Saturday, 6 April 2013

Are CTO’s Any Good? Observations on the OCTET Trial

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.


  1. There won't be a trial comparing like for like patients on a CTO and without because it would never get ethical clearance.

    If a client could benefit from a CTO then it must be used in much the same way as you suggest it is unethical to apply sec 17 leave to someone who could be discharged on a CTO.

    Had a small bit of involvement in this trial. My patient withdrew as she was placed in the sec 17 group and found the impact on her benefits a complicated mess.

  2. The CTO is an enormously personal (blur, for a second, professional boundaries, we work within them all the time) contract between recipient and key members of the MDT. In its inception, it was presented as being about co-operation as much as coercion. If a person has little insight, the coercive aspect will come to the fore and we should be honest about that.

    Most psychiatrists I've seen initiate CTOs based on psychological impact; if you do or don't do something we will bring you back to hospital. At the same time, an MDT has all its work in front of it; to show The Patient care and advantage in engagement.

    Research must be carried out. Extensive qualitative and quantitative study should urgently look at outcomes and include recipient's voices. We also need open debate between parties to foster a better understanding of the nature, in practice, of CTO's and their effect. Honest appraisal would include the admission that professionals are becoming more limited in resources to properly implement programmes that speak to the service user of care, integration and co-operation. We are using CTOs as blunt instruments at present, dependent on increasingly strained relationships between client and professionals.

  3. In regards to the sample size - in a randomised controlled trial, the bigger the numbers, the more power the results have. Randomisation is supposed to mean that the sample is reflective of the population it comes from. I assume the researchers in this study will have known how many participants they needed to recruit in order for the results to have validity. In regards to the third point, the researchers actually wrote an article explaining why they had to compare CTOs to s17 leave rather than to voluntary patients - ethically and legally it wouldn't have been viable to randomise someone to voluntary status or to an intervention such as the CTO which can deprive people of autonomy. Aside from that I hold some agreement with you - the researchers were looking at hospitalisation rates as the main outcome, but CTOs are used for so much more than keeping people out of hospital, and that should be acknowledged in any research. I have the full article if you want it - I could send it to the email address on here if you like?

  4. Thanks, but a very kind person has now sent me a copy!

  5. Can someone help a silly social work student please...even though this question isn't directly related to the above post? I am writing a case study on the MHA and am referring to the Code of Practice 2008. I can only find this document on the gov.national archives site, not on the actual live gov site. Is there a reason for this? It is still active guidance isn't it?
    Any help would be much appreciated, this blog is really useful to students like myself!

    1. Hi Jim
      Don't worry where you found it. Although it's probably overdue for an update, that is currently the most up-to-date and only Code.

    2. This comment has been removed by the author.

    3. Thank you so much! I'm always weary when being directed to an archived gov site!
      I enjoyed this blog before I even started my uni course but a lot of it makes more sense now I can read it in context.
      Your 'Anatomy of a Mental Health Act Assessment' post is particularly useful.
      Thanks again!

    4. I agree the conclusion was wrong; it should have been that the high recall rate (46 percent) was the same for both CTO and section17 leave patients. This is not the same condition as comparing CTO with usual CMHT follow up; since it is part of the hypothesis that CTO has a psychological factor increasing adherence I am sure that being on section 3 does too. I cannot accept the conclusion and would also want to see future research address quality of care which i believe is higher on CTO.

  6. Hi Could anyone please send me a copy of this full article from the Lancet?? It really would be useful for my course?
    email address:

  7. Your comments on sample size are incorrect. The Lancet paper took into account that awfully difficult concept- statistical power- and so the sample size seemed enough to register any effect.

    I am a psychiatric patient and I fear that community treatment orders are Nazi- like. They remove human rights. The balance between psychiatrist and patients is now too much against patients.

    I am elderly. My name is Zekria Ibrahimi and my email adreess is

  8. The OCTET study has recently received heavy criticism from Steven Segal, professor of social welfare at Uni of California at Berkeley. Sorry the link doesn't show the full article.