A brief history of CTOs

The deinstitutionalisation of psychiatric services in the Western world, which began in the 1960s, has led to improved community care provision. However, this has also resulted in some patients having frequent readmissions. ^{Reference Geller7} In North America, CTOs were established in the 1980s to address this problem. Their introduction was thought to offer an ethical alternative to managing at-risk individuals that was less restrictive than formal hospital admissions. Over the past decade there has been a shift in the way CTOs are viewed, from being a tool to manage risk behaviour to being an important treatment intervention that can help prevent relapses, reduce in-patient admission days and possibly lead to higher functioning. ^{Reference Swartz and Swanson8} Until recently, CTOs were used primarily in North American ^{Reference Swartz and Swanson8} and Australasia, ^{Reference Brophy and Ring9} but Scotland, England and Wales, and Israel have now introduced CTOs into their mental health legal framework. However, cross-national comparisons are difficult because of differences in the structure of community mental health services, the legislation and criteria for implementing them. ^{Reference Churchill, Owen, Singh and Hotopf10}

In the USA, CTOs are divided into ‘least restrictive’ and ‘preventive’. The former provides for a least restrictive alternative to hospital treatment. The preventive model enables treatment of deteriorating mental state to prevent dangerousness. The current US trend has been to move towards a preventive CTO model because of difficulties with the design model of least restrictive CTOs. In parts of Canada the preventive CTO model also incorporated ‘consent criteria’. ^{Reference Dawson11} The CTO model in Australasia, Israel and Scotland has incorporated both features of the least restrictive and preventive models. These countries exclude the essential North American criteria of ‘imminent dangerousness’, leading to a much broader criteria for community orders.

Scotland introduced Europe's first CTO in October 2005. The criteria for the Scottish CTO include risk management, a focus on prevention and modified incapacity criteria worded as ‘significant impairment of decision making’. ¹² Prior to the introduction of CTOs in England and Wales in 2008, compulsory community treatment existed in various guises in the Mental Health Act 1983. These included Section 17 for conditional leave from hospital, with patients being sent on extended periods of leave. The Act also made provisions for statutory guardianship under Section 7 in the community for patients who needed a legal safety framework for maintaining conditions of residence but who were willing to cooperate and abide by their treatment plan and did not require mandatory community treatment. For forensic patients there has been provision of SCT in the form of Section 37/41; once the patient is ready to be discharged from in-patient services, the Secretary of State by virtue of the restriction order, Section 41, has to agree and attach conditions to the discharge from hospital. Supervised discharge orders were introduced by the Mental Health (Patients in the Community) Act 1995 to ensure community aftercare provisions for patients with serious mental illness who were detained in hospital. They were primarily used as risk management tools with little leverage for enforcing appropriate treatment adherence.

The use of CTOs in England and Wales was intended to enable patients who no longer need to be detained in hospital to live in the community under the powers of the Mental Health Act. ^{Reference Woolley13} Patients detained under Section 3 or subject to certain specified provisions under Part III of the Act (namely a hospital order, a hospital direction or a transfer direction without restrictions) could be considered for a CTO to prevent their deterioration on discharge from hospital through improved adherence with medication in the least restrictive manner. The Department of Health ¹⁴ stated that the introduction of CTOs was aimed at helping patients engage based on the recovery model and to manage the risk some patients may pose to themselves and others. Despite the absence of clear evidence of their effectiveness, the ethical debate about their use and opposition from patients, mental health charities and the civil rights lobby, CTOs were formally introduced in England and Wales in 2008.

