Coercive,treatment or sensible: What is the place of community treatment orders in psychiatry?

Like it or not Community Treatment Orders (CTOs) have become a part of the psychiatric landscape in the Western world. Many clinicians see them as a necessary tool to ensure people with mental disorder adhere to management and access the care they need. The clinical concern is that without a CTO people will not engage with treatment, and this will lead to myriad problems including difficulties in managing self, increased risk of incarceration in the criminal justice system or death by suicide or homicide. Indeed, many CTO regimes have been enacted in response to pressure following a person with mental disorder killing a member of public, presumably as the belief is a CTO will prevent future events. As homicide rates are immune to implementation of CTOs, with no fall in rates with there enactment it is clear that CTOs do not provide this outcome. A CTO enables enforced care while also providing legal protections to object to this if a person wants to. Despite these protections there are arguments that CTOs breech human rights, run counter to the Convention for the Rights of Persons with Disabilities and ignores the bioethical principle of autonomy.

To complicate the issue further the evidence for the various dimensions of CTO use is not straightforward to interpret. The three major randomised controlled trials examining CTOs are all negative for the primary outcome; readmission to hospital. Each has, however, been scrutinised, and criticised for various reasons. Sample size and attrition (the New York trial), exclusion of risky patients not reflecting the population in normal clinical practice (the New York and North Carolina trials) and significant protocol violations (the OCTET trial) have been mooted as reasons to question these findings. One possible difficulty is these trials, and indeed any interventional randomised controlled trial, has a problem with numbers; the studies are often too small to examine nuance in the characteristics of the people included. This problem is overcome with larger population cohort studies. Examining whole of nation data enables examination of CTOs as a variable, like gender or ethnicity, and correlations can be made and interpreted. Recently this approach has been used in New Zealand to examine CTOs as a characteristic of a whole of nation mental health population subject to a CTO over a 10-year period to see if correlates are made that hold face validity. This approach has thrown up interesting findings with high face validity and go some way towards helping us understand why individual clinicians hold a wide bank of anecdotal memory reflecting the value of CTOs, particularly in the case of psychotic patients, while the randomised controlled trial science is negative.

By combining national databases examining service use, mortality and national dispensing we examined everyone in New Zealand detained under a CTO over a 10-year period from 2009 to 2018. In this analysis, we aggregated outcomes during CTOs and compared these to outcomes during voluntary periods. This is distinct to many other studies that evaluate CTOs over a set time, often 1 year after their initiation. Examining over 14,000 patients, we highlight a relationship between increased contact with services, increased dispensing of psychotropic medication, particularly antipsychotic medication, and CTOs. Importantly a clear correlation between reduction in hospitalisation admissions for people with psychotic disorder and CTO use was found and the converse for people with non-psychotic disorder (Beaglehole et al., 2021). When we examined this in greater detail the reduction in readmission for those with a psychotic diagnosis remained while a notable increased rates of readmission for depressive disorder and personality disorder were identified (Beaglehole et al., 2022). Examination of death rates did not reveal a link between CTOs and reduced mortality. In fact mortality was higher on, as opposed to off, CTOs (Beaglehole et al., 2023). The likely impact of workplace culture and individual psychiatrist choice was found with a more than threefold variation in use of CTOs in the 21 New Zealand regions, between 53 and 184 per 100,000 population (Lees et al., 2023). Socio-demographic variables including ethnicity did not explain variation. In closer examination of ethnicity, however, Māori were found to be more likely to diagnosed with psychotic disorder and receive proportionally less antipsychotic medication suggesting structural inequity in the provision of CTOs (Beaglehole et al., 2024).

So how to understand these findings in light of the mixed evidence in a controversial topic? The most notable finding is, we think, that the randomised controlled trial (RCT) evidence by not identifying outcome by diagnosis may have washed out the benefits to people with psychosis of CTOs, and potentially the detriments to those without psychotic disorder, particularly depressive and personality disorders. Our understanding of this evidence is, simply put, CTOs seem to provide a relative benefit to people with psychosis by increasing service contact, increasing the use of antipsychotics (and depot preparations) and subsequently reducing admission to hospital, an outcome with high face validity for illness severity in this patient group. Underlying this may be the dysexecutive difficulties of non-affective psychosis, clinically reflected as insight. It also raises the question of capacity related to treatment and the importance of a CTO to protect liberal rights when treatment is delivered despite a spoken wish not to receive it, often for difficult to understand reasons. However, for people with depressive disorders, CTOs seem to increase contact and admission. This is also unsurprising as increased contact in a group for whom suicidality is part of the core psychopathology is stressful to manage, and the increased contact reasonably increases the likelihood of admission. Clearly admission for the management of depression is not akin to the delivery of a depot antipsychotic for psychotic mental disorder. The same argument can be made for people with personality disorder, particularly in light of help seeking behaviour displayed. This interpretation of our findings fits well into the evidence as it stands currently (Kisely et al., 2023).

Of course, not too much can be made of one series of studies. We would not suggest this line of work provides the ‘answers’ to the difficult question of the use of CTOs. It does not address the ethical and social components of CTOs. It ignores the different legal settings of CTOs in different jurisdictions. Nor do we suggest this work seeks to recommend all patients with psychotic disorders be placed on a CTO. This line of thinking is akin to stating all New Zealanders speak English; therefore, all English speakers are New Zealanders. Rather it aims to help clinical thinking in the use of CTOs, particularly in Australasia and to support work underway in considering changes to legislation. For example, as New Zealand’s current Mental Health Bill stands there is no consideration of empirical research such as this. These insights could, we think, provide important evidence in shaping such frameworks, potentially limiting the use of CTOs to people with confirmed chronic psychotic disorder. We would encourage clinicians and policy makers to consider this evidence both in day-to-day clinical practice but also in shaping new legislation and the policy’s that surround it.