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What do we know about the use of Community Treatment Orders (CTOs), and the need for further

research?

Tom BurnsSocial Psychiatry Research Unit

University of Oxford

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CTOs inEngland

• Introduced as SCTOs in 2007 MHA

• Proposed by RCPsych 1988, 1993

• Concerns– Initially ethical, ‘not needed’ and

misunderstandings about force in homes– More recently (EBM) emphasis on lack of

convincing evidence• (Churchill review 2007)

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What do we know about CTOs?

Observational and Experimental studies

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Rachel Churchill et al, 2007

Review of 72 empirical studies of CTOs

Origins of studies

• 47 USA

• 10 Australia

• 5 New Zealand

• 4 Canada

• 3 UK

• 2 Israel

• 1 World-wide

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Non-experimental studies

• 21 descriptive studies of practice of CTOs

• 18 stakeholder studies– 14 cross section– 4 qualitative

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Stakeholder studies

• Good clinician acceptance• Consistent practice

– ‘typically males, around 40 years of age, long history of schizophrenia-like or serious affective illness, previous admissions, poor medication compliance, aftercare needs, the potential for violence and displaying psychotic symptoms, especially delusions, at the time of the CTO’

• Strong family support• Some patient support• US and Canada more varied experience:

– Opposition, inexplicable variation, often unused, fragmented services

Experimental studies

• 5 cohort studies– Case control

• 6 controlled before and after

• No significant differences– Questionable methodologies

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Random controlled trials

• Only two RCTs to date (both in US)

• Primary outcome readmission

• No significant difference between groups in either study

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Multiple protocol violations, atypical, chaotic service

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•Well conducted, •264 subjects, good follow up, few violations•No difference in primary outcome (readmission)• Highly variable practice•Duration of CTO and clinical contact

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North Carolina secondary analyses

Swartz et al, 1999

• No CTO, <180 days blue, >180 days CTO green.• < 3 > clinical contacts per month

Results• Mean admissions down 57%, occupancy down 20 days • (73% and 28 days for schizophrenia)

Churchill conclusions• It is not possible to state whether community treatments

orders (CTOs) are beneficial or harmful to patients.

• Review summarizes 72 data-based empirical studies from six countries.

• A range of designs have been used, but many conceptual, practical and methodological problems; quality of evidence is poor. 

• No consistent evidence of benefit from the nine comparative studies, including two RCTs.

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Churchill conclusions• Different stakeholders reported both positive and negative

views in 18 studies.•  • Characteristics of CTO patients remarkably similar in 14 cross-

sectional studies.

• No robust evidence for positive or negative effects on key outcomes (hospital readmission, length of hospital stay, improved medication compliance, or quality of life).

•  • These findings are consistent with the conclusions of other

recent reviews on this topic.

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Current evidence

• Descriptive studies generally positive but methodologically very poor

• Stakeholder views mixed ?positive• Experimental studies

– Non randomised, methodologically poor – RCTs one methodologically good but some clinical

service reservations– Cochrane review very scathing (Kisley)

• 85 CTOs to avoid one admission • 235 CTOs to avoid one arrest

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Conclusion:

‘High quality RCTs urgently needed’

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