A King's Fund paper ¹⁵ in 2005 predicted that the use of CTOs in England would be between 2 and 50 per 100 000 of the general population. The government grossly underestimated the clinical and risk management appeal of CTOs and only expected a few hundred such orders. However, by 2011, the number of CTOs had reached an estimated 10 000 in England and Wales. ⁵ There has been strong support for their use from service providers. ^{Reference Manning, Molodynski, Rugkåsa, Dawson and Burns16} Among UK psychiatrists the potential for treatment adherence, authority to treat the patient and ensuring early identification of relapse have been key points in deciding on a CTO for a patient. ^{Reference Manning, Molodynski, Rugkåsa, Dawson and Burns16,Reference Dawson and Mullen17}

Assertive outreach teams and CTOs

Assertive outreach teams were introduced in England in 1999 as per the National Services Framework on Mental Health. ¹⁸ The basic premise was to engage patients with severe mental illness who had failed to engage with generic CMHTs and had high rates of admission. ¹⁹ Despite the international evidence ^{Reference Marshall and Lockwood20} reporting reduction of in-patient admissions with AOTs, the Randomised Evaluation of Assertive Community Treatment (REACT) in North London ^{Reference Killaspy, Bebbington, Blizard, Johnson, Nolan and Pilling21} and its follow-up study ^{Reference Killaspy, Kingett, Bebbington, Blizard, Johnson and Nolan22} did not find any reduction in rates of in-patient admissions in AOT patients compared with usual care by CMHTs. However, rather inexplicably in the UK700 and REACT trails both AOT and CMHT arms showed large reductions in bed usage, which could potentially be because of methodical weaknesses, such as lack of masking. The patients, however, were better engaged and more satisfied with services when under the care of AOTs. Although the results from the UK raise concerns about the continued existence and funding of AOTs, an interesting point raised by Burns ^{Reference Burns23} is these studies categorised the AOT as ‘the intervention’ with the control being the usual treatment of being under the care of CMHT. It is difficult to judge the effectiveness of a team based on the sole criterion of reducing in-patient admission despite it being a proxy marker of clinical stability. Also the quality of an individual team can have an impact on the outcome of studies, and there is wide variation in the make-up and fidelity of AOTs. ^{Reference Wright, Burns, James, Billings, Johnson and Muijen24} The dwindling availability of in-patient beds in the UK in recent years has resulted in CMHTs being pragmatic about use of beds in contrast to the USA and Australia.

It could be presumed that the use of CTOs would be high in AOTs as their case-loads include the most disengaged, non-adherent population with associated higher risk levels. Studies comparing patient management in AOTs and CMHTs on the basis of in-patient admissions pre-date the implementation of CTOs in England and Wales. It should also be noted that Australia and North America have had CTOs for decades and few studies have looked at their use by AOTs.

Findings from this and other studies into the effectiveness of CTOs

A comparative CTO study ^{Reference Evans, Makala, Humphreys and Mohan25} from Birmingham conducted soon after introduction of CTO legislation showed that most patients on a CTO tend to be younger males with psychotic illness and from ethnic minority backgrounds. Our sample group showed an overrepresentation of Black males on CTOs. This overrepresentation of Black males has also been found in international studies. Current US census data recorded 21.6% of the North Carolina population as being Black or African American, but 66.2% of patients on a CTO in that state were African American. ^{Reference Hiday, Swartz, Swanson, Borum and Wagner26}

