Community Treatment Orders Disconnect

There is a profound disconnect between the positive experiences of many psychiatrists, patients, families, researchers, and reviewers regarding community treatment orders (CTOs) and the conclusions drawn by the authors published in the January 2016 issue of the journal.

Worldwide, based on their perception of the benefits of CTOs, more than 75 jurisdictions have enacted CTOs. In Canada, the eight studies reviewed by Kisley ¹ all had positive results in terms of variables such as reduced hospitalization and better treatment adherence, community engagement, or improved housing. Psychiatrists, families, and some patients were also positive about CTOs. Kisley concludes, however, that “the evidence base for the use of CTOs in Canada is limited” (p. 7).

The five legislated reviews in Canadian provinces ^{2 –6} that involved providers, recipients, and their families and examined provincial and international data have all recommended CTO laws continue. The latest Ontario review ² concluded, “It is clear from this review and from the first review that CTOs are effective for some consumers and that for these consumers and their friends and families, CTOs make a tremendous positive impact on their well-being” (p. 73). Kisley dismisses this evidence.

Despite these positive Canadian findings and the 20 positive studies since 2006 cited by Rugkåsa, ⁷ she concludes, “There is no evidence of patient benefit from current CTO outcome studies.” (p. 15). Dawson ⁸ agrees.

Why is there such a profound disconnect between those who find CTOs to be effective in clinical practice and these reviewers’ opinions? We believe that their overreliance on the findings of the three existing flawed randomized controlled trials (RCTs) is the major issue. As the British Medical Research Council notes for the evaluation of complex interventions, “It is further recommended consideration of alternatives to randomized trials.” ^{9(p. 1655)}

The OCTET study, ¹⁰ an RCT that found no differences in hospitalization, illustrates the issues. First, OCTET did not compare CTO against no CTO but, for ethical reasons, two forms of compulsory care. Second, patients who “really needed” a CTO were excluded by their psychiatrists, because being randomized to the non-CTO group would have been unethical. Third, patients not capable of consenting (probably most of those on CTOs in Canada) were excluded from the study. ¹¹ Fourth, 33% of eligible patients chose not to participate—the very group for whom CTOs are designed. ¹² Fifth, 21% of the patients randomized to the CTO group were not put on a CTO. Sixth, 24% of the patients randomized to be discharged without a CTO had to be transferred to a CTO. Needless to say, no drug study with such a high percentage of protocol violations would be used to conclude that a drug was ineffective. Seventh, the findings cannot be generalized to other jurisdictions because of the marked differences in legislation that affect clinical practice.

Swanson and Swartz, ¹³ who reviewed CTO studies, conclude, “In our view, such evidence is sufficient to justify more widespread implementation of outpatient commitment, accompanied where possible by systematic local evaluations similar to the New York assisted outpatient treatment study.” We agree.

Yours truly,

Thomas J. Hastings, MD, FRCP(C) University of Toronto, Toronto, Ontario McMaster University, Hamilton, Ontario [e-mail] John E. Gray, PhD Western University, London, Ontario [e-mail]