The first year of Community Treatment Orders

Dr M Claire Royston MB ChB MSc FRCPsychMedical Director Care Principles

Lead SOAD, Care Quality Commission

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History of CTOs• First appeared in N. America and Australasia during ‘80s• CTOs exist in 52 separate jurisdictions across the world:– 41 States in USA– Ontario and Saskatchewan in Canada– All states in Australia– New Zealand– Israel– Scotland– England

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History of CTOs

Definition: A legal mechanism by which people with

mental health problems who need treatment are compelled to submit to treatment on an outpatient basis

Restrictive intervention

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History of CTOs

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Conceptualised in response to number of different pressures on psychiatric services:

– Deinstitutionalisation– Homeless mentally ill– Over-representation of mentally ill in prison– Revolving door patients– Dangerous mentally ill in the community

History of CTOs

• Conceptualised as a provision for treatment in a less restrictive environment

• Outcome measures for ‘success’ – Successful maintenance without harm to self

or others

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History of CTOs• Over time the concept of the purpose for the CTO has

evolved into a legal intervention with ‘health benefits’• A legal intervention designed to benefit persons with

serious mental illness who need ongoing psychiatric care and support to prevent relapses, hospital re-admissions, homelessness or incarceration but have difficulty following through with community-based treatments

• This alters the type of outcome measures• Now often considered to be a less restrictive measure

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History of CTOs• 14 major studies completed• Consistency in the characteristics across all jurisdictions

(very different cultural and geographical settings)• Typically; male, around 40 years of age, long history of

mental illness, previous admissions, suffering from a schizophrenia-like or serious affective illness

• Likely to be displaying psychotic symptoms, especially delusions at time of inception of CTO

• Criminal offences and violence not dominant features• Often past history of high admission rates, poor medication

compliance

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CTOs in England

• Came into effect with amendments MHA 1983 on 3 November 2008• “Designed for patients who still require treatment for

mental disorder, on the ground of their own health or safety or protection of others, but such treatment can be given outside of detention hospital, provided there is a power to recall if clinicians have concerns community arrangements are no longer sufficient”

• Estimated number ~200 in the first year

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Number of CTO SOAD visit requests

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3 November 2008 – 31 March 2009, n=1722

Number of recalls to hospital 206

Number of revocations 142

Number of discharges from SCT 32

CTO - changes in legal status

(n = 2,109)

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Number of CTO requests: regionNumber of CTO requests: region

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Study design

From completed CTO second opinions from

3 Nov 2008 to 30 April 2009:• 233 records located• Records showing some change from treatment

plan prioritised, but 111 records showing no change randomly selected.

• Audited by Lead SOAD following coding.

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History & symptom clusters

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Stated diagnosis

Stated diagnosis Frequency

F20 Schizophrenia, schizoaffective or delusional disorder 190

F30-F39 Mood disorders 27

F50-F59 Associated physical/psychological disorders 2

F60-F69 Personality disorders 2

F70-F79 Learning disability 2

F80-F89 Psychological development 3

Non-specific 6

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Assessed riskn = 233

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Categories of drug authorised

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Number of drugs authorised

n = 233

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SOAD visits to SCT – BNF limits

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The CTO experience A legal mechanism by

which people with mental health problems who need treatment are compelled to submit to treatment on an outpatient basis

A legal intervention designed to benefit persons with serious mental illness who need ongoing psychiatric care and support to prevent relapses, hospital re-admissions, homelessness or incarceration but have difficulty following through with community-based treatments

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