Two randomised controlled trials ^{Reference Steadman, Gounis, Dennis, Hopper, Roche and Swartz27,Reference Swartz, Swanson, Wagner, Burns, Hiday and Borum28} in the USA conducted more than a decade ago failed to show any reduction in bed days between patients on a CTO and controls. One of the trials ^{Reference Swartz, Swanson, Wagner, Burns, Hiday and Borum28} in a post hoc analysis showed that patients on a CTO after 6 months had fewer admissions to hospital. However, the recent UK-based randomised controlled Oxford Community Treatment Order Evaluation Trial (OCTET), ^{Reference Burns, Rugkasa, Molodynski, Dawson, Yeeles and Vazquez-Montes6} which compared readmission rates between CTO patients and patients on Section 17 leave, failed to find any difference in readmission rates over a 12-month period and concluded that they could not support the use of CTOs in this country. The findings from the OCTET trial have implications for future policy-making and raise an ethical dilemma regarding curtailment of personal liberties. However, it did not compare the outcomes of CMHT and AOT patients, who are likely to have significant differences both clinically (AOTs use ‘psychosis’ as an admission criterion unlike CMHTs) and in terms of type of interventions. Of note, CHAOS was one of the teams that were included in the OCTET study. The mean clinical contact in the OCTET ^{Reference Burns, Rugkasa, Molodynski, Dawson, Yeeles and Vazquez-Montes6} study for CTO patients was three times per month. However, level of contact is much higher for CHAOS patients especially in the post-discharge period often for supervised treatment adherence, which may have allowed the development of a more supportive and therapeutic relationship. A well-functioning AOT should be able to provide intensive case management with a high level of psychosocial support, closer supervised medication adherence and monitoring of forensic risks. This is in conjunction with recall to hospital at early stages of disengagement and non-adherence. Delaying recall of non-adherent and disengaged patients by clinicians, before they show significant signs of relapse, is an important factor that potentially negates the effectives of CTOs. ^{Reference Lambert, Singh and Patel29} Assertive outreach teams may act earlier in this regard as they tend to have a more risky case-load than CMHTs and are able to detect disengagement earlier because of their level of contact with their patients. Hence, it is possible that the combined ability in delivering intensive case management and earlier recall to hospital by AOTs might make implementation of CTOs more effective, but such individual factors need closer scrutiny.

Assertive outreach teams have been one of the most utilised and funded initiatives to counteract the significant reduction of psychiatric in-patient beds. It has been shown that in the UK, because of the already low usage of in-patient beds, AOTs have not resulted in a reduction in hospital admissions. ^{Reference Burns, Creed, Fahy, Thompson, Tyrer and White30} The widespread presence of CMHTs, with their ability to provide a degree of intensive case management, also potentially dilutes the clinical benefits of AOTs over generic services. A possibility to consider is that CTOs are most effective in a subpopulation of patients at increased risk, possibly in those with psychotic disorders, irrespective of the make-up of treating teams. In a climate of dwindling mental health funding the relevance of existing AOTs is under close scrutiny. Further evidence looking at their ability to deliver effective CTOs in an expensive and impaired psychiatric subpopulation could decide the future of this model in the UK.

Our study showed a sizable reduction in both overall bed usage and readmission rates following implementation of CTOs. Individual duration of admission was shortened fractionally (by 4 days). However, the total reduction of bed days in the whole cohort was 4529, which contributed to considerable savings for the local healthcare system. The reduction in the number of Mental Health Act assessments involving multiple agencies such as the police and ambulance services possibly reduced costs further as well as reduced patient trauma and stigma. Of note, there was a corresponding 40% reduction in the funding of CHAOS during the study period and so it did not lead to increased service costs. A similar naturalistic study in Suffolk ^{Reference Dye, Dannaram, Loynes and Dickenson31} demonstrated an increase in engagement, a decrease in the number of admissions and increased time spent outside hospital.

In our study the proportion of CTO patients on depot antipsychotics was only 45.9%, which is lower than other studies; ^{Reference Evans, Makala, Humphreys and Mohan25,Reference Lambert, Singh and Patel29} this could be because of the ability of the AOT to supervise regular oral medication. Improvement in medication adherence was noted in over three-quarters of the patients during the CTO phase. This could indicate a relationship between reduced hospital admission rate and improved treatment adherence. However, a previous systematic review ^{Reference Churchill, Owen, Singh and Hotopf10} had failed to find such a link. Other factors such as improved engagement and reduction of substance misuse may also contribute. Apart from monitoring medication adherence, all patients received input from a dual-diagnosis worker, occupational therapist support, psychoeducation and insight improvement work by their care coordinators. We recognise that in the absence of a dedicated psychologist the amount of psychological input was limited. However, the cover of the CTO provided a framework where these forms of support as well as intensive case management could be delivered to the patient, which is likely to have contributed significantly to the overall clinical outcome.

