Download - CTOs inEngland
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What do we know about the use of Community Treatment Orders (CTOs), and the need for further
research?
Tom BurnsSocial Psychiatry Research Unit
University of Oxford
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CTOs inEngland
• Introduced as SCTOs in 2007 MHA
• Proposed by RCPsych 1988, 1993
• Concerns– Initially ethical, ‘not needed’ and
misunderstandings about force in homes– More recently (EBM) emphasis on lack of
convincing evidence• (Churchill review 2007)
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What do we know about CTOs?
Observational and Experimental studies
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Rachel Churchill et al, 2007
Review of 72 empirical studies of CTOs
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Origins of studies
• 47 USA
• 10 Australia
• 5 New Zealand
• 4 Canada
• 3 UK
• 2 Israel
• 1 World-wide
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Non-experimental studies
• 21 descriptive studies of practice of CTOs
• 18 stakeholder studies– 14 cross section– 4 qualitative
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Stakeholder studies
• Good clinician acceptance• Consistent practice
– ‘typically males, around 40 years of age, long history of schizophrenia-like or serious affective illness, previous admissions, poor medication compliance, aftercare needs, the potential for violence and displaying psychotic symptoms, especially delusions, at the time of the CTO’
• Strong family support• Some patient support• US and Canada more varied experience:
– Opposition, inexplicable variation, often unused, fragmented services
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Experimental studies
• 5 cohort studies– Case control
• 6 controlled before and after
• No significant differences– Questionable methodologies
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Random controlled trials
• Only two RCTs to date (both in US)
• Primary outcome readmission
• No significant difference between groups in either study
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Multiple protocol violations, atypical, chaotic service
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•Well conducted, •264 subjects, good follow up, few violations•No difference in primary outcome (readmission)• Highly variable practice•Duration of CTO and clinical contact
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North Carolina secondary analyses
Swartz et al, 1999
• No CTO, <180 days blue, >180 days CTO green.• < 3 > clinical contacts per month
Results• Mean admissions down 57%, occupancy down 20 days • (73% and 28 days for schizophrenia)
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Churchill conclusions• It is not possible to state whether community treatments
orders (CTOs) are beneficial or harmful to patients.
• Review summarizes 72 data-based empirical studies from six countries.
• A range of designs have been used, but many conceptual, practical and methodological problems; quality of evidence is poor.
• No consistent evidence of benefit from the nine comparative studies, including two RCTs.
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Churchill conclusions• Different stakeholders reported both positive and negative
views in 18 studies.• • Characteristics of CTO patients remarkably similar in 14 cross-
sectional studies.
• No robust evidence for positive or negative effects on key outcomes (hospital readmission, length of hospital stay, improved medication compliance, or quality of life).
• • These findings are consistent with the conclusions of other
recent reviews on this topic.
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Current evidence
• Descriptive studies generally positive but methodologically very poor
• Stakeholder views mixed ?positive• Experimental studies
– Non randomised, methodologically poor – RCTs one methodologically good but some clinical
service reservations– Cochrane review very scathing (Kisley)
• 85 CTOs to avoid one admission • 235 CTOs to avoid one arrest
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Conclusion:
‘High quality RCTs urgently needed’
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OCTET at 14.00 hrs