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Community treatment orders: current practice and a framework to aid clinicians

  • Peter Lepping (a1) (a2) and Masood Malik (a1)
Abstract
Aims and method

Community treatment orders (CTOs) have been used more than anticipated. We report data from the North Wales audit about their current use and explain how a SMART framework can be used to potentially improve their effectiveness.

Results

Findings from this audit confirm those from other studies, with the reasons for use of CTOs extending beyond that of medication adherence to risk management. The combined recall and voluntary admission rate was 40%, which raises questions about the effectiveness of CTOs.

Clinical implications

More research is needed as it remains to be seen whether CTOs are able to achieve their intended aims. The SMART framework can be used to aid clinicians in ensuring that conditions placed on patients have a specific purpose and are clinically meaningful.

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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.
Corresponding author
Peter Lepping (peter.lepping@wales.nhs.uk)
Footnotes
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See also commentary (pp. 58–59) and current practice (pp. 60–64), this issue.

Declaration of interest

In the past 3 years P.L. has received honoraria for educational talks from Eli Lilly and AstraZeneca. M.M. has organised general practice training courses sponsored by Pfizer.

Footnotes
References
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1 Woolley, S. Involuntary treatment in the community: role of community treatment orders. Psychiatrist 2010; 34: 441–6.
2 Department of Health. Code of Practice: Mental Health Act 1983. Department of Health, 2008.
3 Churchill, R, Owen, G, Singh, S, Hotopf, M. International Experiences of using Community Treatment Orders. Department of Health, 2007.
4 Department of Health. Patient Information (STC-Pt3). Department of Health, no date (http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_097278.pdf).
5 Kisely, S, Campbell, LA. Does compulsory or supervised community treatment reduce ‘revolving door’ care? Legislation is inconsistent with recent evidence. Br J Psychiatry 2007; 191: 373–4.
6 Thomson, LDG. The Mental Health (Care and Treatment) (Scotland) Act 2003: civil legislation Psychiatr Bull 2005; 29: 381–4.
7 Cañete-Nicolás, C, Hernández-Viadel, M, Bellido-Rodríguez, C, Lera-Calatayud, G, Asensio-Pascual, P, Pérez-Prieto, JF, et al. Involuntary outpatient treatment (IOT) for severe mental patients: current situation in Spain. Actas Esp Psiquiatr 2012; 40: 2733.
8 O'Reilly, RL. Does involuntary out-patient treatment work? Psychiatr Bull 2001; 25: 371–4.
9 NHS, The Health and Social Care Information Centre. In-patients Formally Detained in Hospitals under the Mental Health Act 1983 and Patients subject to Supervised Community Treatment: 1998–99 to 2008–09. The Health and Social Care Information Centre, 2009 (http://www.ic.nhs.uk/webfiles/publications/mental%20health/mental%20health%20act/inpatientdetmha0809/KP90_October_2009.pdf).
10 Evans, R, Makala, J, Humphreys, M, Mohan, CRN. Supervised community treatment in Birmingham and Solihull: first 6 months. Psychiatrist 2010; 34: 330–3.
11 O'Dowd, A. Use of community treatment orders for mental health patients rises 29% in a year. BMJ 2011; 343: d8346.
12 Welsh Assembly Government. Admission of Patients to Mental Health Facilities in Wales, 2010–11. Welsh Assembly Government, 2011 (http://wales.gov.uk/topics/statistics/theme/health/mentalhealthservices/admissions/?lang=en).
13 Manning, C, Molodynski, A, Rugkåsa, J, Dawson, J, Burns, T. Community treatment orders in England and Wales: national survey of clinicians' views and use. Psychiatrist 2011; 35: 328–33.
14 Glover, GR, Robin, E, Emami, J, Arabscheibani, GR. A needs index for mental health care. Soc Psychiatry Psychiatr Epidemiol 1998; 33: 8996.
15 Regier, DA, Farmer, ME, Rae, DS, Locke, BZ, Keith, SJ, Judd, LL, et al. Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study. JAMA 1990; 264: 2511–8.
16 Welsh Assemmbly Government. Mental Health Act 1983: Code of Practice for Wales. Welsh Assembly Government, 2008.
17 Malik, M, Hussein, N. Qualitative outcome for community treatment orders Psychiatr Bull 2009; 33: 437–8.
18 Lepping, P. Coercive measures in the community (community treatment order) – experiences from Wales. Psychiatr Prax 2011; 38: 310–2.
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Community treatment orders: current practice and a framework to aid clinicians

  • Peter Lepping (a1) (a2) and Masood Malik (a1)
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eLetters

Response to 'Community treatment orders: current practice and a framework to aid clinicians'

Simon H Lawton-Smith, Head of Policy
18 July 2013

Lepping and Malik's analysis (1) of the conditions placed on patients subject to a community treatment order (CTO) in England and Wales, and suggestions for improving their robustness, is timely. We have only recently seen the results of the OCTET study published in The Lancet (2) that showed that CTOs are no more effective in reducing ratesof readmission to hospital than Section 17 leave. The study also found that CTOs confer no greater benefits for patients in terms of clinical or social functioning. In the authors' words, "their current high usage should be urgently reviewed".

