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The first year of Community Treatment Orders Dr M Claire Royston MB ChB MSc FRCPsych Medical Director Care Principles Lead SOAD, Care Quality Commission 5/24/2017 Dr M Claire Royston 0 History of CTOs • First appeared in N. America and Australasia during ‘80s • CTOs exist in 52 separate jurisdictions across the world: – 41 States in USA – Ontario and Saskatchewan in Canada – All states in Australia – New Zealand – Israel – Scotland – England 5/24/2017 Dr M Claire Royston 1 History of CTOs Definition: A legal mechanism by which people with mental health problems who need treatment are compelled to submit to treatment on an outpatient basis Restrictive intervention 5/24/2017 Dr M Claire Royston 2 History of CTOs Conceptualised in response to number of different pressures on psychiatric services: – Deinstitutionalisation – Homeless mentally ill – Over-representation of mentally ill in prison – Revolving door patients – Dangerous mentally ill in the community 5/24/2017 Dr M Claire Royston 3 History of CTOs • Conceptualised as a provision for treatment in a less restrictive environment • Outcome measures for ‘success’ –Successful maintenance without harm to self or others 5/24/2017 Dr M Claire Royston 4 History of CTOs • Over time the concept of the purpose for the CTO has evolved into a legal intervention with ‘health benefits’ • A legal intervention designed to benefit persons with serious mental illness who need ongoing psychiatric care and support to prevent relapses, hospital readmissions, homelessness or incarceration but have difficulty following through with community-based treatments • This alters the type of outcome measures • Now often considered to be a less restrictive measure 5/24/2017 Dr M Claire Royston 5 History of CTOs • 14 major studies completed • Consistency in the characteristics across all jurisdictions (very different cultural and geographical settings) • Typically; male, around 40 years of age, long history of mental illness, previous admissions, suffering from a schizophrenia-like or serious affective illness • Likely to be displaying psychotic symptoms, especially delusions at time of inception of CTO • Criminal offences and violence not dominant features • Often past history of high admission rates, poor medication compliance 5/24/2017 Dr M Claire Royston 6 CTOs in England • Came into effect with amendments MHA 1983 on 3 November 2008 • “Designed for patients who still require treatment for mental disorder, on the ground of their own health or safety or protection of others, but such treatment can be given outside of detention hospital, provided there is a power to recall if clinicians have concerns community arrangements are no longer sufficient” • Estimated number ~200 in the first year 5/24/2017 Dr M Claire Royston 7 Number of CTO SOAD visit requests 3 November 2008 – 31 March 2009, n=1722 5/24/2017 Dr M Claire Royston 8 CTO - changes in legal status Number of recalls to hospital 206 Number of revocations 142 Number of discharges from SCT 32 (n = 2,109) 5/24/2017 Dr M Claire Royston 9 Number of CTO requests: region 5/24/2017 Dr M Claire Royston 10 Study design From completed CTO second opinions from 3 Nov 2008 to 30 April 2009: • 233 records located • Records showing some change from treatment plan prioritised, but 111 records showing no change randomly selected. • Audited by Lead SOAD following coding. 5/24/2017 Dr M Claire Royston 11 History & symptom clusters 5/24/2017 Dr M Claire Royston 12 Stated diagnosis Stated diagnosis F20 Frequency Schizophrenia, schizoaffective or delusional disorder 190 F30-F39 Mood disorders 27 F50-F59 Associated physical/psychological disorders 2 F60-F69 Personality disorders 2 F70-F79 Learning disability 2 F80-F89 Psychological development 3 Non-specific 5/24/2017 6 Dr M Claire Royston 13 n = 233 Assessed risk 5/24/2017 Dr M Claire Royston 14 Categories of drug authorised 5/24/2017 Dr M Claire Royston 15 n = 233 Number of drugs authorised 5/24/2017 Dr M Claire Royston 16 SOAD visits to SCT – BNF limits 5/24/2017 Dr M Claire Royston 17 The CTO experience A legal mechanism by which people with mental health problems who need treatment are compelled to submit to treatment on an outpatient basis 5/24/2017 A legal intervention designed to benefit persons with serious mental illness who need ongoing psychiatric care and support to prevent relapses, hospital readmissions, homelessness or incarceration but have difficulty following through with community-based treatments Dr M Claire Royston 18