An Updated Meta-Analysis of Randomized Controlled Evidence for the Effectiveness of Community Treatment Orders

Kisely, Steve; Hall, Katharine E.

doi:10.1177/070674371405901010

Cited by 39 publications

(38 citation statements)

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“…Around 35 outcome studies and three RCTs have investigated the effect on hospitalisation (rates, duration and time to readmission following placement on CTO) and community service usage. While non-randomised studies vary in quality and have inconsistent findings, all analyses of randomised data found no effect of CTOs [4, 7–9]. A meta-analysis of the patients from the three RCTs also found no effect on admissions or bed days or any improvement in psychiatric symptoms or global functioning [7].…”

Section: Introductionmentioning

confidence: 99%

“…While non-randomised studies vary in quality and have inconsistent findings, all analyses of randomised data found no effect of CTOs [4, 7–9]. A meta-analysis of the patients from the three RCTs also found no effect on admissions or bed days or any improvement in psychiatric symptoms or global functioning [7]. Additionally, the OCTET trial testing the English regime [10] found no effect on subgroups [11] or any long-term (36 months) effect on hospital outcomes or on engagement with services [12].…”

Section: Introductionmentioning

confidence: 99%

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Recall of patients on community treatment orders over three years in the OCTET CTO cohort

et al. 2016

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BackgroundRandomised studies consistently show that Community Treatment Orders (CTOs) do not have the intended effect of preventing relapse and readmissions of patients with severe and enduring mental illness. Critics suggest this in part can be explained by RCTs studying newly introduced CTO regimes and that patients therefore were not brought back to hospital for short-term observations (‘recall’) as frequently as intended. Our purpose was (i) to test the hypothesis that CTO practice as regards recall of patients to hospital in England and Wales was as rigorous under the OCTET trial period as in current routine use and (ii) to investigate the reasons for and outcomes of recalls and whether this changed over time.MethodThirty six-month observational prospective study of 198 patients in the OCTET Follow-up Study.ResultsForty percent of patients were recalled, 19 % more than once. This is in line with current national use. Deterioration in clinical condition was the most common reason for recalls (49 %), and 68 % of recalls resulted in revocation of the order (i.e., retention in hospital under compulsion). This pattern remained stable over time.ConclusionThe use of recall cannot explain why RCTs have not confirmed any benefits from CTOs, and their continued use should be reconsidered.Trial registrationThe OCTET Trial was retrospectively registered on 12 November 2009 (ISRCTN73110773)

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Recall of patients on community treatment orders over three years in the OCTET CTO cohort

et al. 2016

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“…Only a small number of studies, however, investigate CTO outcomes with such a high level of rigour: 3 RCTs, 19-21 2 systematic reviews, 2,6 1 Cochrane review, 22 and 2 meta-analyses. 23,24 Most published outcome studies to date use nonrandomized methods. They are mainly controlled before-andafter (CBA) studies with matched non-CTO control subjects, uncontrolled before-and-after (UBA) studies where the patient's clinical status is compared before and after being placed on CTOs, or epidemiological studies that observe, but do not match, CTO and non-CTO populations.…”

