New Study: Outpatient Treatment Orders Don't Reduce Readmissions

NYAPRS Note: A newly published Oxford University study has found that "in well coordinated mental health services the imposition of compulsory supervision does not reduce the 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." Stay tuned for more about this... Compulsory treatment orders for mental illness need reviewing Community treatment orders may not benefit psychiatric patients but involve significant periods of compulsory treatment. Medical Xpress March 27th, 2013

Discharging mental health patients on community treatment orders after they have been involuntarily hospitalised may require them to be on long periods of compulsory treatment without any benefit for the patient, a new study has found.

Community Treatment Orders (CTOs) have been controversial since their introduction in the UK in 2008. An Oxford University study has now found they do not alter the likelihood of patients<> being hospitalised again, compared with an older and less restrictive type of supervised discharge called Section 17 leave.

'This is the largest randomised trial<> of CTOs, and we did not find any evidence that they achieve their intended purpose of reducing readmission<> in so-called "revolving door" patients with a diagnosis of psychosis<>,' says Professor Tom Burns of the Department of Psychiatry at Oxford University, who led the study.

He says: 'The evidence is now strong that the use of CTOs does not confer early patient benefits despite substantial curtailment of individual freedoms. Their current high usage should be urgently reviewed.'

The findings are published in the medical journal The Lancet.

CTOs were introduced for psychiatric patients<> that are often repeatedly involuntarily hospitalised, leading to the idea of 'revolving door syndrome'. This group of patients are likely to have diagnoses of bipolar disorder or schizophrenia, are often men, lead unstable lives, and experience social exclusion<> and unemployment.

The measure was intended to address growing rates of involuntary hospital admissions<> due to mental ill health<> in the UK. CTOs allow clinicians and mental health practitioners to monitor a patient's condition when leaving hospital after an involuntary admission, with the aim of providing a period of stability when relapse is considered likely.

Currently, around 4,000 people annually are made subject to a CTO in the UK, with perhaps 10,000 people on a CTO at any point.

Similar legislation has also been introduced in the USA, Australasia, some parts of Canada, and several other European countries.

However, several mental health<> organisations have expressed concerns that CTOs are an unacceptable infringement on patients' civil liberties, as they allow specific conditions to be imposed on the patient, and that there is insufficient evidence to show that they are effective.

CTOs can include requirements that the patient takes certain medication, attends regular assessments, or lives in a certain place. If a patient breaks any of these conditions, the responsible clinician has the ability to recall them to hospital for up to 72 hours without formally readmitting them.

This is unlike the older provision of Section 17 leave, a period of leave from a hospital's inpatient unit which, if it goes well, is followed by discharge and voluntary treatment.

The OCTET study looked at whether 166 patients on CTOs experienced fewer hospital admissions compared with 167 patients released under Section 17 leave.

The Oxford University researchers found that the number of patients readmitted to hospital over 12 months did not differ between the groups. Just over a third (36%) of patients in each group were readmitted at some point.

Nor were there any significant differences in the time to readmission, or the number or duration of hospital admissions. The use of CTOs was not found to affect any of the patients' clinical or social outcomes.

But there was a great difference in the length of compulsory supervision of patients. Although the patients received equivalent levels of clinical contact, the patients on CTOs received compulsory treatment for an average of around 6 months. Those in the Section 17 group received compulsory treatment for an average of just over a week.

Professor Sonia Johnson of University College London, who was not involved in the study, comments in the Lancet: 'A strong respect for civil liberties is imperative for professionals entrusted with coercive powers, and arguments that CTOs infringe human rights seem persuasive if benefits cannot be shown.' ----------------

Community Treatment Orders For Patients With Psychosis (OCTET): A Randomised Controlled Trial Prof Tom Burns<> DSc a<> [Corresponding Author] <> [Email Address] <mailto:tom.burns at> , Jorun Rugkåsa<> PhD a<> d<>, Andrew Molodynski<> MBChB e<>, John Dawson<> LLD f<>, Ksenija Yeeles<> BSca<>, Maria Vazquez-Montes<> PhD b<>, Merryn Voysey<> MBiostat c<>, Julia Sinclair<> DPhil g<>, Prof Stefan Priebe<> FRCPsych h<>

Summary Background Compulsory supervision outside hospital has been developed internationally for the treatment of mentally ill people following widespread deinstitutionalisation but its efficacy has not yet been proven. Community treatment orders (CTOs) for psychiatric patients became available in England and Wales in 2008. We tested whether CTOs reduce admissions compared with use of Section 17 leave when patients in both groups receive equivalent levels of clinical contact but different lengths of compulsory supervision. Methods OCTET is a non-blinded, parallel-arm randomised controlled trial. We postulated that patients with a diagnosis of psychosis discharged from hospital on CTOs would have a lower rate of readmission over 12 months than those discharged on the pre-existing Section 17 leave of absence. Eligible patients were those involuntarily admitted to hospital with a diagnosis of psychosis, aged 18-65 years, who were deemed suitable for supervised outpatient care by their clinicians. Consenting patients were randomly assigned (1:1 ratio) to be discharged from hospital either on CTO or Section 17 leave. Randomisation used random permuted blocks with lengths of two, four, and six, and stratified for sex, schizophrenic diagnosis, and duration of illness. Research assistants, treating clinicians, and patients were aware of assignment to randomisation group. The primary outcome measure was whether or not the patient was admitted to hospital during the 12-month follow-up period, analysed with a log-binomial regression model adjusted for stratification factors. We did all analyses by intention to treat. This trial is registered, number ISRCTN73110773. Findings Of 442 patients assessed, 336 patients were randomly assigned to be discharged from hospital either on CTO (167 patients) or Section 17 leave (169 patients). One patient withdrew directly after randomisation and two were ineligible, giving a total sample of 333 patients (166 in the CTO group and 167 in the Section 17 group). At 12 months, despite the fact that the length of initial compulsory outpatient treatment differed significantly between the two groups (median 183 days CTO group vs 8 days Section 17 group, p<0·001) the number of patients readmitted did not differ between groups (59 [36%] of 166 patients in the CTO group vs 60 [36%] of 167 patients in the Section 17 group; adjusted relative risk 1·0 [95% CI 0·75-1·33]). Interpretation In well coordinated mental health services the imposition of compulsory supervision does not reduce the 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. Funding National Institute of Health Research