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Community Treatment Orders

Community Treatment Orders. Prof Peter Lepping Consultant Psychiatrist/Associate Medical Director (BCULHB) and Visiting Professor (Glyndŵr University) Dr Masood Malik Consultant Psychiatrist (BCULHB). CTOs. Introduced as part of 2007 amendments to 1983 MHA

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Community Treatment Orders

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  1. Community Treatment Orders Prof Peter Lepping Consultant Psychiatrist/Associate Medical Director (BCULHB) and Visiting Professor (Glyndŵr University) Dr Masood Malik Consultant Psychiatrist (BCULHB)

  2. CTOs • Introduced as part of 2007 amendments to 1983 MHA • Place conditions on patients that may cover any aspect of someone’s health and social care • To “ensure that the patient receives medical treatment for [his or her] mental disorder, prevent a risk of harm to the patient’s health or safety, or protect other people”

  3. Purpose • 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. It is intended to help patients maintain stable mental health outside hospital and to promote recovery. (Code of Practice, England, 2008) • to address the specific problem of ‘revolving door’ patients. (DoH, 2007)

  4. used where treating clinician believes that the patient is “well enough to leave hospital but is concerned that [the patient] may not continue with treatment, or may need to be admitted to hospital again at short notice for more treatment” (DoH, 2008) Unequivocally intended to facilitate treatment in community and prevent relapse Does not authorise forced treatment, but can facilitate it Allows for patient to be recalled to hospital (f.ex. to give depot medication)

  5. Extended trial leave with conditions • Germany • France • Belgium • Luxemburg • Portugal • Israel

  6. Forced or covert community treatment • Spain (some cities) • USA (some federal states): judicial decision, varying provisions and consequences of non-compliance • Australia: judicial decision and forced treatment • New Zealand and Canada

  7. Since 2009 (Wales) • CTOs often fail (one third need recall) • Wide regional variations • Wide range of conditions • Rationale for conditions often not clearly documented • Conditions often non-specific, e.g. compliance with care plan • 25% of conditions aimed at containing risk, not compliance (Psychiatric policing?)

  8. Problems • In Britain, rapid increase in use, which is far higher than envisaged (29% increase in 2011) • Recall possible without breach of conditions • Judging when conditions have been breached • Use to control risk, not compliance • All 3 serious incidents occurred when conditions were used for risk management (North Wales audit) • Authoritarian and ethically questionable • Compatible with recovery? • Determining when to end a CTO can be very difficult as success proves continued usefulness

  9. Welsh audit, conditions • Make available for extension* 100% • SOAD* 100% • Appointment with care team* 100% • Take medication 98% • Appointments with psychiatrist 72% • Reside at address 46% • Allow access to team 24% • Attend drug counselling, provide UDS 20% • Refrain from drugs and alcohol 18% • Allow nursing care support 16% • Attend day service, leisure, education 12% • Noncompliance leading to recall 10% • Attend blood tests 8% • Restricted home visits to family 4% • Family to contact services 4% • Stop driving 2% • Adverse directive 2% • Check Mail 2% • Compliance with care plan 2%

  10. SMART framework

  11. Recent Lancet article, Burns • We tested whether CTOs reduce admissions compared with use of Section 17 leave • Methods: RCT, diagnosis of psychosis, aged 18–65 years, who were deemed suitable for supervised outpatient care by their clinicians. Patients were randomly assigned (1:1 ratio) to be discharged from hospital either on CTO or Section 17 leave. • Results: 333 patients (166 in the CTO group and 167 in Section 17 group). At 12 months, readmission did not differ between groups (36% in both groups). • Interpretation: In well coordinated mental health services the imposition of compulsory supervision does not reduce 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.

  12. Conclusion • CTOs are problematic, especially when used to control risk • A more rigorous approach to conditions and plans might enhance compliance and outcome

  13. References • Lepping P, Malik M. Community treatment orders: current practice and a framework to aid clinicians, The Psychiatrist (2013) 37: 54-57 • Burns T, Rugkåsa J, Molodynski A, Dawson J, Yeeles K, Vazquez-Montes M, Voysey M, Sinclair J, Priebe S. Community treatment orders for patients with psychosis (OCTET): a randomised controlled trial. Lancet. 2013 Mar 25

  14. Thank you very much

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