I recently read the abstract of the OCTET research into the use of Community Treatment Orders for patients with psychosis published in the Lancet on 26th March 2013. I’ve only read the abstract because, despite the research being funded from public money via the National Institute of Health Research, the full report is only available behind a paywall. So I apologise now if I’ve missed something important.
The burgeoning use of CTO’s since 2008 to manage mentally disordered people in the community is something I have written about on a number of occasions, if only because it has become an increasingly large part of an AMHP’s work – the AMHP has to endorse an application for a CTO, an extension of a CTO and the revocation of a CTO. All these require assessments, reports on the assessments, and these actions also often precipitate a Managers Hearing or a Mental Health Tribunal, both of which require the writing of a report and attendance at the hearing.
The trial selected detained patients with a diagnosis of psychosis. The total sample consisted of 333. Half the sample (166) were discharged on a CTO and the other half (167) were made subject to extended Sec.17 leave. Sec.17 leave is a process whereby a patient is not formally discharged from detention under Sec.3 Mental Health Act, but allowed out of the hospital on leave. They can be recalled at any time, with little formality.
The object of the research was to see if CTO’s reduced readmission. They monitored the samples for 12 months. Their conclusion was that “the imposition of compulsory supervision does not reduce the rate of readmission of psychotic patients. We found no support in terms of any reduction in overall hospital admission to justify the significant curtailment of patients' personal liberty.”
The message from this research seems to be unequivocal: CTO’s don’t work, and therefore shouldn’t be used.
AMHP’s and Psychiatrists clearly do not want to be engaging in practices which could be regarded as oppressive and/or counter productive: we’d all much prefer that patients should stay out of hospital and to use the least restrictive means to achieve that. The initial response to these conclusions would therefore appear to be a reluctance to subject anyone else to a CTO.
But how much credence can we give to this research?
A number of things strike me as making the results not as unequivocal as they at first seem.
The first is the size of the sample. They looked at 166 patients who were subject to Supervised Community Treatment. However, since 2008, when CTO’s were introduced, until March 2012, which is the most recent date for which figures are available, a total of 14,295 people have been placed on CTO’s. This means that their sample accounts for less than 1.2% of the total up to March 2012. This, to me, seems to be a very small sample on which to be base such serious and potentially far reaching conclusions.
The second is the selection of only people with a diagnosis of psychosis, which according to the abstract were those with schizophrenia. In my experience, CTO’s are not only used for people with schizophrenia, but are also often used for people with bipolar affective disorder, eating disorders, and other diagnoses. Would outcomes have been different if bipolar affective disorder had been selected, or if there had not been a restriction on diagnosis at all? We can’t possibly know without further research.
The third is the comparisons used. The two samples were people on CTO’s versus people subject to Sec.17 leave.
The Code of Practice does not exactly encourage the use of extended Sec.17 leave. In fact, the CoP (21.9-10) states:
“When considering whether to grant leave of absence for more than seven consecutive days, or extending leave so that the total period is more than seven consecutive days, responsible clinicians must first consider whether the patient should go onto supervised community treatment (SCT) instead… The requirement to consider SCT does not mean that the responsible clinician cannot use longer-term leave if that is the more suitable option, but the responsible clinician will need to be able to show that both options have been duly considered."
In practice, extended Sec.17 leave should only be used sparingly, and only for very good reasons. Yet, it appears that for the purposes of the study, patients “were randomly assigned to be discharged from hospital either on CTO (167 patients) or Section 17 leave (169 patients)”. Is this within the spirit of the MHA and the Code of Practice?
In the real day to day world of working within the MHA, Sec.17 leave is not an alternative to discharge on a CTO. It does not therefore seem to be a valid comparison. It might have been more useful to compare outcomes for patients discharged on a CTO with patients discharged with no CTO at all. What would the figures have shown with these two samples? We can’t possibly know without further research, but they may have shown a more positive result for CTO’s.
I have been working with people on CTO’s for several years now. These have been people with diagnoses of psychosis, bipolar affective disorder, and anorexia. While my own sample is tiny, and I would not want to draw any firm conclusions from my experience, I would say that overall, CTO’s have helped to keep patients out of hospital who otherwise would have been “revolving-door” patients.
I recently looked for research into the numbers and efficacy of the use of CTO’s for people with eating disorders. There was hardly anything to be found. In fact, this trial appears to be the first significant piece of research into CTO’s in this country.
That is why I would like to see much more research into the use of CTO’s, on much larger samples, using more realistic comparators, and looking at other diagnostic groups, before making a blanket decision to stop endorsing new CTO’s.