet 2013; 381: 1627-33.

3.Sensky T, Hughes T, Hirsch S. Compulsory psychiatric treatment inthe community. 1. A controlled study of compulsory community treatment with extended leave under the Mental Health Act: special characteristics of patients treated and the impact of treatment. Br J Psychiatry 1991; 158: 792-799.

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Conflict of interest: None declared

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