Saturday, 23 March 2013

When Do You Stop Extending a Community Treatment Order?

Patients subject to CTOs at 31 March 2012, by gender and by year

Community Treatment Orders were introduced into the MHA 1983 by the 2007 amendments. The Code of Practice (25.2) states that: “The purpose of SCT is to allow suitable patients to be safely treated in the community rather than under detention in hospital, and to provide a way to help prevent relapse and any harm – to the patient or to others – that this might cause. It is intended to help patients to maintain stable mental health outside hospital and to promote recovery.”

The intention of Parliament was for CTO’s (or Supervised Community Treatment) to prevent “revolving door” patients – that is, people with severe and enduring mental illness such as schizophrenia or bipolar affective disorder who would tend to become unwell, require hospital admission , recover and be discharged on medication, which they would then stop taking, leading to relapse and further acute admission.

Since this part of the Act came into force in 2008, CTO’s have become increasingly popular. The report on use of the MHA for 2010-11 reported: “The number of people on CTOs at the end of the year rose, even though the number of new CTOs made during the year reduced. This was due to the number of new orders made being greater than the number of orders from which people were discharged: 3,834 new CTOs were made in 2010/11 and 2,185 orders were closed.”

The data for 2011-12 shows that “there were a total of 4,220 uses of community treatment orders (CTOs) across the NHS and independent sector. This represents a 10 per cent increase from 3,834 in 2010/11.” The latest report said that the statistic suggest “that there were 6,964 CTOs in place at the end of the 2011/12”.

The main reason for this would appear to be that people on CTO’s frequently get them extended.

Typically, what happens is this: a patient is detained in hospital under Sec.3 MHA for treatment. When they are ready for discharge, consideration is given for them to be discharged under Supervised Community Treatment (SCT) and they would then be on a CTO. Although the patient’s psychiatrist is responsible for making an Order, an AMHP has to endorse this.

The first period of SCT lasts for 6 months. Towards the end of this period, the patient’s psychiatrist reviews the effectiveness of the CTO in keeping the patient well and out of hospital, and considers the need to extend it. An AMHP also has to endorse any extension. The first period of extension lasts for another 6 months. If the CTO is extended again, the period lasts for 1 year, and each subsequent extension will be for 1 year.

Patients on CTO’s rarely appeal against either the initial CTO, or subsequent extensions. In fact, in my experience, they often want nothing to do with the Tribunal or Manager’s Hearing which can be automatically triggered by a discharge of a CTO or an extension. Some of them have even told me that they feel safer knowing that they are on a CTO. I guess they feel that they are less likely to be abandoned by mental health services.

This often leads to strange Tribunals, where only the Community Responsible Clinician and an AMHP or care coordinator are present.

The difficulty with this system is that it is much easier to make a decision to extend the CTO, than to discharge it or let it lapse. After all, if the patient has complied with the conditions of the CTO, which are generally that they should see their care coordinator and community responsible clinician and that they should take their prescribed medication, and they have remained out of hospital, then that is surely evidence that the CTO is working, and therefore should continue. Isn’t it?

Andy is a man with bipolar affective disorder. I have been his care coordinator for over 4 years. Andy does not like taking medication, and has little insight into his mental illness. His view is that if he is well, then he obviously does not need to take medication, as that is only for people who are unwell. Consequently, when he is discharged from hospital well, he will very quickly stop taking his medication. He then becomes acutely unwell, and is soon detained under Sec.3 MHA again.

Not only does he become acutely and distressingly unwell, but his behaviour becomes very reckless and dangerous, and he invariably comes to the attention of the police. In the past, he has hijacked vehicles, threatened people with knives, and damaged property.

In the year prior to his being placed on a CTO, Andy had three acute hospital admissions, all via the police, and all under the MHA. His behaviour was often so unmanageable on an acute ward that he would need a period of time in a Psychiatric Intensive Care Unit (PICU). His wife was at the end of her tether and was considering leaving him. It was decided that he would be given depot medication by injection once a fortnight and was discharged under a CTO.

