CTOs do not work...and that's according to the evidence base
treatment orders will help protect the public from mentally people
who kill, says the government. But what of the evidence for such
a claim, asks Adam James?
assessing psychiatric clinical treatments "evidence-based"
is the mantra. Evidence-based practice underpins every clinical
guideline and initiative from the National Institute for Health
and Clinical Excellence and the National Institute for Mental Health.
Before being approved, the mantra dictates, every psychiatric drug
and psychological therapy must be validated by dozens, if not hundreds,
of randomised-controlled trials.
turn, then, to the government’s plans for community treatment
orders (CTOs). In what is part of the biggest shake up of mental
health law for more than 20 years, so-called "revolving door"
patients could, when released from a hospital section, be then be
ordered take their psychiatric medication while living in the community.
It’s a key measure by the government in its new mental health
bill to try and reduce the 50 or so annual homicides (out of a total
of 500-600) committed by the mentally ill. But what of the evidence
base supporting the effectiveness of CTOs? Well, no such supportive
evidence base exists.
According to Tony Zigmond, the Royal College of Psychiatrists' spokesman
on the government’s plans to amend the laws determining how
and when patients should be compulsory detained, there is, actually,
only one published review on CTO effectiveness. It’s a Cochrane
review published last year. The review aimed to examine the “clinical
and cost effectiveness of CTO treatment for people with severe mental
illness.” Reviewers found “only two” relevant
randomised-controlled clinical trials. These two trials both focused
on patients in the USA subjected to 416 court-ordered ‘outpatient
commitments’, the American equivalent to CTOs.
did the reviewers conclude? Firstly, they said CTOs are neither
an effective alternative to standard care, nor are they cost effective.
Secondly, CTOs had no clinically meaningful benefit to a patient's
social functioning, mental state, quality of life or satisfaction
with care. Thirdly, CTOs would have to be used on 85 patients to
avoid one admission, and 238 to avoid one arrest, stated the reviewers.
can’t be clearer than that. According to the evidence base,
CTOs are not clinically useful. Or, as Zigmond puts it, CTOs are
inclusion of CTOs in the mental health bill to “protect mental
health patients and the public” came on the heels of an “independent”
review of 25 homicides by people diagnosed with a severe mental
author, Tony Maden, professor of forensic psychiatry at Imperial
College, London, investigated what went wrong in the patient care
and treatment in each of the killings. One of his recommendations
was that CTOs be introduced “to allow compulsory treatment
in the community of patients with a serious mental illness and a
history of violence and non-compliance” So, what was his evidence
base for this CTO endorsement? Well, none was actually included
in his review. Moreover, Maden admits he has not even read the Cochrane
of the government’s claim that Maden’s review was “independent”?
Maden is an advocate of CTOs and a “risk-based” assessment
approach to deciding whether or not a patient should be compulsory
detained and treated. This is slightly different to Zigmond's view,
for example. While Zigmond is not “in principle” opposed
to CTOs he fears that, in England and Wales, CTOs could be administered
with insufficient checks and balances. Unlike Maden, Zigmond supports
the introduction of a capacity test (whereby a patient must be judged
to lack capacity before being compulsory treated whether in hospital
or the community) as enscribed in Scottish law which has been implementing
CTOs since October last year.
Maden admits his review was tailored towards his conviction that
the Home Office and Department of Health are not going to back down
from introducing CTOs. Ministers are also, says Maden, not going
to introduce a capacity test. “The government is just not
going to do it,” Maden told me.
Controversially, Maden also says it’s futile for mental health
professionals to oppose the government. Instead, says Maden, they
should help “work towards finding the best way of having that
sort of legislation [the mental health bill]”
the politically-charged debate of whether to increase compulsory
treatment powers over those diagnosed with a mentally illness, such
words ring of conviction, not “independence” (if ever
such a concept is applicable in mental health and psychiatry).
And without a supportive evidence base the only conclusion we can
arrive at is that CTOs are a product of a politically expedient
conviction that CTOs will keep the mentally ill less ill and this
will, in return, reduce homicides. But, I repeat, there's no evidence
base to support this conviction.
James is the editor of psychminded.co.uk
review of community treatment orders
Dec 1: Government
presses ahead to force some psychiatric patients to take medication
in community - plans in new mental health bill
Nov 9, 2006: Are homicides
by people with mental health problems preventable? Tony Maden
believes recommendations he submitted to the government could result
in a cut in homicide rate by psychiatric patients of 10 per cent
in five years. Is he realistic?
11, 2005: We can do a power of good - Many clinical psychologists
welcome the draft mental health bill because it would give them
extra powers, such as preventing the use of ECT or the over-medication
of patients. Moreover, argues Peter Kinderman,
it's time clinical psychologists stopped clinging to the myth that,
at present, they have no power
something important to say? Send us your
comment of 800 words.
Contact details here
do you think? Email your comments on the above
article to the editor using the form below. Selected comments will
© 2001-7 Psychminded Limited. All
about this article