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.
16 thoughts on “How can Community Treatment Orders still be justified?”
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Your argument is compelling.
Do we know what the costs to the health service are of the side effects produced by forced continuance of the ‘antipsychotic’ drugs? Is this a case of the mental health services believing they are lowering their costs by simplifying treatment, whilst other parts pick up the bill dealing with the physiological problems created? Perhaps a useful, albeit rather dispassionate, study could look at cost/benefits in financial terms?
Some costs savings are mentioned here:
However, this article contains two other studies that show the evidence for CTOs is not effective – therefore it seems odd that they estimate cost savings of £8M to £48M due to reduced hospital stays.
Perhaps, this cost savings estimate is proof that treatment in hospital is just as ineffective as CTOs!
I found outpatient commitment to be harder on me in some ways than hospitalization. I worked so hard to get to a place where I could live on my own again. I did my best to create a sanctuary and this was violated by my “treatment team” coming with my biweekly antipsychotic injections. Knowing that I was only “allowed” to live on my own in exchange for drug treatment didn’t do much for me or for the therapeutic relationship with my doctor. Thankfully, that’s all over now.
My sense is that outpatient commitment allows psychiatry to capture many, many more people than could be hospitalized and I believe the already lax standards slip further. I have thought from to time that there might be a window to civil disobedience here — if everybody rejected outpatient drugging at the same time, there simply would not be enough hospital beds to hold all the “offenders.”
There are two other studies that show that CTO’s are not effective:
It’s not just anti-psychotics that can go on a CTO, but lithium and valproate too. For mania, Valproate is the same as placebo for long term prevention of mania:
There is a logical fallacy that Psychiatrists use despite no evidence of long term benefits (and evidence of harm) of such drugs:
1) We have to do something; 2) This (e.g. Valproate) is something; 3) Therefore, we have to do this
It’s a bit like the logical fallacy:
1) All cats have 4 legs; 2) My dog has 4 legs; 3) Therefore, my dog is a cat
Surely, if Psychiatry claims to be a legitimate medical profession it must be evidence based! There is no evidence of chemical imbalance theories, yet this does not stop them for prescribing harmful drugs in the long term. I’m not anti-drugs, as there is a place in the short term for them (particularly minor tranquilisers).
In the US, some states have AOT (Assisted Outpatient Treatment) laws. Here’s a very interesting article about them, which is about homeless people but makes some really key points:
The above article raises ethical issues e.g. why do we treat mental health service users worse than violent criminals, who do not have to be forcibly given a chemical lobotomy when out of prison!
It’s a bit like the laws that gave homosexuals the option of prison or chemical castration in the 50s, which resulted in Alan Turing (inventor of computing and code breaker in Bletchly Park) injecting an apple with cyanide and taking a bite in order to commit suicide (hence the logo used by Apple). Of course, homosexuality used to be listed in the DSM as a mental disorder and is one of the few things to ever be removed from the DSM.
Here’s some more information about mental health law for CTOs:
I believe that legally you have to agree to be on a CTO, but you can be blackmailed into doing it rather than staying in hospital.
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I have personally been subjected to these Community Treatment Orders more than once; and, as described in the article, I had to get a lawyer to represent my interests at a Tribunal in Edinburgh. After about six months on the CTO and living in the community, I successfully managed to get the CTO rescinded. Community Treatment Order sounds nice when in fact my usual expansion of the abbreviation is compulsory treatment order. At the moment I am in the process of reading Dr Moncrieff’s new book The Bitterest Pills and, rather disturbingly it has confirmed many of my darkest suspicions.
