Compulsory community treatment not found to reduce hospitalisation rates of mentally ill patients

The controversial practice of discharging people under Community Treatment Orders (CTOs) after they have been involuntarily hospitalised due to mental health problems has no effect on the patients’ likelihood of being subsequently hospitalised, compared to Section 17 leave, an older and less restrictive type of supervised discharge, according to a randomised trial published Online First in The Lancet.

CTOs were introduced in the UK in 2008, and were intended to address growing rates of involuntary hospital admissions due to mental ill health seen in the UK (referred to by some practitioners as “revolving door syndrome”, where patients are repeatedly involuntarily hospitalised).  They allow clinicians and mental health practitioners to monitor a patient’s condition when leaving hospital after being involuntarily admitted, and are imposed when relapse – leading to further involuntary hospital admission – is considered likely.  By being under compulsory community treatment it was anticipated that this group of patients, who often lead unstable lives and experience social exclusion and unemployment, would have a period of stability which would improve their condition. Similar legislation has also been introduced in the USA, Australasia, some parts of Canada, and several other European countries. In the UK, around 4,000 people annually are made subject to a CTO.

Unlike Section 17 leave, a period of leave from a hospital’s inpatient unit which, if it goes well, is followed by discharge and voluntary treatment, CTOs allow specific conditions to be imposed on the patient.  These can include requirements that the patient takes certain medication, lives in a certain place, or attends regular assessments.  If a patient breaks any of these conditions, the responsible clinician has the ability to recall them to hospital for up to 72 hours, without formally readmitting them. 

Several organisations have expressed concerns that CTOs are an unacceptable infringement on patients’ civil liberties, and that there is insufficient evidence to show that they are effective.  Until now, only two randomised trials of compulsory community treatment have taken place, both in the USA, neither of which showed any clear benefits of the practice. 

In this study, a group of researchers led by Professor Tom Burns of the University of Oxford, UK, tested whether 166 patients who received CTOs experienced fewer hospital admissions compared to 167 patients released under Section 17 leave.  The patients received equivalent levels of clinical contact, but different lengths of compulsory supervision, with patients under a CTO receiving an average of 183 days’ compulsory treatment, and those in the Section 17 group receiving an average of 8 days’ compulsory treatment. 

The number of patients readmitted to hospital within 12 months of randomisation did not differ between the groups, with just over a third (36%) of patients in each group being readmitted.  The researchers also measured the time to readmission, the number and duration of hospital admissions, and whether the use of CTOs affected any of the patients’ clinical or social outcomes, but found no significant differences between the two groups for any of these indicators.

According to Professor Burns, “This is the largest, randomised trial of CTOs, and we did not find any evidence that they achieve their intended purpose of reducing readmission in so-called revolving door patients with a diagnosis of psychosis.  The evidence is now strong that the use of CTOs does not confer early patient benefits despite substantial curtailment of individual freedoms. Their current high usage should be urgently reviewed.”

In a linked Comment, Professor Sonia Johnson of the Mental Health Sciences Unit, University College London, UK, said “A strong respect for civil liberties is imperative for professionals entrusted with coercive powers, and arguments that CTOs infringe human rights seem persuasive if benefits cannot be shown. The large amounts of senior professional time currently invested in CTO implementation also needs to be clearly justified…If the continued use of CTOs is contemplated, further evidence regarding their effect will need urgently to be sought.”

In another research Article published alongside the research on CTOs, a team of researchers led by Professor Graham Thornicroft of the Institute of Psychiatry, Kings College London, UK, examined whether Joint Crisis Plans (JCPs) – a negotiated statement by a patient of treatment preferences for any future psychiatric emergency, when he or she might be unable to express clear views – affect the rate and length of compulsory psychiatric admissions, amongst other factors.  In a comparison between a group of 285 patients who produced JCPs and 284 patients who received treatment as usual, JCPs appeared to have no effect on the number and length of compulsory admissions, although the researchers note that JCPs have been poorly implemented in many cases, and suggest that this might be reducing their effectiveness.

According to Professor Sonia Johnson, “We do not yet know whether changing relationships between staff and patients can reverse the continuing rise in compulsory admissions, but, with the apparent failure of CTOs, we need to keep trying.”