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CTOs and ACT: Necessary? Effective? Ethical? R. O’Reilly A Successful CTO – Background 27 year old single male Diagnosis – Paranoid schizophrenia 7 previous hospitalizations Several charges Assault Concealed weapon Possession drugs Threatened GP with knife Abused cannabis & other drugs Successful CTO – Admission Hearing messages from electric wires Believed members of a motorcycle gang were going to kill his brother Rambled into brother’s school yelling and threatening to kill people Had a short hospitalization Discharged: assaulted mother and brother Readmitted as an involuntary patient Successful CTO – Hospital Course Believed patients were transmitting the smell of farts to his nose Believed the nurses were giving him erections Very agitated Gradually settled on high-dose oral risperidone Psychotic symptoms resolved, but no insight Adamant that he would not take medication or follow-up with team when discharged Successful CTO – Treatment Plan Transferred to an ACT team Placed on a CTO Mother substitute decision maker Treatment Plan Take medication as directed See Dr. O’Reilly monthly ACT visit home daily for medication observation Live in area served by the ACT team Provide urine for random drug screens Successful CTO – Follow-up Initially lived with mother and brother GP agreed to take him back (reluctantly) ACT team did daily medication observation ACT team helped patient get identification Patient complied, but kept minimal contact At 2nd renewal, mom refused CTO consent Successful CTO – Outcome Stopped medication when off CTO Became symptomatic and threatened family Readmitted to hospital as involuntary patient Mom again consented to CTO Patient insisted risperidone be stopped Placed on LAI typical antipsychotic Successful CTO – Aftermath Did have 2 subsequent short voluntary admissions associated with heavy drinking In last 6 years, has had no symptoms Agreed to take medication without CTO Moved to his own apartment Little motivation, but no legal charges Briefly held a part-time job An Unsuccessful CTO - Background 27 year old single male Diagnoses – Bipolar disorder type 1 Antisocial and narcissistic personality traits Polysubstance abuse Dull normal intelligence 4 previous hospitalizations Assaultive when manic Unsuccessful CTO – Admission Non-adherent to medication Abusing cannabis and cocaine Became manic with delusions that he was God Evicted from apartment Up all night shouting and aggressive in shelter Hospitalized involuntarily Unsuccessful CTO – Hospital Course Treated with sodium valproate and quetiapine Many assaults and periods in seclusion Slowly resolved over 8 month admission Referred to an ACT team Unsuccessful CTO – Treatment Plan Live in a 24-hour supervised group home See Dr. O’Reilly every 2 months Take medication as prescribed by Dr. O’R See ACT workers 3 times weekly Refrain from using cocaine Give urine for drug screen on request Unsuccessful CTO – Outcome Took treatment and attended appointments Continued to use cannabis, no evidence cocaine Mood remained stable Good therapeutic relations: occasional tensions 9 months moved to non-supervised group home Unsuccessful CTO – Outcome Quickly non-adherent with medication regimen ACT team instituted daily medication observation Not available for medication observation Started using cocaine Multiple breaches of CTO with 4 hospitalizations Deterioration of therapeutic relationships Gave nurse a cold urine sample – Gave up! Unsuccessful CTO - Aftermath Attempt to manage with ACT alone Patient agreed to injections of risperidone Re-hospitalized after 6 months with mania Took injection – limited adherence to oral medications when discharged Ongoing substance abuse Further hospitalizations with violence Many legal problems Left the catchment area Why we need CTOs Do they work? Is ACT an alternative to using CTOs? Review of ACT and CTOs Which patients are suitable for a CTO? What care and treatment under a CTO? How long should a CTO last? Why Do We Need CTOs? Deinstitutionalization is a massive public policy experiment Deinstitutionalization is relocating the locus of treatment to the community The authority to treat in hospital settings must be extended to the community Do CTOs Work? Three randomized controlled trials New York North Carolina England & Wales Some case-controlled studies Many before-and-after studies A few studies using data-bases Is ACT an alternative to CTOs? If we had sufficient services would not need CTOs Not when there is outright refusal of Rx Not when ACT alone has failed because of non-adherence to Rx Should we try ACT alone first? CTO can dispense with repeated cajoling CTO has more procedural justice CTO renewals can reignite irritation North Carolina RCT Less 3 services per month North Carolina RCT More 3 services per month Typical use of ACT and CTOs London, Ontario Average Range 17% 10-30% Indiana State Median Range 16% 0-65% Moser 2009 Research on ACT and CTOs CTO & ACT compared with ACT alone Doubled engagement with services Halved hospitalization Swartz 2010 > medication adherence & < admissions after CTO ended: CTO < 6 months needed ACT CTO > 6 months persisted without ACT Van Dorn 2010 ACT, CTOs and Coercion CTOs increase perception of coercion ACT does not increase perceived coercion No addition when CTOs & ACT combined Galon 2011 London ACT/CTO Study Did you use ACT alone before adding CTO Yes No No response 57% 40% 3% Reasons ACT Insufficient Patients refused medication Patients unavailable for Rx and F/U CTO recall powers necessary for timely Rx Patients had violent potential or Hx Who is Placed on a CTO? There is remarkable consistency in the characteristics of patients on CTOs across jurisdictions embedded in very different cultural and geographical settings. The descriptive data indicate that patients are typically males, around 40 years of age, with a long history of mental illness, previous admissions, suffering from a schizophrenia-like or serious affective illness, and likely