Towards the end of the first 6 months we reviewed him. During that time, Andy had complied with all the conditions of the CTO, especially the condition that he attended for his fortnightly injection. During that time, he had committed no offences and had not had any relapses. His wife said that she was pleased with his stability overall, but expressed concern about his sedation. However, Andy said he was completely satisfied with the medication regime and did not want any changes. Nevertheless, in view of the serious consequences not treating his mental illness in the past, we decided that it was appropriate to extend his CTO for a further 6 months.

We reviewed the CTO again a few weeks before it was due to lapse. There had been no problems or any evidence of relapse during that period, and Andy again said he was happy with his medication. However, his wife said that she was still concerned by his lack of motivation, complaining that he spent most of the day in bad and was reluctant to leave the house or socialize.

It was decided to change his depot medication to see if that improved these side effects. In view of this change, it was also decided to extend the CTO again, this time for 12 months.

We reviewed Alan a few days ago. Things were much the same – he was still happily attending for his injection, he had not been in any trouble, and he appeared to be free of the grandiose and aggressive symptoms that had troubled him in the past. However, his wife was still complaining about his lethargy and complete lack of any motivation.

I was concerned about this situation. What was the best thing to do? Should we stop his medication altogether? Should we stop the injection, but try him on oral medication, which could not be given by injection? By now, he had been out of hospital and mentally stable for 2 years. Should we discharge the CTO? Should we allow the risk of relapse, on the basis that his quality of life appeared to be seriously impaired?

We knew that he would still be unlikely to take oral medication, and if it was his sole medication, he would be at almost inevitable risk of relapse. In the end, it was decided that he would be prescribed an oral mood stabiliser in addition to the injection to see if that had an effect on his overall presentation.

Because of this further change in medication, it was also decided to extend the CTO, the consequence of which was that by the time of the next review, he would have been on a CTO continually for 3 years. I didn’t feel very comfortable about this decision, but was reluctant to disagree with the recommendation of his psychiatrist, and equally reluctant to risk a repetition of his behaviour when unwell.

The question remains: when could it be considered worth risking the relapse of a patient who has remained stable on a CTO?

I don’t have an answer to that.


  1. Locally, when the patient does not wish to attend a renewal hearing the managers hold a 'paper hearing' based on reports - they don't even meet together sometimes which doesn't seem to be in the spirit of the law.
    Our team (AOT) has used more CTOs than the rest of the adult services put together. We have seldom gone past 12 months with a CTO unless we have had to recall and revoke.
    We are currently re-evaluating using them altogether. Our problem being that as you have to identify a bed before recalling, there are never beds (massive bed reduction in the last two years) and then section admissions take the beds. We had a patient which the RC felt needed to be recalled had to wait 4 weeks for a bed before he could be admitted.
    Whilst he was not in full crisis when the decision to recall was made, he was by the time he was admitted and his needs had gone beyond the point where we would have asked for MHAA.I also think the duration of his admission will be longer as a result.

    Is it now " necessary that the RC should be able to exercise the power to recall the
    patient to hospital" given that admission could be easy to achieve through detention than recall??

  2. We recalled a patient on a CTO yesterday. I organised a bed (we needed a specialist eating disorder bed, which wasn't actually too difficult to obtain), the RC did a home visit and wrote a recall letter right then, and the patient's parents then took him to the hospital (which was a long way away). It was a lot easier than arranging a fullblown MHA Assessment.

  3. It is really difficult and there is no guidance on how many times it is appropriate to extend. I have found that family members feel secure when a patient is on a CTO. As for recall there is still the same issue with finding a bed which can drag on until the situation becomes a crisis. I don't know what the answer is!

