Little evidence for community treatment orders – a battle fought with heavy weapons

Abstract

This editorial discusses the pros and cons of community treatment orders (CTOs) from the perspective of community general adult psychiatry. There is little scientific evidence supporting the application of CTOs. Preconditions of a CTO to work are likely to be met by few patients. The time for the application of a CTO may be better spent for patient-centred care until there is sufficient new and robust evidence that identifies the patients that might profit.

Community treatment orders: Are they useful?

“…However, the profile of the patients in the trials matches closely those on CTOs across countries (Burns 2013; Rugkåsa 2015). According to Heun and colleagues (2016), and we would agree, given the current evidence base the onus should now be on proponents of CTOs to identify, with some scientific rigor, which subgroup would benefit.…”

“…Issues of attrition, protocol violations and crossovers are undoubtedly limitations of the RCTs (as with most pragmatic trials). However, it is highly unlikely that all of the RCTs and meta-analyses would have resulted in false-negative findings (Heun 2016). Given the exceptionally clear nature of these findings, reservations do not give cause for concern in the way they would have if the results had been approaching statistical significance (Szmukler 2015).…”

Notes on the use of randomised controlled trials to evaluate complex interventions: Community treatment orders as an illustrative case

“…Conversely, CTO opponents argue that one cannot see a probabilistic outcome that takes months to manifest itself and that the use of CTOs should be halted based on the negative findings of the RCTs . These sharply opposing stances have resulted in a state of apparent dissociation between academic research and clinical practice …”

“…58,63,64 These sharply opposing stances have resulted in a state of apparent dissociation between academic research and clinical practice. [65][66][67]…”

‘The government is the cause of the disease and we are stuck with the symptoms’: deinstitutionalisation, mental health advocacy and police shootings in 1990s Victoria

“…Communitycounselling could also be imposed. In the nearly three decades since CTOs were introduced in Victoria, three large-scale, randomized control trials and their meta-analyses have indicated that CTOs are ineffective in achieving their two principal aims: (1) lowering hospitalization rates or (2) protecting individuals subject to them (Heun, Dave, and Rowlands 2016), though no such studies have examined CTO-use in Australia. However, there is some evidence that CTOs were associated with reduced mortality rates, even when taking into consideration the use of community services, age, gender, inpatient experience, and diagnosis (Segal and Burgess, 2006).…”