to be displaying psychotic symptoms, especially delusions, at the time of the CTO. Criminal offences and violence are not dominant features amongst CTO patients. This picture is largely reinforced in the comparative data, which suggest that CTO patients are more likely to be severely mentally ill with high hospital admission rate histories, poor medication compliance, and aftercare needs. The Churchill Report 2007 Who Should be on a CTO? ~Geller’s Criteria~ Wants to leave hospital Previously failed in community Understands treatment order Can comply Not dangerous if complies Treatment previously effective Treatment meets the patient’s needs and can be delivered by system Treatment can be monitored Outpatient system must be willing partner Inpatient system must be willing partner Geller 1990 Who Does Well on a CTO? Patients refusing Rx who can be convinced Patients with high probability of default Patients who lack insight (incapable) Patients who respond to the treatment Patients with psychotic disorders Patients on long-acting injections Those without Cluster B personality disorder Who is suitable for a CTO? ~North Carolina RCT~ Patients with psychotic disorders who were placed on a CTO for > 6 months showed a 72% decrease in hospitalization In contrast, patients with affective disorders on CTO for > 6 months disorders showed no decrease Why Psychotic > Mood? Most mood disorder patients fully recover Most mood disorder patients have insight More mood disorder patients have PD? Mood disorder patients take oral meds What Care and Treatment? Medication Clinical monitoring Stable residence Laboratory tests Counselling/therapy Refrain from substances The Importance of Medication 50% of patients with schizophrenia lack insight Amador et al 1993 74% of patients with schizophrenia nonadherent within 2 years of discharge Weiden & Olfson 1995 When LAIs stopped in 1st episode patients, 78% relapsed within 1 year and 96% within 2 years Gitlin et al 2001 Mortality increased X 12 after stopping meds Tiihonen et al 2006 Long-acting Injections Modest evidence for superior effectiveness Naturalistic studies stronger than RCTs Zhornitsky & Stip 2012 Better treatment adherence independent of being on a CTO Swartz et al 2001 NSW < admissions on CTO with depot vs. oral Vaughan et al 2000 Specifying Residence on a CTO “Treatment can be monitored” Observe medication Daily monitoring of symptoms Nighttime supervision Limits drug use Three square meals Geller 1990 Specifying Residence on a CTO PG&T will give consent The individual will reside in a group home or residential setting which, by program design, supports the development of life skills and promotes treatment adherence CCB has upheld the practice Case of Ms. MBG July 2003 Laboratory Tests Monitoring mood stabilizers Tests for specific medical indications Segal 2006 Kisely 2013 Screening for drugs of abuse What Care and Treatment? Medication Clinical monitoring Stable residence Laboratory tests Counselling/therapy Refrain from substances How Long Should a CTO Last? North Carolina study reported positive outcomes when CTO was continued > 6 months Actually found that the longer the CTO, the better the outcomes Swartz et al 1999 New York study also suggests 6 month minimum Van Dorn 2010 Iowa study average duration was 4.5 years Rohland et al 2000 A Successful CTO – Background 58 year old separated male Diagnosis – Paranoid schizophrenia at 45 Destroyed property when living with family 3 previous hospitalizations Past delusions about poison injected up nose He surgically removed a polyp from his nose Severe hemorrhage Refused to take thyroid hormone post-surgery Successful CTO – Admission Delusions that sister was poisoning family Saved his vomitus for analysis Went to the police to press charges Hoarding and eating rotten food Increasingly irascible Admitted as an involuntary patient Successful CTO – Hospital Course Adamant that he had no mental illness Refused medication Attributed all physical discomfort to meds Deemed treatment incapable Daughter SDM Started on injectable antipsychotic Plan to discharge to a group home Gradually became less paranoid Referred to ACT team Ex-wife agreed to his return to family home Successful CTO – Treatment Plan Treatment Plan Take medication as directed See Dr. O’Reilly monthly Daily visits for medication observation Provide blood or urine for laboratory tests on request Successful CTO – Follow-up Initially unrealistic with bizarre behaviour Continued to attribute discomfort to meds Applied to the CCB every 6 months Reluctant to have a cystoscopy Gradually became less bizarre and ornery Good relationship with wife and children Good relationship with ACT team Mother died: I was able to help with will An Unsuccessful CTO - Background 31 year old single male Diagnosis – Paranoid schizophrenia with polysubstance abuse 15 previous hospitalizations An Unsuccessful CTO - Admission Non-adherence to medication Psychotic & jumped from 5th floor window Fractured ribs and humerus; lacerated liver and spleen; pneumothorax Unsuccessful CTO – Hospital Course Mother agreed to be SDM ACT agreed to serve patient outside area Plan to manage patient on a combination of LAI and oral antipsychotic Unsuccessful CTO – Treatment Plan See Dr. O’Reilly at least every 3 months Take medication as prescribed by Dr. O’R See ACT workers weekly Give urine for drug screen on request ACT must agree to change of residence Unsuccessful CTO – Outcome ACT had problems from the beginning Often unavailable for home visits Drug tests positive for cocaine and opiates I refused to prescribe Concerta Refused to see me – two Form 47s Evicted from his apartment Left catchment area to live with father Had fight with father - superficial stab wound: father ruptured spleen Unsuccessful CTO – Aftermath Lived with various relatives Stole from relatives to support drug habit Charged with assault, but no conviction Had to call Security during an office visit ACT team still believes that ensuing treatment is worth the cost