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Community treatment orders in England and Wales: national survey of clinicians' views and use

  • Catherine Manning (a1), Andrew Molodynski (a1), Jorun Rugkåsa (a1), John Dawson (a2) and Tom Burns (a1)...
Abstract
Aims and method

To ascertain the views and experiences of psychiatrists in England and Wales regarding community treatment orders (CTOs). We mailed 1928 questionnaires to members of the Royal College of Psychiatrists.

Results

In total, 566 usable surveys were returned, providing a 29% response rate. Respondents were generally positive about the introduction of the new powers, more so than in previous UK studies. They reported that their decision-making regarding compulsion was based largely on clinical grounds.

Clinical implications

In the absence of research evidence or a professional consensus about the use of CTOs, multidisciplinary input in decision-making is essential. Further research and training are urgently needed.

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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
Andrew Molodynski (andrew.molodynski@oxfordhealth.nhs.uk)
Footnotes
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Declaration of interest

None.

Footnotes
References
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2 Crawford, MJ, Gibbons, R, Ellis, E, Waters, H. In hospital, at home, or not at all. A cross-sectional survey of patient preferences for receipt of compulsory treatment. Psychiatr Bull 2004; 28: 360–3.
3 Canvin, K, Bartlett, A, Pinfold, V. Acceptability of compulsory powers in the community: the ethical considerations of mental health service users on supervised discharge and guardianship. J Med Ethics 2005; 31: 457–62.
4 Bindman, J. Involuntary outpatient treatment in England and Wales. Curr Opin Psychiatry 2002; 15: 595–8.
5 Moncrieff, J, Smyth, M. Community treatment orders – a bridge too far? Psychiatr Bull 1999; 23: 644–6.
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7 Pinfold, V, Bindman, J. Is compulsory treatment ever justified? Psychiatr Bull 2001; 25: 268–70.
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10 Department of Health, National Institute of Mental Health. Supervised Community Treatment – A Guide for Practitioners. Department of Health, 2008.
11 Dawson, J. Community treatment orders. In Principles of Mental Health Law and Policy (eds Gostin, L, McHale, J, Fennell, P, Mackay, RD, Bartlett, P): 513–54. Oxford University Press, 2010.
12 Dawson, J. Factors influencing the rate of use of community treatment orders. Psychiatry 2007; 6: 42–4.
13 Care Quality Commission. Regulator Emphasises Need for Improvement in Care Provided to People Detained under the Mental Health Act. Care Quality Commission, 2009.
14 Appelbaum, PS. Thinking carefully about outpatient commitment. Psychiatr Serv 2001; 52: 347–50.
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17 Romans, S, Dawson, J, Mullen, R, Gibbs, A. How mental health clinicians view community treatment orders: a national New Zealand survey. Aus N Zeal J Psychiatry 2004; 38: 836–41.
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Community treatment orders in England and Wales: national survey of clinicians' views and use

  • Catherine Manning (a1), Andrew Molodynski (a1), Jorun Rugkåsa (a1), John Dawson (a2) and Tom Burns (a1)...
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eLetters

Community treatment orders. Worth the paper it's written on?

Roji P Thomas, Specialist registrar
30 November 2011

Molodynski et al (1) presented an interesting survey on the views of clinicians on community treatment orders.

A recent Cochrane review (2), found no statistically significant difference between CTO and control groups in terms of hospital outcomes such as admissions, length of stay, contact with services, and compliance with treatment. There was also no statistically significant difference between the two groups in patient outcomes including social functioning, arrests, homelessness, general mental state, psychopathology, quality of life or carer satisfaction. In terms of numbers needed to treat, it wouldtake 85 CTOs to prevent one readmission, 27 to prevent one episode of homelessness and 238 to prevent one arrest (2). These findings point to a clear lack of evidence that CTOs result in meaningful long-term positive outcomes.