I was on a cto as well. The idea of a cto in theory to me makes some sense but it’s the way it’s implemented that is so unfair at least in Canada. For instance they are only supposed to put you on one if you don’t have the “mental capacity” to make your own decisions — when people argue about it they give examples of someone being delusional and wanting to cut off their arm and they argue that professionals should have the ability to medicate this person — and that seems reasonable. But in my case I ended up in the hospital for a failed suicide attempt and after a couple weeks in the psych ward I no longer wanted to commit suicide. Still they put me on a CTO and I lost my appeal even though I’m a reasonably intelligent person — I have a masters degree in physics at least — that wasn’t delusional. It wasn’t until almost two years later that I got off the CTO (I gave up appealing after the first year). It seems so unfair because what is a fair test of mental competence? I was told I had to be on the medication for a year to make a competent decision about its effects. But I don’t think I need to take something I hate for an entire year to learn about it. I was also told if you are mentally ill you are not competent as well but this isn’t fair at all.
I’m on a CTO as well. I was hospitalized September through December 2014 for mania which I certainly was suffering from. However, I recovered and now I’m stuck with Risperdal so I can “stay well.” So if I’m sick or if I’m well, they’ve got me forcibly drugged. I see no end in sight.
I found it surprising that the public opinion is that a schizophrenic (couldn’t find surveys on other mental illnesses) should not be allowed to make their own decisions even if they are doing well — most people really aren’t concerned with our rights or the suffering that being on medication causes.
And a large part of the problem is that many of the side effects of the antipsychotics aren’t recognized. For instance look at the list of side effects people report for invega http://www.askapatient.com/viewrating.asp?drug=21999&name=INVEGA who would take a drug willingly that causes these things? A lot of these side effects though aren’t listed on the warning sheet for the drug. I experienced severe depression, bad memory, trouble expressing problems/ideas to people and my doctor said they were due to my illness even though I didn’t have them before the medication and after I stopped taking the meds and all these symptoms went away his argument is then that I imagined everything… he thinks antipsychotics make people smarter.
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I’m on a CTO… it’s the worst thing in the world. How do psychiatrists think they’re doing a normal job, when they’re forcing chemical labotomy on mostly healthy people (I imagine most of us are healthy)
Also, this type of power in the hands of the wrong people is scary. For instance, my nurse, knowing how awful it is to be forced to alter medication in a way that would physically and mentally harm someone, is always going against me and the things I research. It seems he actually gets off on different drugs doing harm to me, so he’ll argue i need to ‘stick with’ the bad side effect etc.. He knows his power, it’s scary as hell to have things forced on you which cause harm, and you need the approval of incompetent nurses and doctors to stop it.
I had a CPN and constant contact with mental health services. My consultant of 18 years unfailingly protected my right to be informed and to consent. He twice over-ruled registrars who told me they would use a section to give me ECT, despite believing ECT would help, to allow me to make my own decision, no in each case. He only used a section once in my care, which was for ECT, when my near-catatonic state resulted in approachingly-dangerous dehydration. He reversed it as soon as he believed capacity had returned. I consented to the treatment for a while but, when I told him I would refuse further ECT he simply commented that that was up to me.
2014 I moved back to my home city. I was refused a CPN, not on clinical grounds, but because they did not have enough. Contact with mental health services stops between crises. Following a recent urgent referral from my GP, a member of the ‘intensive team’ has just visited, with an accompanying student. I told my GP (always patient and understanding) of my decision to stop my medication as I wanted to induce a state of depression as the only means of achieving a suicidal state. I said I knew what I was doing, so no one could stop me. He expressed doubt, saying he had never known me speak or behave like this (I haven’t,) but added he did not want it to reach a stage where others felt they should make decisions for me. When I admitted I had decided to stop medication, the nurse visiting commented, ‘as is your right’. I refused to explain my reasons. On leaving, the nurse asked if I wanted their help, adding that it would depend on my complying with medication; so much for my rights. Since I refused to agree to be coerced, whatever .for, as the price of receiving support. I have not been admitted, so presumably a CTO cannot be applied – ?? Who needs them anyway, with these tactics.
Having been under the care of my principled consultant in Oxford, I have never really appreciated why so many people resent psychiatric medical care. I’m beginning to learn.
Re previous comment: there should be a comma after ‘help’ in the second sentence, without which the semantics are unclear and misleading. Please insert.
I inserted the comma. Thanks for sharing your experiences.