Community treatment orders

CTOs refer to a civil court procedure ordering an individual with mental illness to adhere to a specified treatment plan

Introduction

My intention in writing this blog is to share the experiences that I went through with my son, starting with the first manifestation of his illness and our journey through numerous subsequent episodes. Also to provide commentary as a parent and psychiatrist on issues that these experiences bring up, such as how the diagnostic process works in mental health, how to work with treatment providers and medication issues. My hope is that reading this may be helpful for people with mental health issues and also their families and friends.

Community treatment order

Because of Bill’s multiple hospitalizations his psychiatrist at Mendota was finally willing to initiate the extensive paperwork to apply to get him involuntarily committed for mandatory outpatient treatment, termed a “chapter 51” commitment. She documented the multiple inpatient hospital stays, the many issues with non-compliance with medication, the fact that when he became ill it took a long time to stabilize him, even though the onset of the illness happened with surprising speed. The process was conducted formally with a hearing in the courthouse in front of a judge. Upon hearing the very long history of his illness, with an emphasis on medicine keeping him well when he was on his medication, the judge granted the order. Because Bill was now not allowed to take medication on his own he had to live in a community based residential facility licensed to dispense medicine. He was especially unhappy about this aspect of the treatment plan, even though he acknowledged that he had not done a good job of taking medicine in the past.

Mandatory outpatient treatment or “outpatient commitment” also called assisted outpatient treatment (AOT) or community treatment orders (CTO)—refers to a civil court procedure wherein a legal process orders an individual diagnosed with a severe mental disorder to adhere to a specified, individualized treatment plan that has been designed to prevent further relapse and deterioration or recurrence that is harmful to themselves or others. This form of involuntary treatment is distinct from involuntary commitment in that the individual subject to the order continues to live in their home community rather than being detained in hospital or incarcerated. The individual may be subject to rapid recall to hospital, including medication over objections, if the conditions of the order are broken, or the person's mental health deteriorates. This generally means taking psychiatric medication as directed and may include other forms of treatment as well as attending appointments with a mental health professional, and sometimes even not to use non-prescribed illicit drugs and not associate with certain people or in certain places deemed to have been linked to a deterioration in mental health in that individual. Patients are often monitored and assigned to case managers or a community dedicated to treating mental health known as assertive community treatment (ACT). The number of communities where this is available is approximately 70 worldwide, limited by the number of communities with a legal jurisdiction to issue legal orders for treatment.

The terminology, "outpatient commitment", and legal construction often equate outpatient commitment with inpatient commitment but provide the patient more freedom. When introducing the bill introducing CTO in the UK Lord Warner, then Minister of NHS reform, said "That modern approach strikes a balance between individual autonomy and protection of the patient and the public." CTOs were first conceived as a less restrictive alternative to involuntary hospital admission. They allowed patients detainable under mental health legislation to be treated outside hospital and had the same stringent criteria as involuntary admissions. From the perspective of clinicians, patients and their families, as well as human rights lawyers, ‘least restrictive’ CTOs were considered preferable to hospital detention. Most proponents involved in the outpatient commitment debate made the case based on the quality of life and cost associated with untreated mental illness and recidivism, with patients cycling through hospitalization, treatment and stabilization, release, and decompensation. While the cost of repeated hospitalizations is indisputable, quality-of-life arguments rest on an understanding of mental illness as an undesirable and dangerous state of being. The need for care is balanced against the cost of living on the streets, or held prisoner by terrible delusions and hallucinations.

In one study (Swartz) 74% fewer participants experienced homelessness; 77% fewer experienced psychiatric hospitalization; 83% fewer experienced arrest; 87% fewer experienced incarceration; 49% fewer abused alcohol; 48% fewer abused drugs; and there was a 56% reduction in length of hospitalization. Consumer participation and medication compliance improved. The number of individuals exhibiting good adherence to meds increased 51%. The number of individuals exhibiting good service engagement increased 103%. Consumer perceptions were positive. 75% reported that CTO helped them gain control over their lives. 81% said CTO helped them get and stay well. 90% said CTO made them more likely to keep appointments and take meds.

However, these were based on observational studies of immediate outcomes, whereas in some randomized clinical trials, which have less inherent bias, there was no evidence for superiority in longer term 12 month readmission rates (Rugkasa 2013). As the authors pointed out this may have been due in part to patient refusal, attrition and protocol violations. They concluded that the benefit of CTO may derive more from the intensive community services offered than from the compulsory nature of the treatment. In Bills case it seemed clear that these two aspects worked together to keep him well as long as he was on compulsory treatment. In other words during the time he was living in a facility that monitored his meds or in the next phase of his treatment where he lived on his own but had to report to a crisis center every evening to take the meds while observed (checking under his tongue) he stayed well and was able to move forward with his life. Had there simply been a court order, without the daily means to implement it, undoubtedly he would have stopped taking his meds and decompensated. But in addition, during this time he received more intensive outpatient treatment, including group and individual therapy. He began to think about the possibility that he might be a good person to help other patients cope with their mental illness, since he had experienced so many episodes.

Extensive New Independent Support for Assisted Outpatient Treatment from AHRQ Report". Mental Illness Policy Org. 17 November 2016.

Swartz, Marvin S.; Wilder, Christine M.; Swanson, Jeffrey W.; et al. (October 2010). "Assessing Outcomes for Consumers in New York's Assisted Outpatient Treatment Program". Psychiatric Services. 61 (10): 976–81. doi:10.1176/ps.2010.61.10.976. PMID 20889634.

Rugkåsa, Jorun; Dawson, John (December 2013). "Community treatment orders: current evidence and the implications". British Journal of Psychiatry. 203 (6): 406–8. doi:10.1192/bjp.bp.113.133900. PMID 24297787

Southard, Marvin (February 24, 2011). Assisted Outpatient Treatment Program Outcomes Report (PDF) (Report). Los Angeles, CA: Los Angeles County Department of Mental Health. Archived from the original (PDF)

Weich S et al. Evaluating the effects of community treatment orders (CTOs) in England using the Mental Health Services Dataset (MHSDS): protocol for a national, population-based study

BMJ Open (2018) Oct 18;8(10):e024193 doi: 10.1136/bmjopen-2018-024193