  4. If the medication was causing excessive sedation, wouldn't it have made more sense to reduce the dosage than to add even more, but different, medication? If the injection itself could not contain less medication, it could have been less frequent, such as once every 3 weeks or a month. Moreover, even by your own criteria, the patient did fine for 2 years. How long does it take for a compliant patient to finally escape the long arm of the mental health system? At what point does treatment really become just a tool for social control and crime prevention, since it is actually reducing the patient's quality of life? Can that even be called treatment and is it morally right to make him undergo it, since the supposed illness is not cured and the patient does not feel better, so it's not for his own benefit that he is being "treated"? Is such a long period of forced "treatment" really better than just paying the price for criminal activities that perhaps wouldn't even have happened after all? Could at least some improvement in the patient's behaviour actually be due to his own self-control, experience and fear of punishment (for instance, if he won't do any more the things that got him in trouble before) and wouldn't it be better to teach him such skills than to just keep him heavily sedated? If such skill-based therapy was attempted and he won't listen, that would be his choice. He should have the right to make his own decisions, including poor decisions.

    1. Those are really good questions, Monica.

    2. To be honest, I actually think that if "help" or "treatment" means sticking a needle in some unwilling person's behind and/or making the person too sedated to enjoy life, and that, even when the individual is well-behaved and law-abiding, prison is actually preferable. It sounds almost dignified in comparison, there is some due process, it won't happen without a crime being committed and one cannot be kept in prison longer than the duration of the sentence. Forced "treatment" is one of the worst things that can happen to a human being.

    3. Any treatment that you can 'appeal' is probably not going to be a very nice treatment... i am currently on a cto myself and find the whole process of being forced to take drugs that cause all manner of side effects somewhat in breach of my human rights. My social functioning has actually decreased since being on them and my quality of life is comparitively poorer. I have had issues with medication since being prescribed depixol and promptly realising that all i wanted to do was kill myself. Something has to be said about partially or otherwise shutting down the reward system in someones brain... i am on a cto because i am a revolving door patient. I have spent the last three summers in psych wards and the last two winters either on meds or recovering from them. I recieved the call to have me hospitalised when i was sitting in the park with friends, i was psychotic i guess but that state was preferable to me than the state i am currently in. My friends didnt up and leave me nor did they complain about my madness. I think it wad obvious that i wasnt a danger to them. No way was i similiar to the case study in this blog. I was talking about time running backwards and some other crazy shit that would most likely be disproven in a week or two, seems that way... i dont think my friends would have gotten me hospitalised either so it would assume that all my care coordinator had to go on was that i was being less responsive in tedious meetings, considering i was off medication at the time i suppose that spelt d a n g e r and i needed to be 'treated' before it was too late or something. I am on palliperidone now and it is more bareable than the depixol, i dont see my friends anymore apart from one of them as i cant really be bothered. For the most part i think people should have the right to collaboratively work out a viable treatment particularly if the patient is not violent. If medication is not tolerated then offer cbt or other psychotherapies. The coercive model does nothing but disuade me from engaging with psychiatry as i feel it abuses me rather than treats me.

  5. I think maybe that the assumption that if someone is on a CTO they should also be on a depot is questionable. Surely in a case like this, by this point, you would extend the CTO but change the medication back to oral and see what happens with the 'safety net' of recall there? That way you're taking a risk, but it is a controlled one - you would still have the monitoring and recall powers of a CTO but you would be bale to test out how someone does back on oral.

  6. That is what we are doing now with an AOT patient on CTO after a s37. He never agreed that he was ill, but the offence meant we monitored him daily taking meds orally for 2 years, now the dose is being reduced slowly while on CTO with the intention of taking it to zero in a controlled way while we monitor mental states. He is clear as soon as he is discharged from the CTO he will not take meds at all or have contact with services.

  7. Hi all

    Come across a tricky one today...CTO patient in prison (for less than 6 months) and CTO is due to expire at midnight on the 28th December. Am I right in thinking that under section 22 the RC the RC is given an extra week after the day on which the patient is released from prison to extend the CTO despite the extension date lapsing whilst in prison? How would this work in terms of completing the CTO7 as the dates would be skewed...thanks for your help.

  8. It's a tricky one. I suggest you join the Masked AMHP Facebook group and ask there. You'll get a lot of response if you need a quick reply. Link is on right hand side of the blog.