There are concerns that in some cases CTO provide an alternative to more intensive care in the community such as assertive outreach services. A research group found that although patients who received prolonged involuntary community treatment had reduced hospital readmissions and bed days, it was difficult to separate out how much of the improvement was dueto compulsory treatment and how much to intensive community management (3)

According to the Procedural Guide to MHA 2007 (4), the service user would need to understand what is being asked of them and would need to share the RCs wish for SCT to work. This view is echoed in Supervised Community Treatment: A Guide for Practitioners (5), where it is suggested that, in practice, SCT is a kind of contract between patients and the clinical teams working with them. SCTwill only work if the patient accepts the conditions.

This then begs the question , that if the patient is in a position tomake an informed capacitous decision to being placed on the CTO ,or in other words, accepts the various conditions of treatment ,then is it necessary or even appropriate to use such coercive means to ensure that the patient keeps to his word. Particularly since clinicians already have powers to recall patients on section 17 and the option of arranging mental health assessments for non- detained patients suspected of being unwell.

1.Manning, et al. Community treatment orders in England and Wales: national survey of clinicians' views and use. The Psychiatrist Online September 2011 35:328-333

2.Kisely SR, Campbell LA, Preston NJ. Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Cochrane Database of Systematic Reviews 2011, Issue 2. Art. No.: CD004408.DOI: 10.1002/14651858.CD004408.pub3.

3.Swartz MS, Swanson JW, Ryan Wagner H, Burns BJ, Hiday VA. Effects of involuntary outpatient commitment and depot antipsychotics on treatmentadherence in persons with severe mental illness. Journal of Nervous and Mental Disease 2001; 189(9):583-92.

4.Jeremy Patton. Procedural Guide to The Mental Health Act 1983. West Midlands Mental Health Policy Collaborative , 2008

5.Department of Health, National Institute of Mental Health. Supervised Community Treatment - A Guide for Practitioners. Department of Health,2008

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Conflict of interest: None declared

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Community Treatment Orders - Logistical Issues !

Piyush Prashar, Senior Psychiatric Registrar (ST6)
21 September 2011

As pointed out in the survey by Molodynski et al, it is notable that usefulness of Community Treatment Orders (CTOs) still remains unclear.1-2

Following my three months 'Acting Up' consultant job in the AssertiveOutreach Team, I realised that there are a few niggling practical issues in managing patients on CTOs. In principle, CTOs should potentially be suitable for patients with severe and enduring mental illnesses, like withour patients in the Assertive Outreach Team. But often, in my experience, it proved otherwise. Even after employing the CTO, it was not easy to makepatients adhere to the 'mandatory requirements'. Because strictly speaking, apart from the requirement of residing at a specific address, the other requirements are not actually mandatory. Many of this group of patients have long drawn histories of non adherence to management plans. This may be one of the reasons why fear of being recalled may not affect how they function in the community setting.

There are other logistical problems. Following reduction of acute inpatient beds trust wide, there is often a waiting list for beds which are prioritised as per clinical need. And it becomes difficult to simply recall CTO patients as soon as they become non compliant because they may not be out rightly relapsing or presenting immediate risk issues. If thereare no inpatient beds available, arranging for an out of area bed is a difficult proposition as many trusts will not accept a CTO patient unless the CTO is first revoked. Interestingly, the specific name of the inpatient ward needs to be mentioned on the recall notice; hence it can betricky to serve the recall notice unless it is known which inpatient ward the patient will be recalled to.

When serving recall notice to patients who may have absconded or living out of area temporarily, significant delays have occurred with our patients, as we had to wait for the recall letter to first reach them before arranging for the patient to be brought back. I myself have on one such occasion been standing in the post office queue to send a recall letter by Royal Mail Special Delivery!

Often it is easier to arrange for an inpatient admission for a non CTO patient, by simply arranging for a Mental Health Act assessment which is relatively easier and quicker to organise.

I am not averse to the idea of CTO, as in some situations it may workwell. But we will need to incorporate the provision of CTO into the Acute Care Pathways in a more seamless way. This would hopefully avoid delays inrecalling patients and getting over the logistical issues.

1.Manning C, Molodynski A, Rugkasa J, Dawson J, Burns T. Community Treatment Orders in England and Wales: national survey of clinicians' views and use. Psychiatrist 2011;35:328-333

2.Woolley S. Involuntary treatment in the community: role of community treatment orders. Psychiatrist 2010,34:441-446

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Conflict of interest: None declared

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