Community treatment orders don’t benefit ‘revolving door’ mental health patients, study finds

Placing mental health patients on community treatment orders (CTOs) after a period of involuntary hospitalisation does not alter the likelihood of them being hospitalised again, and their use should be reviewed, a study has found.

The study by Oxford University found that placing patients on CTOs, which curtail some of their freedoms in the community, does not reduce the chance of them being re-admitted to hospital, compared to the previous – and less restrictive – type of supervised discharge, called Section 17 leave.

CTOs were introduced in 2008 for psychiatric patients that are often repeatedly involuntarily hospitalised, also known as 'revolving door' patients. This group are likely to have diagnoses of bipolar disorder or schizophrenia, are often men, lead unstable lives, and experience social exclusion and unemployment.

Patients subject to a CTO can have to fulfil specific requirements, such as taking certain medication, attending regular assessments, or living in a certain place. 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.

Use of CTOs  

The use of CTOs is growing in the UK. There were 4,200 CTOs in 2011/12, an increase of 10% on the previous year, according to the Health and Social Care Information Centre.

There were also 2,100 CTO recalls – 30% more than in the 2010/11. About 70% of such recalls in 2011/12 ended in a revocation, compared to around 60% the previous year. 

“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,” said Professor Tom Burns of the Department of Psychiatry at Oxford University, who led the study.

“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.”

The study looked at whether 166 patients on CTOs experienced fewer hospital admissions compared with 167 patients released under Section 17 leave.

The researchers found that the number of patients readmitted to hospital over 12 months did not differ between the groups. Just over a third (36%) of patients in each group were readmitted at some point.

Nor were there any significant differences in the time to readmission, or the number or duration of hospital admissions. The use of CTOs was not found to affect any of the patients' clinical or social outcomes.

But there was a great difference in the length of compulsory supervision of patients. Although the patients received equivalent levels of clinical contact, the patients on CTOs received compulsory treatment for an average of around 6 months. Those in the Section 17 group received compulsory treatment for an average of just over a week.

The findings are published in medical journal The Lancet.

Professor Sonia Johnson of University College London, who was not involved in the study, said in The Lancet: “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.”