Doubting the Doubts About the Clinical Effectiveness of Community Treatment Orders

Dear Editor:

Dawson’s ¹ conclusion that “there is no robust evidence that the mandatory element in a CTO … produces greater clinical benefits for patients than simply offering them the same package of services on a voluntary basis” contrasts substantial evidence to the contrary. Further, absence of evidence is not evidence of absence. Appropriately used, community treatment orders (CTOs) are a critical tool to help prevent patient disengagement from mental health care. Otherwise, these patients would become unable to consistently and longitudinally access evidence-based treatments and the supports necessary for relapse prevention and optimization of recovery. A CTO helps ensure recovery-focused, patient and service provider participation in a comprehensive plan of treatment, care, and supervision.

Disengagement from mental health services occurs in a large minority of patients with both schizophrenia and bipolar disorder. Various studies ^{2 –8} demonstrate disengagement rates of 25% to 30%. The National Comorbidity Survey ⁴ showed that 53% of individuals with serious mental illnesses hadn’t received any mental health treatment in the prior year. When asked for reasons, more than half of respondents reported that they didn’t believe they had a problem requiring treatment (that is, anosognosia). In a 5-year follow-up study, Fischer et al ⁶ found that among patients with schizophrenia and bipolar disorder, 25% had 1 or more gaps in care lasting at least 12 months and 9% had gaps of 2 years or more. O’Brien et al ⁷ observed 30% disengagement from services in a follow-up period of 9 years. Similar rates of disengagement occur in patients served by even intensive multidisciplinary assertive outreach teams (for example, early psychosis programs ⁸ and assertive community treatment teams). While there are many potential strategies to enhance engagement, ⁹ it seems highly unlikely that these strategies will ever be sufficient to ensure care to a core group of treatment refusers. Where the alternatives to care include involuntary hospital admission, legal involvement, and violence to self and others with resulting coercive consequences, CTOs represent a coercion reduction tool. They also help save scarce beds for other patients with severe mental illnesses. As a separate issue, another large group of patients may be engaged in services but remain inadequately adherent to medication ⁸ that is also necessary for their long-term recovery and avoidance of the consequences of relapse.

While questions remain about what factors are most critical to the success of CTOs, there is little doubt in the minds of most clinicians and families with experience with CTOs that they remain an indispensable tool for some patients who would otherwise not avail themselves of the care they need. The strength of the effect of CTOs will likely always be determined by appropriate patient selection, the strength of the treatment plan, and the many variables involved in its implementation. Patients most likely to benefit from CTOs are treatment-incapable, treatment refusers, who prefer to remain out of hospital and have recurrent/persistent severe mental disorders that benefit from the interventions proposed as part of the community treatment plan.

No treatment in medicine is 100% effective. Let’s not abandon an intervention that still helps prevent hospitalization for many patients.

Yours sincerely,

Jamie Karagianis, MD, FRCPC Waypoint Centre for Mental Health Care, University of Toronto Penetanguishene, Ontario