Metal Health under the magnifying glass

CTOs do not work…and that’s according to the evidence base

Community treatment orders will help protect the public from mentally people who kill, says the government. But what of the evidence for such a claim, asks Adam James?


When assessing psychiatric clinical treatments “evidence-based” is the mantra. Evidence-based practice underpins every clinical guideline and initiative from the National Institute for Health and Clinical Excellence and the National Institute for Mental Health. Before being approved, the mantra dictates, every psychiatric drug and psychological therapy must be validated by dozens, if not hundreds, of randomised-controlled trials.

Let’s turn, then, to the government’s plans for community treatment orders (CTOs). In what is part of the biggest shake up of mental health law for more than 20 years, so-called “revolving door” patients could, when released from a hospital section, be then be ordered take their psychiatric medication while living in the community. It’s a key measure by the government in its new mental health bill to try and reduce the 50 or so annual homicides (out of a total of 500-600) committed by the mentally ill. But what of the evidence base supporting the effectiveness of CTOs? Well, no such supportive evidence base exists.

According to Tony Zigmond, the Royal College of Psychiatrists’ spokesman on the government’s plans to amend the laws determining how and when patients should be compulsory detained, there is, actually, only one published review on CTO effectiveness. It’s a Cochrane review published last year. The review aimed to examine the “clinical and cost effectiveness of CTO treatment for people with severe mental illness.” Reviewers found “only two” relevant randomised-controlled clinical trials. These two trials both focused on patients in the USA subjected to 416 court-ordered ‘outpatient commitments’, the American equivalent to CTOs.

What did the reviewers conclude? Firstly, they said CTOs are neither an effective alternative to standard care, nor are they cost effective. Secondly, CTOs had no clinically meaningful benefit to a patient’s social functioning, mental state, quality of life or satisfaction with care. Thirdly, CTOs would have to be used on 85 patients to avoid one admission, and 238 to avoid one arrest, stated the reviewers.

It can’t be clearer than that. According to the evidence base, CTOs are not clinically useful. Or, as Zigmond puts it, CTOs are “probably pointless.”

The inclusion of CTOs in the mental health bill to “protect mental health patients and the public” came on the heels of an “independent” review of 25 homicides by people diagnosed with a severe mental illness.

The author, Tony Maden, professor of forensic psychiatry at Imperial College, London, investigated what went wrong in the patient care and treatment in each of the killings. One of his recommendations was that CTOs be introduced “to allow compulsory treatment in the community of patients with a serious mental illness and a history of violence and non-compliance” So, what was his evidence base for this CTO endorsement? Well, none was actually included in his review. Moreover, Maden admits he has not even read the Cochrane review.

And what of the government’s claim that Maden’s review was “independent”? Maden is an advocate of CTOs and a “risk-based” assessment approach to deciding whether or not a patient should be compulsory detained and treated. This is slightly different to Zigmond’s view, for example. While Zigmond is not “in principle” opposed to CTOs he fears that, in England and Wales, CTOs could be administered with insufficient checks and balances. Unlike Maden, Zigmond supports the introduction of a capacity test (whereby a patient must be judged to lack capacity before being compulsory treated whether in hospital or the community) as enscribed in Scottish law which has been implementing CTOs since October last year.

Moreover, Maden admits his review was tailored towards his conviction that the Home Office and Department of Health are not going to back down from introducing CTOs. Ministers are also, says Maden, not going to introduce a capacity test. “The government is just not going to do it,” Maden told me.

Controversially, Maden also says it’s futile for mental health professionals to oppose the government. Instead, says Maden, they should help “work towards finding the best way of having that sort of legislation [the mental health bill]”

In the politically-charged debate of whether to increase compulsory treatment powers over those diagnosed with a mentally illness, such words ring of conviction, not “independence” (if ever such a concept is applicable in mental health and psychiatry).

And without a supportive evidence base the only conclusion we can arrive at is that CTOs are a product of a politically expedient conviction that CTOs will keep the mentally ill less ill and this will, in return, reduce homicides. But, I repeat, there’s no evidence base to support this conviction.

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