Compulsory Community Treatment (CCT) otherwise know at Community Treatment Orders (CTOs) are highly controversial. They can give clinicians the legal power to enforce certain conditions for service users whilst living in the community. These can range from recall to hospital, compliance with medication or treatment plans (e.g. contact or appointments).
There are differences in how Compulsory Community Treatments are enacted across the international countries that have adopted them (mainly Western ones). Broadly speaking, they do not appear to influence the outcome measures that are often selected in trials.
You can read about previous research on Community Treatment Orders in these elf blogs.
As part of the recent Independent Review of the Mental Health Act, the new NIHR Mental Health Policy Research Unit was asked to review the effectiveness of Compulsory Community Treatment (CCT) in reducing readmission and length of stay in hospital and increasing community service use and treatment adherence.
Research into controversial Community Treatment Orders has failed to find any significant effect on inpatient services.
Methods
The reviewers undertook a systematic review, but took a broader approach than previous ones. They searched three electronic databases. They focused on quantitive evidence from trials and other non-randomised studies, including studies comparing outcomes pre- and post- the implementation of CCTs, and studies comparing groups with and without CCTs during the same time period. The inclusion of naturalistic studies was the main change from the previously published systematic reviews.
The review protocol is available online for those who wish to read more about how this study was carried out.
Results
Forty-one studies were included in the review. These focused on readmission (n=30), hospital bed days (n=16), community services (=14) and adherence to medication (n=5).
| Study design | Outcomes | Effect size | Standard mean difference (SMD) |
| Pre-Post comparisons | Re-admission | Large | 0.8 (CI: 0.53 to 1.08) |
| Use of community services | Large | 0.83 (CI: 0.46 to 1.21) |
|
| Treatment adherence | Large | 2.12 (CI: 1.69 to 2.55) |
|
| Length of stay | Medium | 0.66 (CI: 0.46 to 0.85) |
|
| CCT vs no CCT (RCTs & natural experiments) | Re-admission | -0.14 (CI: -0.41 to 0.14) |
|
| Use of community services | Moderate | 0.38 (CI: 0.19 to 0.58) |
|
| Treatment adherence | 0.91 (CI: -0.70 to 2.51) |
||
| Length of stay | 0.13 (CI: -0.08 to 0.34) |
Adapted from tables 2 and 3 of the original paper.
This review found “no consistent evidence that CCT reduces readmission or length of inpatient stay, although it might have some benefit in enforcing use of outpatient treatment or increasing service provision, or both”.
Conclusion
The authors concluded:
Before and after comparisons showed improvements across all outcomes, but contemporaneous comparisons (both randomised and non-randomised) showed little to no effect on readmission to and length of stay in hospital, or treatment adherence. In contemporaneous comparisons, some evidence supported increased use of community services with CCT, suggesting the treatment might be effective in increasing service provision or treatment attendance, or both. Treatment adherence was not consistently reported. Therefore, our results are mixed, but more methodologically robust designs indicate that CCT does not, as intended, reduce readmissions to or length of stay in hospital.
Those with lived experience concluded:
As service users and carers, we are not inspired by measures of readmissions and inpatient bed-days; we want to know what difference interventions make to the quality of people’s lives and wellbeing. Although data on such outcomes are disappointingly missing from the literature, the evidence that researchers have analysed in this systematic review still paves the way for a prompt review of the use of compulsory community treatments (CCTs). We hope that future work will address the glaring omissions in existing data that have been highlighted by this study….For the moment, this study, like all previous studies, suggests that CCTs have little effect on inpatient services, but have some effect on the use of community services. But would coercion be needed if people could easily access appropriate community services? And also, how many studies coming to the same conclusion does it take before action is taken?
“How many studies coming to the same conclusion does it take before action is taken?”
Discussion
It is welcome that the authors have taken a broader approach to include more studies in this review than previous systematic reviews. The distinction between naturalistic studies and randomised controlled designs does provide some interesting differences, which could be further explored. It may very well be that the naturalistic studies reflect the real world clinical population better than controlled studies that often have strict inclusion/exclusion criteria than the normal population.
The authors have taken a conservative view of effectiveness. It may be that for some people CCT appear to encourage engagement with community services and may help maintain mental health enough to stay out of hospital. However, this needs to be balanced with the deprivation of liberty associated with CTOs, which has clearly been a focus of the independent review of the Mental Health Act. Clearly, further testing will be needed to see if the changes suggested by this review will lead to better outcomes for patients.
It is important to remember that these studies focus on the same medically driven outcome criteria as most previous research in this area. We do need to discuss the rationale for selecting these criteria instead of other important things like quality of life. The lack of reviews on service user/carer perspectives of Compulsory Community Treatment is striking, and it makes sense for this to be an area of focus for the new NIHR Mental Health Policy Research Unit.
Given that CCTs do not appear to be effective, similar research about the effectiveness of treatment orders linked to home office restrictions for offenders with mental health problems (as they move into the community) is desperately needed. There appeared to be no discussion of these community orders in the latest review.
We need more research exploring service user/carer perspectives of Compulsory Community Treatment.
Links
Primary paper
Barnett P, Mathews H, Lloyd-Evans B, Mackay E, Pilling S, and Johnson S (2018) Compulsory community treatment to reduce readmission to hospital and increase engagement with community care in people with mental illness: a systematic review and meta-analysis. The Lancet Psychiatry, 5, 12, P1013-1022, Dec 2018.
Other references
Community treatment orders still don’t work at 36 months: OCTET trial follow up
Photo credits
- Photo by Artyom Kulikov on Unsplash
- Jwslubbock [CC BY-SA 4.0], from Wikimedia Commons
- Jean-Etienne Minh-Duy Poirrier CC BY 2.0
Whilst agreeing with the research conclusions on the basis of personal experiences, IMHO CTOs are not used as a way to reduce readmission or improve patient outcomes, to my mind the research is asking the wrong questions.
The first questions that should be asked are: (a)why are CTO used so extensively and (b) are they being used appropriately
My belief is (a) they are used as a convenience for bed management and (b) they are NOT being used appropriately in many cases