The arguments on the pro-side

Supporters of CTOs put forward a number of arguments in their favour, some of which are listed below.

1. • Coercion with treatment for mental disorder in the patients' best interest is justified on ethical grounds and is a feature of the legislative arrangements in many jurisdictions. ^{Reference Dale6}

2. • There is no clear logical reason why this right or duty to appropriate treatment should be available in the restrictive hospital setting, but not in the community.

3. • For this purpose, it can be necessary to force non-adherent patients to accept necessary treatment and medication. ^{Reference Mustafa4}

4. • There is sufficient professional experience of patients improving under a CTO to justify this type of coercion. ^{Reference Mustafa4}

5. • Many clinical studies of CTOs have shown relevant benefits for patients. ^{Reference Nakhost, Perry and Frank7–Reference Maughan, Molodynski, Rugkåsa and Burns10}

6. • Randomised controlled trials (RCTs) with negative results have not included the right group of patients that are likely to benefit from a CTO ^{Reference Mustafa4} or have not applied the CTO appropriately. ^{Reference Curtis11}

The arguments on the con-side

Counter-arguments are being proposed by those who believe CTOs are not as beneficial to patient care as their supporters assert. We have collected some of those arguments below.

1. • Many patients relapse under a CTO. ^{Reference Smith, Branton and Cardno12}

2. • CTOs increased health service use. ^{Reference Preston, Kisely and Xiao13}

3. • A number of non-randomised studies have provided negative and conflicting results and thus have not provided sufficient evidence to support CTOs. ^{Reference Rugkåsa, Dawson and Burns3,Reference Kisely, Xiao, Crowe, Paydar and Jian14,Reference Castells-Aulet, Hermnandez-Viadel, Jimenez-Martos, Canete-Nicolas, Bellido-Rodriguez and Calabuig-Crespo15}

4. • Three independent RCTs and a meta-analysis of their data have shown no benefit of the CTO on the number of hospital admissions and other relevant outcomes. ^{Reference Swartz, Swanson, Wagner, Burns, Hiday and Borum16–Reference Rugkåsa, Molodynski, Yeeles, Vazquez Montes, Visser and Burns20}

5. • Patients on a CTO have shown even less adherence to depot injections than those not on a CTO. ^{Reference Suetani, Foo and Wilson21}

6. • Anecdotal reports do not provide significant evidence for the efficacy of a CTO. They may be the result of the regression to the mean (i.e. the CTO is implemented at a time when the patient is at their most ill) and improvements are therefore the likely results of natural variance of the disease course. ^{Reference Hunt, da Silva, Steve Lurie and Goldbloom22}

7. • Patients' human rights might be violated by CTOs. ^{Reference O'Brien23}

8. • Owing to flaws in the application of compulsory community care, patients are at risk of being subjected to new forms of social control of an unclear nature without proper legal protection. ^{Reference Zetterberg, Sjöström and Markström24}

9. • Without evidence there cannot be any ethical justification to use coercion and severe deprivation of freedom and liberty against psychiatric patients. ^{Reference Rugkåsa, Dawson and Burns3}

Necessary conditions for a CTO to work in principle

Psychiatrists in the National Health Service (NHS) work within a legislative framework that includes CTOs. Community psychiatrists with typically sized case-loads will inevitably have experience of working with patients who are subject to CTOs and will have experienced the ethical dilemmas they present. Assuming that CTOs are effective in at least some individual patients, there are necessary preconditions which must be fulfilled for the order to work.

1. • The patient has a treatable mental disorder (i.e. a disorder that has shown some response to treatment).

2. • The patient does not want to continue to take the medication that is likely, from the perspective of the treating psychiatrist, to help maintain improvement and reduce risk of relapse. This may be for a range of reasons including side-effect burden, a disagreement that the medication is responsible for any improvement, a subjective perception that the medication has not helped, a belief that the medication is not necessary to maintain wellness or a disagreement that the problem being treated is a treatable mental disorder.

3. • The subjective, implicit or explicit, benefit–disadvantage evaluation of the patient has thus led to a decision against the treatment continuing in the community.

4. • Previous treatment in the hospital has not been sufficiently effective to lead to remission or improvement and has not increased the insight of the patient into their condition and their willingness to accept treatment.

