CTOs inEngland

1. What do we know about the use of Community Treatment Orders (CTOs), and the need for further research? Tom Burns Social Psychiatry Research Unit University of Oxford

5. 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)

6. What do we know about CTOs? Observational and Experimental studies

7. Rachel Churchill et al, 2007 Review of 72 empirical studies of CTOs

8. Origins of studies • 47 USA • 10 Australia • 5 New Zealand • 4 Canada • 3 UK • 2 Israel • 1 World-wide

9. Non-experimental studies • 21 descriptive studies of practice of CTOs • 18 stakeholder studies • 14 cross section • 4 qualitative

10. 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

11. Experimental studies • 5 cohort studies • Case control • 6 controlled before and after • No significant differences • Questionable methodologies

12. Random controlled trials Only two RCTs to date (both in US) Primary outcome readmission No significant difference between groups in either study

13. Multiple protocol violations, atypical, chaotic service

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

16. 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)

17. 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.

18. 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.

19. 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

20. Conclusion: ‘High quality RCTs urgently needed’

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