Recently I attended a Mental Health Review Tribunal, set up to review a Community Treatment Order (CTO), as an independent witness. Although I agreed with the doctors who were treating the patient that the individual concerned did have some mental health problems, I was confident that these could be effectively managed without the need for a CTO. Many patients with similar problems are managed without one. The patient in question found the experience of being on a CTO demeaning and degrading and desperately wanted to be free of it.
In preparing my report for the Tribunal, I made a careful study of the patient’s medical notes, and it was clear to me that the antipsychotic medication the patient was being forced to take made no difference to the symptoms or problems. These were present just as much during periods of taking the medication, as during periods without it. It was true that there had been an improvement in aspects of the patient’s situation and behaviour over the last few months, but the CTO had been in place for two years, and it seemed to me that the improvement was likely to be due to changes in social circumstances and a process of maturation, rather than the CTO.
The treating doctors disagreed with me. They felt the improvement was attributable to the enforced drug treatment and other restrictions of the CTO and they insisted that the CTO needed to continue.
Professionals have an inbuilt prejudice towards thinking that what they are doing is helpful. Otherwise we would never have had insulin coma therapy or lobotomy or centuries of bloodletting. That is why randomised controlled trials can be so important in establishing whether an intervention really does what it is thought to do or not.
The OCTET study was a remarkable randomised controlled trial that was set up to test whether being on a CTO really does what it is intended to do; that is whether it keeps people mentally well and out of hospital (Burns et al, 2013). The lead researcher, psychiatrist Tom Burns, has been a long-term advocate of CTOs. The study involved 333 participants who were all considered suitable to go onto a CTO by their psychiatrist after an inpatient admission. They were randomised either to go onto a CTO, or to be managed without one. After one year the two groups showed no difference in terms of the rate of readmission to hospital, which was 36% per cent in both groups. There was also no difference in the total number of days people spent in hospital during follow up, the number of readmissions people had, the number of people having multiple readmissions, the severity of symptoms that people showed or in people’s level of functioning. People who went onto a CTO were subjected to an average of 183 days of compulsory outpatient treatment, whereas people in the non-CTO group spent an average of 8 days in the community under restrictions that predated the introduction of CTOs (the system for leave from hospital while under a Section 3 of the Mental Health Act, known as ‘X17 leave’).
Despite Professor Burn’s previous commitment to CTOs, the study report concluded that there is no evidence that CTOs have any benefits and that they do not ‘justify the significant curtailment of patients personal liberty’ (Burns et al, 2013, p 1627). In presentations around the country, Professor Burns has not shrunk from acknowledging that his previous ideas about the benefits of CTOs were wrong.
So why are CTOs still being used? I mentioned the OCTET study at the Tribunal hearing, and the doctor on the panel was well aware of it, but it made no difference to the Tribunal’s decision. The patient’s CTO was continued.
Professionals like CTOs because they make life easier in overstretched services. Since administration of medication can simply be legally enforced, staff don’t have to spend as much time forging an alliance with patients. If patients relapse, the mechanism to bring them back into hospital is quicker and easier than if they were not on a CTO (and of course therefore there are fewer safeguards against wrongful admission). Moreover, CTOs now seem to be used sometimes as a means to discharge people from hospital before they have fully recovered from the acute episode that led to admission. Underpinning all these practical reasons, however, is a difficulty in recognising that sometimes our interventions might not be as useful as we think.
Tribunals also appear to suffer from the prejudice that things that are done to patients in the name of ‘treatment’ must be a good thing. CTOs are notoriously difficult to challenge. If people are mentally well, this can be attributed to the CTO and used to argue that it should continue, and since people can never prove that they would have remained well without the CTO, the CTO can be justified indefinitely. If, on the other hand, someone is not doing well, then it can be argued that they remain in need of compulsory treatment. In any individual case, it is impossible to know for certain what would have happened had a CTO not been put in place. That is why it is only by doing a study like the OCTET study that we can judge whether CTOs are useful or not.
We should not forget that the treatment people are forced to take by CTOs consists of toxic drugs (antipsychotics) that are known to cause brain damage (tardive dyskinesia) and brain shrinkage with long-term use, as well as weight gain, diabetes, heart disease and sexual dysfunction among other unpleasant effects. I am not saying that the use of antipsychotics is not sometimes justified, but CTOs potentially consign people to a lifetime of exposure to these effects with no evidence that such enforced treatment makes any difference.
The fact that CTOs are still being applied after the OCTET study found that they do not keep people out of hospital, or improve people’s mental health, demonstrates how deeply embedded and influential is the idea that people who are psychiatric patients are ‘sick,’ and need to have whatever treatment the doctor orders. The attitude that led to lobotomy, that meant it was acceptable to sever parts of people’s brains because they were mentally ill and it was called ‘treatment,’ is obviously still with us!
Burns T, Rugkasa J, Molodynski A, Dawson J, Yeeles K, Vazquez-Montez M, Voysey M, Sinclair J, Priebe S (2013) Community treatment orders for patients with psychosis (OCTET): a randomised controlled trial. Lancet 381, 1627-33.