5. • The patient is fully informed about the CTO and understands the conditions of the CTO. ^{Reference Stroud, Banks and Doughty2}

6. • They then accept and submit to the conditions of the CTO. ^{Reference Stroud, Banks and Doughty2}

7. • The patient's experience of a hospital stay was negative and the possibility of a hospital readmission is seen as a sufficiently coercive or aversive threat.

8. • This threat is sufficient enough to make the patient change their previous rejection and to accept treatment they otherwise would not accept.

9. • This treatment then improves the patient's mental health and reduces the likelihood of admission to hospital.

The number of patients for whom all these conditions apply may be limited.

Some practical points to consider

There are additional, very relevant issues, including some practical points to consider which we draw from our previous experience with CTOs in the UK since 2008.

1. • The administration of a CTO is time consuming, bureaucratic and draws time away from appropriate patient-centred care. (In our experience, mental health tribunal reports, manager's report, capacity assessments and CTO renewal assessment can take up to 8–20 h, depending on the patient.)

2. • A doctor writing a report or completing the necessary forms does not provide any direct, if any, therapeutic benefit for or influence on the day-to-day care of a patient.

3. • The increase in CTO use with the associated costly legal machinery of mental health tribunals has led to an increase in expenditure which diverts spending from direct patient care.

4. • Threats and coercion may negatively affect the patient–psychiatrist relationship. The applications of a CTO may support paternalistic practice, ^{Reference Patel25} and thus have an impact on the psychiatrist's role as a patient supporter, therefore limiting their influence on the patient.

5. • Many patients do not know that they are under a CTO, are not fully informed or do not understand the regulations of a CTO. ^{Reference Rolfe, Sheehan and Davidson26}

6. • CTOs are favoured by relatives and carers, ^{Reference Vine and Komiti27} possibly to force patients to comply with their wishes; this may on some occasions be in their own, but not necessarily in the patient's, best interest.

7. • The functional split between in-patient and out-patient consultants makes regulations and administration difficult. An in-patient consultant may utilise a CTO for one purpose, such as with a view to shorten an in-patient admission, without proper consultation with the psychiatrist and team who will have the task of implementing the order in the community over the longer term. In practice, it is our experience that collaborative planning of CTOs between in-patient and out-patient consultants is not a routine occurrence. ^{Reference Stroud, Banks and Doughty2}

8. • The power to recall a patient to hospital by one doctor alone may reduce clinical governance in comparison with a full Mental Health Act assessment. It may have the advantage of being implemented more easily than a full Mental Health Act assessment but this is potentially at the expense of a less complete and balanced assessment.

9. • The recall of a CTO does not allow treatment. Patients who are recalled may stay on a ward for up to 72 h just to wait for a Mental Health Act assessment to happen.

10. • The CTO may be used to submit a patient to less than optimal depot medication, and may prevent the search for better suitable alternative treatments. ^{Reference Lambert, Singh and Patel28}

11. • It may be difficult to assume that the simple threat of a hospital admission actually reduces such admissions and our experience has been that this has not appeared to be sufficient. On the other hand, we also have anecdotal examples of patients who may have done well under the framework.

Recommendations

It could be argued that the time, money and resources spent on administration and report writing within the current CTO legislative framework would be better spent working with patients on developing more collaborative approaches to the ongoing management of their condition.

There may be nothing lost if the current CTO is replaced by the better governed use of Section 2 or 3 of the Mental Health Act, utilising the existing provisions of the Act, until the proponents of CTOs have, with some scientific rigour, identified the subgroup of patients for whom it may help and that it does what it is intended to do.

If there is a subset of patients who may benefit from this extension of coercion into the community, it is important that there is a better delineation of the group of patients who benefit through a proper scientific evaluation that does not rely on anecdotal evidence. Such studies are urgently needed to justify the continued application of CTOs in the UK and also worldwide ^{Reference Light1,Reference Kisely and O'Reilly30,Reference Rugkåsa and Dawson31} within mental health systems that are continually under resource pressures.

It may also be helpful to look at how other countries, which have or do not have a comparable legislation, deal with this subgroup of non-adherent patients ^{Reference O'Brien23} and indeed what other paths the UK could have taken in 2007.

We believe also that there is an urgent need for greater transparency over the resource costs associated with the system that has developed over the past 7 years and a debate over how such sums of money are best spent for the benefit of patients.