A suitable case for treatment? first appeared in Mental Health Today in February 2011. To subscribe to the magazine click here.

The number of community treatment orders given out has far exceeded government expectations, but they are not necessarily having a positive effect on service users, reports Sally Gillen

Reka Krieg should have been the perfect candidate for a community treatment order (CTO). By her own admission she was a 'revolving door' patient who chose to stop taking her medication because she loathed the numbing effects of the antipsychotics she was prescribed and was afraid they could cause diabetes or damage to her liver.

In April 2009, following a third section, she agreed to be placed on a CTO, which meant attending fortnightly appointments to have injections and taking oral medication. Although restrictions in themselves, aside from keeping her appointments, no other conditions were written into her CTO. Once discharged from hospital, she was free to go where she pleased and see who she wanted. She believes she was more fortunate than many in receiving "very good support," mainly from her social worker. Yet the year Krieg spent on her CTO was, she says, "the worst of my life." [see box below]  


Reka's story

Reka Krieg, 30, was diagnosed with bipolar in 2006 and subsequently sectioned three times in quick succession, once after she ran out of her home naked into a busy road. "I thought I was running through hell because I was barefoot and my feet hurt. Then I was in an ambulance. I don't really remember much else about it," she says.

In April 2009, she was put on a CTO and then experienced what she describes as "the worst year of my life.

"I was like a zombie. I had no quality of life. I used to go clubbing but I could no longer dance. I just moved stiffly from one foot to another and I had a tremor in my leg and I felt so depressed. The support I had was very good. My social worker visited weekly and tried to encourage me to take up badminton and to get involved in voluntary work but I felt too unwell to engage."

Krieg complained that she felt depressed and was offered cognitive behavioural therapy that she says did not help. After six months she appealed her CTO unsuccessfully. In April 2010 she was taken off it and shortly afterwards stopped attending appointments for her injections, but she does take a mood stabiliser.

"Since I stopped the injections I've just felt better and better. I now take care of myself, take exercise, go clubbing, and I'm also a tutor at a recovery college. It's the first of its kind in the UK and is run by the South West London and St George's Mental Health Trust. I feel angry that I was put on a CTO but it is in the past." 



CTOs were controversial when they were introduced in November 2008. Carers, service users and professionals alike had repeatedly expressed grave concerns about them through the long and difficult passing of the Mental Health Act 2007. Among their many concerns was an anxiety that CTOs would be used not for revolving door patients alone, or the very small number of patients who posed a risk to others, but instead to compel huge numbers of people with mental health problems, who fell within neither camp, to receive treatment.

Figures on the numbers of CTOs made, included in an October 2010 report by regulator the Care Quality Commission, which monitors the use of mental health legislation, reported that the orders were being used 10 times more than the government predicted. To the dismay of many working in mental health services, their bleak prediction had been right. An average of 367 orders was made each month, totalling 6,241 since their introduction.

"The numbers are so high because the criteria for CTOs are drawn so broadly," explains Mat Kinton, author of the report and CQC policy analyst. "This issue was raised with government when the bill was going through parliament but the government rejected opposition amendments to narrow the criteria because it said it didn't want people to fail before they could be given a CTO."

Worryingly, 30% of 200 people on CTOs, whose cases were looked as part of the research, had no history of non-compliance or disengagement with services, an issue raised as a concern in the report, alongside a suggestion that more research be carried out into the "defensive" use of the power.

Paul Farmer, chief executive of mental health charity Mind, says: "This is of real concern to us. It compounds our concerns that CTOs are being made too easily based on criteria that are too broad, hanging heavy over the heads of people who are trying to rebuild their confidence and independence."

No success

Indeed, if the explicit aim of CTOs was to reduce the number of hospital admissions, then at this stage it cannot be judged a success, argues Dr Tony Zigmond, mental health law lead at the Royal College of Psychiatrists. "The government said it would be a way of stopping revolving door patients and keeping them well. But the detention rate has also gone up. If they are the same people then that means they are revolving even quicker. And even if they are new people then the system has failed. We can say that."

He believes that while CTOs are the right option for a very small number of patients who may be a danger to others, most people with a mental health problem should not be denied the right to stop taking their medication, a right removed when a CTO is enforced.

"It is very difficult to decide what the measurement of success should be. Even if a CTO had done some good clinically that is not a measure of success. What matters is how the patient feels about them. Just 8% of people who have had a heart attack continue with their medication, even though they are advised to keep taking it. They are allowed to do that. But someone on a CTO is forced to continue medication. What the CQC should be doing is focusing on what patients want."

Mixed patient experience

A mixed picture of patients' experiences has emerged from the CQC research. It says those who are involved in their care have a better experience, as do those who receive good support in the community. But without those, and if well co-ordinated inpatient and outpatient services are missing, people on CTOs are left lonely and isolated. "It can be disastrous for people who do not have that continuity of care," says Kinton. "I came across cases where the first the community psychiatrist knew of someone being discharged on a CTO was a letter from the hospital.

"You would hope that patients would meet their community psychiatrist before being discharged. It is a system that should work perfectly but we are talking about the real world."

One explanation as to why inpatient and outpatient care has been split, often resulting in a lack of continuity of care for patients, is the creation of specialist mental health teams, such as outreach and crisis intervention. Kinton says this may have been an "unintended consequence" of what are widely regarded to have made a positive contribution to the system.

For Reka Krieg, the lack of contact between her inpatient and outpatient consultants meant she was forced to continue on medication that she was assured would be gradually reduced. "I was told by the consultant in hospital that I would need to have fortnightly injections and oral medication but that my injections would be reduced over time. But my consultant in the community insisted that I stay on the injections because she said I was doing well. There was a lack of communication between the two," she says.

Her experience and those of the thousands of others placed on CTOs will be the ultimate test of whether they are a success and the only way of measuring that is by looking at the long-term outcomes for patients. More research needs to be done into how they are being used, says Kinton, adding that the CQC is partnering a PhD student at the University of Nottingham to look into CTOs in more depth.

Oxford University is also carrying out a study examining the effectiveness of CTOs, based on the experiences of around 300 patients from 20 health trusts across England, looking at the long-term outcomes for people on them. It will look at how often someone on a CTO is readmitted to hospital and their length of stay, as well as their quality of life.

The last measure will be particularly important to Krieg and others like her. "In their book they probably did well with me because I was kept out of hospital  - but at what price?" she asks. "They kept saying to me 'you're doing so well.' But I wasn't doing well; I was suffering big time. It was the worst year of my life."  

The Care Quality Commission (2010) Mental Health Act Annual Report 2009-2010. Available at http://www.cqc.org.uk/mentalhealthactannualreport2009-10.cfm