There are two points made by Lepping and Malik that might be elaborated on.

The first is that "CTOs have been very popular with treating teams and clinicians". This suggests all psychiatrists are in favour of CTOs. Infact, the use of CTOs has varied considerably and one consultant psychiatrist has gone on record saying "I have not used CTOs in my practice despite having a large community caseload, and have removed CTOs if patients are transferred to my care on them. I justify this because they lack an evidence base" (3). We should not forget either, that there have been occasions when Approved Mental Health Professionals (AMHPs) - often forgotten in this whole debate - have vetoedclinicians' applications.

Secondly, the authors suggest that CTOs "have been used more than anticipated". Certainly their use has been higher than the Department of Health estimated at the time. However, estimates have been published by the King's Fund, based on my own analysis (4) that suggested in the first years of a new Act, up to 5000 people would be placed under an order (pretty much reflecting the numbers today), and that the use oforders in England and Wales was likely to build over a period of some 10-15 years to between 7800 and 13000 people in total.

It remains to be seen whether this latter estimate will be accurate. Much will depend on whether clinicians change their practice in the light of the OCTET evidence. There is certainly an urgent need for the Department of Health and the Royal College of Psychiatrists to encourage clinicians to limit CTO applications only to genuinely 'revolving door' patients with impaired decision-making (as in Scotland), a history of non-engagement followed by relapse with significant risk to self or others, and a known positive response to medication given.

Of course, in the light of both past reviews pointing to a lack of evidence that CTOs are associated with any positive outcomes (5) and the recent OCTET findings, there is a strong argument for repealing the CTO powers completely. Whether or not there is the politicalwill to do so is another matter.

References:

1. Lepping P and Malik M. Community treatment orders: current practice and a framework to aid clinicians. The Psychiatrist 2013; 37: 54-57

2. Burns T, Rugkasa J, Molodynski A, Dawson J, Yeeles K, Vazquez-Montes M, Voysey M, Sinclair J, Priebe S. Community treatment orders for patients with psychosis (OCTET): a randomised controlled trial. Lancet 2013; 11;381(9878):1627-33.

3. Stafford N. Mental Health Today Magazine, May 2013. Pavilion Publishers UK.

4. Lawton-Smith (2005). A Question of Numbers http://www.kingsfund.org.uk/publications/question-numbers-community-based-treatment-orders-england-wales

5. Churchill R, Owen G, Singh S, Hotopf M (2007). International experiences of using community treatment orders http://psychrights.org/research/Digest/OutPtCmmtmnt/UKRptonCTO.pdf



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Conflict of interest: None declared

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Community Treatment Orders: Current Practice with regard to Human Rights Act

Maung Oakarr, Speciality Registrar (ST6), Plymouth Community Healthcare,
18 April 2013

We read with interest the article by Peter Lepping and Masood Malik "Community treatment orders: current practice and a framework to aid clinicians" (1). We were struck by the potential legal implications surrounding the discretionary conditions, in particular social conditions such as conditions on driving, restricted family visits and checking mail, which are authoritarian in their approach. Lepping and Malik rightly pointed out that these conditions raise ethical issues. Article 5(4) of the European Convention on Human Rights (ECHR) sets out that persons detained unlawfully should be able to secure their release by petition to an independent court of law. The power of Mental Health Review Tribunals to order discharge from CTOs appears to meet this requirement. However, the Tribunal does not have the power to vary the conditions of a CTO, and the patient does not have the right to appeal these (2). Severe restrictions which effectively amount to a deprivation of liberty would almost certainly be challengeable on human rights grounds with regard to a breach of Article 8 'Rights to a private and family life' (3). In many countries where CTOs are used, the conditions are authorized by the judicial system as opposed to the UK where the Responsible Clinician instigates the conditions. We would like to highlight that Responsible Clinicians should consider both Article 5 and 8 of the Human Rights Act when considering setting conditions for the CTO as in the authors’ opinion this remains a likely area for potential judicial review. References 1. Peter Lepping, Masood Malik. Community Treatment Order: current practice and a framework to aid clinicians. Psychiatrists February 2013; 37: 54-57 2. R. Daw, ‘The Mental Health Act 2007 - The Defeat of an Ideal’ J. Mental Health L. 2007, Nov.131-148, p.143 3. L. Gostin, P. Bartlett, P. Fennell, J.McHale and R. MacKay, Principles of Mental Health: Law and Policy (OUP, 2010) P.531 Conflict of interest: none declared ... More

Conflict of interest: None Declared

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