Canadian Studies on the Effectiveness of Community Treatment Orders

Abstract

Objectives: Community treatment orders (CTOs) for people with severe mental illnesses are used across most of Canada. It is unclear if they can reduce health service use, or improve clinical and social outcomes. This review summarizes the evidence from studies conducted in Canada. Method: A systematic literature search of PubMed and MEDLINE to March 2015 was conducted. Inclusion criteria were quantitative and qualitative studies undertaken in Canada that presented data on the effect of CTOs on outcomes.Results: Nine papers from 8 studies were included in the review. Four studies compared health service use before and after compulsory treatment as well as engagement with psychosocial supports. Three were qualitative evaluations of patients, family, or staff and the last was a postal survey of psychiatrists. Hospital readmission rates and days spent in hospital were all reduced following CTO placement, while outpatient attendance and participation in psychiatric services and housing all improved. Family members and clinicians were generally positive about the effect of CTOs but patients were ambivalent. However, the strength of the evidence was limited as many of the studies were small, only one included control subjects, and there was no adjustment for potential confounders using either matching or multivariate analyses. Only 2 qualitative studies included the views of patients and their families. Conclusions: The evidence base for the use of CTOs in Canada is limited and this lack of Canadian research is in marked contrast to other countries where there have been large studies that have used randomized or matched control subjects. Their use should be kept under review. Abré géObjectifs : Les ordonnances de traitement en milieu communautaire (OTMC) pour les personnes souffrant de maladie mentale grave sont utilisées presque partout au Canada. Il n'est pas déterminé si elles peuvent réduire l'utilisation des services de santé, ou améliorer les résultats cliniques et sociaux. Cette revue résume les données probantes des études menées au Canada. Mé thode : Une recherche systématique de la littérature a été menée dans PubMed et MEDLINE jusqu'en mars 2015. Les critères d'inclusion étaient des études quantitatives et qualitatives menées au Canada qui présentaient des données sur l'effet des OTMC sur les résultats.Ré sultats : Neuf articles sur huit études ont été inclus dans la revue. Quatre comparaient l'utilisation des services de santé avant et après le traitement obligatoire ainsi que le recours aux soutiens psychologiques. Trois étaient des évaluations qualitatives des patients, des familles ou du personnel, et le dernier consistait en un sondage postal des psychiatres. Les taux de

Effectiveness of Community Treatment Orders: The International Evidence

“…7 Clinicians prefer to have CTOs available as an option 8,9 and many believe CTOs have the desired effects. 10,11 Family members often find CTOs necessary or helpful 12 but are concerned that the order is insufficient to help patients lead better lives, and that other community services must also be offered.…”

Community Treatment Order Outcomes in Quebec: A Unique Jurisdiction

“…Considering the ethical concerns regarding the perceived coercion associated with CTOs, 30,31 authors skeptical about the outcome literature caution against the infringement on autonomy that CTOs involve and promote less restrictive alternatives. [32][33][34][35] These authors tend to highlight the 2013 The Oxford Community Treatment Order Evaluation Trial (OCTET) study from England that utilized a RCT in showing no advantage of CTOs compared to a less restrictive control group. 34,36 The persistence of this controversy is apparent in various articles and in an exchange of letters to the editor in a 2016 issue of this journal between Dawson 37 and Hastings.…”

“…[32][33][34][35] These authors tend to highlight the 2013 The Oxford Community Treatment Order Evaluation Trial (OCTET) study from England that utilized a RCT in showing no advantage of CTOs compared to a less restrictive control group. 34,36 The persistence of this controversy is apparent in various articles and in an exchange of letters to the editor in a 2016 issue of this journal between Dawson 37 and Hastings. 38 With these methodological considerations in mind, we employed a naturalistic technique for our CTO study.…”

Service Users’ Knowledge and Views on Outpatients’ Compulsory Community Treatment Orders: A Cross-Sectional Matched Comparison Study

“…[18][19][20][21] However, these types of studies have their own significant methodological limitations. 22 In addition, position papers by both the Canadian and the American Psychiatric Associations support the use of CTOs. 23,24 Bearing all these factors in mind, the current body of evidence points to a potential positive impact of CTOs in individuals with SMI and poor treatment compliance in some jursiodictions.…”