Abstract
The recent CPA position paper—“Community Treatment Orders and Other Forms of Mandatory Outpatient Treatment”—reviews mandatory outpatient treatment for patients with serious and persistent mental illnesses and advocates for their use in specific clinical and legal contexts. 1
More than 75 jurisdictions worldwide (including 9 Canadian provinces, most of the United States, Australia, England, Wales, New Zealand, Scotland, Sweden, Denmark, Norway, Switzerland) have enacted Community Treatment Order (CTO) legislation. 2 Although the specific legal frameworks for CTO enactment across Canadian provinces are not identical, most generally build upon the criteria for involuntary inpatient hospitalization (e.g., the individual is likely to cause harm to themselves or others or experience serious deterioration or physical impairment). 3 For example, in Ontario, a CTO can be implemented if the individual has been a patient in a psychiatric setting 2 or more times, equating to a 30 day or longer stay within the past 3 years, or if a previous CTO has been in effect.
An additional requirement involves identifying a substitute decision maker (SDM) to assume treatment-making capacity for the individual named in the CTO. The SDM is decided upon by the physician’s reference a preestablished hierarchy of choices from the Health Care Consent Act. SDMs are typically represented as a partner or spouse, close relative, friend, or an adult child who is prepared to contribute to making health care decisions on behalf of their loved one. As families are often called upon to be SDMs, a recent qualitative review examined their perspectives on CTOs. 4 While the benefits generally outweighed the drawbacks, families tended to be displeased with the structure, process, and implementation of CTOs, and families were also concerned generally about mental health system services. 4
It is possible that SDM-related factors, such as stress, burnout, and poor communication, may diminish the effectiveness of CTOs. However, there have been no previous studies exploring whether improvement of these factors leads to improved outcomes for persons who are on CTOs or not, such as hospital readmission rates, days spent in hospital, housing, outpatient attendance, and participation in psychiatric services. 3 To that end, we propose future mixed-methods research to focus on characterizing the relationship between SDM stress, burnout, and communication with CTO-related outcomes, such as medication adherence and readmission rates. First, we aim to measure symptoms of burnout among SDMs with the aim of understanding how caregiver burnout may affect the caregiver’s ability to act as the patient’s SDM. Second, we will explore whether the SDM’s satisfaction with the care provided to the patient who is on a CTO will improve if burnout is appropriately addressed. Third, we will determine whether addressing SDM burnout will improve the quality of care provided for a patient on a CTO as well as the patient’s prognosis. Combining such quantitative and qualitative findings may provide valuable information for health care professionals, policy makers, community health administrators, and other researchers regarding the experience of SDMs to improve the CTO experience and process.