Section: Types Of Outcome Studiesmentioning

confidence: 99%

Effectiveness of Community Treatment Orders: The International Evidence

Rugkåsa

2016

Can J Psychiatry

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Objective: Community treatment orders (CTOs) exist in more than 75 jurisdictions worldwide. This review outlines findings from the international literature on CTO effectiveness. Method: The article draws on 2 comprehensive systematic reviews of the literature published before 2013, then uses the same search terms to identify studies published between 2013 and 2015. The focus is on what the literature as a whole tells us about CTO effectiveness, with particular emphasis on the strength and weaknesses of different methodologies. Results:The results from more than 50 nonrandomized studies show mixed results. Some show benefits from CTOs while others show none on the most frequently reported outcomes of readmission, time in hospital, and community service use. Results from the 3 existing randomized controlled trials (RCTs) show no effect of CTOs on a wider range of outcome measures except that patients on CTOs are less likely than controls to be a victim of crime. Patients on CTOs are, however, likely to have their liberty restricted for significantly longer periods of time. Meta-analyses pooling patient data from RCTs and high quality nonrandomized studies also find no evidence of patient benefit, and systematic reviews come to the same conclusion. Conclusion: There is no evidence of patient benefit from current CTO outcome studies. This casts doubt over the usefulness and ethics of CTOs. To remove uncertainty, future research must be designed as RCTs. Abré géObjective : Les ordonnances de traitement en milieu communautaire (OTMC) existent dans plus de 75 administrations du monde entier. Cette revue présente les résultats de la littérature internationale sur l'efficacité des OTMC. Mé thode : L'article puise à deux revues systématiques complètes de la littérature publiée avant 2013, puis utilise les mêmes termes de recherche pour identifier les études publiées entre 2013 et 2015. L'accent est mis sur ce que la littérature dans son ensemble nous dit sur l'efficacité des OTMC, en insistant particulièrement sur les forces et faiblesses des différentes méthodologies.Ré sultats : Les résultats de plus de 50 études non randomisées étaient partagés. Certains montrent les avantages des OTMC alors que d'autres ne présentent aucun des résultats les plus fréquemment observés concernant: la réhospitalisation, le séjour à l'hôpital, et l'utilisation des services communautaires. Les résultats des trois essais randomisés contrô lés (ERC) existants n'indiquent aucun effet des OTMC sur ces mesures des résultats (ou une gamme plus vaste de mesures), excepté que les patients des OTMC sont moins susceptibles d'être victimes de criminalité. Les patients des OTMC sont toutefois susceptibles de se voir restreindre leur liberté pour des périodes de temps significativement plus longues. Les méta-analyses regroupant les données des patients des ERC, et les études non randomisées de grande qualité n'offrent pas non plus de preuves des avantages pour les patients, et les revues systématiques en viennent à la même conclusion.

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“…The issue of care planning with consumers on CTOs is complex, with CTO legislation, service delivery models and resource availability all impacting upon implementation [14]. Significant concerns regarding the effectiveness and ethics of CTOs also exist with a recent review examining CTO effectiveness finding no differences in social functioning, quality of life or service use for individuals on CTOs compared to those receiving standard voluntary care [15]. Advocates for CTOs cite clinical improvement and being the ‘least restrictive’ treatment option as benefits [16, 17], whilst advocates against CTOs, often ex- service users, consider forced treatment a major barrier to collaborative, person-centred care [18].…”

Section: Introductionmentioning

confidence: 99%

Care planning for consumers on community treatment orders: an integrative literature review

et al. 2016

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BackgroundCase management is the established model for care provision in mental health and is delivered within current care philosophies of person-centred and recovery-oriented care. The fact that people with a mental illness may be forced to receive care and treatment in the community poses challenges for clinicians aiming to engage in approaches that promote shared decision-making and self-determination. This review sought to gain an in-depth understanding of stakeholders’ perspectives and experiences of care planning for consumers’ on CTOs.MethodsAn integrative review method allowed for inclusion of a broad range of studies from diverse empirical sources. Systematic searches were conducted across six databases. Following appraisal, findings from included papers were coded into groups and presented against a framework of case management.ResultsForty-eight papers were included in the review. Empirical studies came from seven countries, with the majority reporting on qualitative methods. Many similarities were reported across studies. Positive gains from CTOs were usually associated with the nature of support received, highlighting the importance of the therapeutic relationship in care planning. Key gaps in care planning included a lack of connection between CTO, treatment and consumer goals and lack of implementation of focussed interventions.ConclusionsCurrent case management processes could be better utilised for consumers on CTOs, with exploration of how this could be achieved warranted. Workers need to be sensitive to the ‘control and care’ dynamic in the care planning relationship, with person-centred approaches requiring core and advanced practitioner and communication skills, including empathy and trust.Electronic supplementary materialThe online version of this article (doi:10.1186/s12888-016-1107-z) contains supplementary material, which is available to authorized users.

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An Updated Meta-Analysis of Randomized Controlled Evidence for the Effectiveness of Community Treatment Orders

Abstract: CTOs may not lead to significant differences in readmission, social functioning, or symptomatology, compared with standard care. Their use should be kept under review.

Cited by 39 publications

References 9 publications

Recall of patients on community treatment orders over three years in the OCTET CTO cohort

Recall of patients on community treatment orders over three years in the OCTET CTO cohort

Effectiveness of Community Treatment Orders: The International Evidence

Care planning for consumers on community treatment orders: an integrative literature review

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