Patient views of CTOs

Previous studies have suggested that patients tend to be ambivalent about CTOs, which was echoed in this study. Patients focused on the timely but short admissions to hospital along with viewing CTOs as providing a support framework. Despite the objective evidence of improvement in terms of reduced admissions, improved adherence and reduced drug use, a theme of feeling restricted under a CTO was evident in this cohort. Studies have shown that patients' level of understanding of the impact of CTO legislation and restrictions could be in contrast to their objective clinical improvement. ³² It has been shown that patients' negative views of CTOs were primarily the result of feeling coerced, ^{Reference Gibbs, Dawson, Ansley and Mullen33} their prolonged use and possibly medication side-effects. ^{Reference Lawton-Smith, Dawson and Burns34} By the nature of their legislative framework, CTOs are ‘expected to be coercive’; ^{Reference O'Reilly, Keegan, Corring, Shrikhande and Natarajan35} it is important to recognise and address this with psychoeducation and possible peer support.

A qualitative analysis of the use of CTOs in Canada ^{Reference O'Reilly, Keegan, Corring, Shrikhande and Natarajan35} has shown that initial resentment towards CTOs from patients is superseded by an acceptance of stability on account of the structure of a CTO. Qualitative research on the use of CTOs has shown that patients also see them as providing security, preventing hospital admissions or as an alternative to prison. ^{Reference Gibbs, Dawson and Mullen36} Of importance, many patients did not feel that being placed on a CTO affected the therapeutic alliance with their responsible clinician. ^{Reference Gibbs, Dawson, Ansley and Mullen33} However, these findings could be the result of systematic bias as patients who agree to be involved in such studies could be assumed to have developed greater insight.

Care coordinators' views of CTOs

The feedback we obtained from the care coordinators generally reflected a positive view of CTOs, which were seen to support adherence, reduce hospital admissions and provide therapeutic structure. The care coordinators also raised some pertinent questions about the ethics of subjecting patients to restrictions in the community and the increased administrative workload on clinicians. These are recurrent themes that have been raised by clinicians in other studies ^{Reference O'Reilly, Keegan, Corring, Shrikhande and Natarajan35} despite generally viewing CTOs as a positive step and in the long-term helping form a therapeutic alliance. ^{Reference Romans, Dawson, Mullen and Gibbs37}

An ethical debate about CTOs is beyond the remit of this article as decision-making around implementation is complex. The political and media fervour of highlighting acts of violence by psychiatric patients could lead to CTOs being unjustifiably used as a risk management tool. ^{Reference Lawton-Smith, Dawson and Burns34} The motivations behind the decision to subject a patient to a CTO needs to be explicitly clinical and should be in the best interest of the patient at an individual level and not just for cost-benefits or simply as a risk management tool, although these are important considerations at a public health level.

Strengths and limitations

The main strengths of the paper include the sizable number of patients studied under one team with the patients acting as their own comparators in a naturalistic setting. The quality of the data was of a high standard as they were obtained from the Trust electronic patient database. The retrospective nature of the study also negates interventional bias. The main weakness of the study was the absence of a non-CTO comparison group to measure any changes in service provision on clinical outcome measures. The study was based in an inner-London borough and involves only one individual AOT and may not be generalisable to other settings.

Implications

Despite the conflicting evidence of the benefits of CTOs, their use has become widespread in England and Wales. This study indicates the potential benefits of CTOs in reducing readmissions and bed occupancy in a disengaged AOT population, possibly through improved engagement, adherence to treatment and reduced substance misuse. This may have significant clinical, service planning and cost-benefit implications that need further research. Any such gains need to be balanced with the potential negative impact on patients' autonomy, therapeutic alliance as well as possible deskilling of staff as a result of reliance on coercion rather than interactive therapeutic approaches to achieve adherence, ^{Reference Freckelton and Lesser38} excessive medicalisation of care through depot use ^{Reference McDonnell and Bartholomew39} and the extra logistical burden on medical staff. ^{Reference Jaworoswski and Guneva40} However, CTOs cannot be ignored as a potential therapeutic tool in supporting adherence in a difficult-to-engage and potentially high-risk patient group. At its best, it can be helpful in allowing patients to remain stable in the community, build therapeutic relationships with clinicians and reduce the cost burden on health and criminal justice systems.