Community Treatment Orders: relationship to clinical care, medication compliance, behavioural disturbance and readmission

Community Treatment Orders (CTOs), in use inNew South Wales, Australia since 1991, are intendedto reduce the rehospitalisation rate for patients whohave an established history of exacerbation of symp-toms due to non-compliance with treatment, particu-larly treatment with antipsychotic medications. It ishoped that CTOs will encourage patients to complywith the maintenance phase of treatment and soremain outside hospital long enough to experiencethe positive aspects of social and community life that

Community Treatment Orders: relationship toclinical care, medication compliance,behavioural disturbance and readmission

Kevin Vaughan, Neil McConaghy, Cherry Wolf, Craig Myhr, Terry Black

Objective: The objective of this study was to investigate the readmission rate, andthe level of patient disturbance and community care associated with readmission following Community Treatment Orders (CTOs) in New South Wales, Australia.Method: The readmission rates of all patients given CTOs within a 4-year periodand a matched comparison group were investigated. The following factors were com-pared before, during and following a CTO: medication non-compliance, number ofclinical services and duration of disturbed behaviour preceding hospitalisations.Results: Of 123 patients on CTOs (mean length, 288 days; SD, 210 days), 38 werereadmitted during the CTO, the majority in the first 3 months and a further 21 patientswere readmitted following termination of the CTO. Evidence of lower severity ofillness in the comparison patients prevented meaningful evaluation of the readmis-sion rates of the two groups. While on CTOs, patients receiving depot medicationsshowed high compliance and a significantly reduced readmission rate compared withthat of patients receiving oral medications. In the 2 months prior to hospitalisationsduring CTOs, compared with those before or after CTOs, patients received morefrequent consultations and showed a shorter duration of medication non-complianceand disturbed behaviour. The level of services in the 3 months following dischargewere comparable for patients on CTOs and the comparison group.Conclusions: CTOs may reduce rehospitalisations by use of depot medication.Earlier and possibly more frequent readmissions in the CTO group shortened thedisturbance associated with illness recurrence. It would appear that to establish acontrol group with equivalent severity of disorder necessary to evaluate the impact ofCTOs requires a random allocation design.Key words: Community Treatment Orders, disturbed behaviour, rehospitalisation,schizophrenia.

Australian and New Zealand Journal of Psychiatry 2000; 34:801–808

Kevin Vaughan, Senior Clinical Lecturer, Department of PsychologicalMedicine, The University of Sydney (Correspondence); Cherry Wolf,Administrative Officer; Craig Myhr, Clinical Nurse Specialist; TerryBlack, Computer Analyst

Department of Mental Health, Hornsby Ku-Ring-Gai Hos-pital, Hornsby, New South Wales 2077, Australia. Email:[email protected]

Neil McConaghy, Visiting Professor

School of Psychiatry, The University of New South Wales, Sydney,Australia

Received 10 December 1999; second revision 2 June 2000; accepted 7 June 2000.

stability can bring [1]. This is in keeping with a coreprinciple underlying community treatment thatcourt-ordered treatment is the least restrictiveoption in that it ultimately reduces the total timespent in hospital. Other potential benefits that couldaccrue from CTOs include fewer episodes of vio-lence and self-harm, less social and occupationaldisability and less family burden. Despite thesepotential benefits, many psychiatrists in the USAregard CTOs as unconstitutional [2] and the use ofCTOs are in conflict with the guidelines of theAmerican Psychiatric Association [3]. In the UK the inability to allow the enforced delivery of medi-cations to patients is regarded by many as renderingCTOs ineffective [4].

Swartz et al. [5] reported an unpublished recentoutpatient commitment study in New York City thatfound no significant differences between groupsunder voluntary or court-ordered treatment in hos-pital readmissions or other outcomes. The bestquality study in the area of CTOs comes from NorthCarolina [5] where a random-allocation, controlledtrial of Community Treatment Orders failed todemonstrate an overall impact on readmission. Apost-hoc analysis found that CTOs maintained for atleast 180 days when combined with a higher fre-quency of outpatient services (> 6/month) wereassociated with a reduced readmission rate. In thatstudy, CTOs could not enforce medications againstthe patient’s will and no information was providedon medication compliance or types of medicationsprescribed. The lowered readmission rate associatedwith a high frequency of outpatient services and aperiod of 180 or more days on a CTO does not establish causality. Patients on longer orders are aselected group and a high level of patient–staffcontact could independently predict a better out-come. However, the study raises the possibility thatprolonged increased contact may prevent readmis-sions by inducing a more robust remission or byearlier intervention during exacerbations.

Studies such as that of Swartz et al. [5] empha-sise that CTOs are best seen as complementing casemanagement, making the patient more accessible tocounselling, psychoeducation and rehabilitation.Increased responsibility is also borne by the com-munity services to provide adequate treatment. Tobe effective, CTOs may rely on the adequacy of the community services and their capacity to deliverincreased community care: this may be a crucialvariable to address when evaluating the efficacy of CTOs.

Community Treatment Orders in New SouthWales

Community Treatment Order legislation in NewSouth Wales (NSW) is as favourable and easy toimplement as in any developed society [6]. To obtaina CTO, mental health services are obliged to presenta magistrate or a Mental Health Tribunal with a community management plan, which usuallyincludes requirements to accept medication and toattend outpatient appointments and sometimes re-habilitation programs. Should patients later refuse tocomply with the requirements, the legislation allowsthe Health Care Agency to enforce CTOs. If an oraland written warning to patients of the consequencesof breaching the conditions of the CTOs fails toensure compliance the patients may be brought intohospital, if necessary by the police. There, if theycontinue to refuse medication following counselling,they may be detained as involuntary inpatients andforcibly given medication. Maximum duration ofCTOs was 3 months prior to October, 1997, and 6 months subsequently. Applications for further CTOscan be made to the Mental Health Tribunal prior totheir expiry. Patients have the right to appeal undercertain circumstances. The powers to detain thepatient as an inpatient and to administer medicationforcibly following breach of the order, are the twounusual features of the NSW Mental Health Act thatdistinguish it from the legislation in most countries[7]. The present study attempted to investigatewhether CTOs in NSW reduce hospitalisation and/orinfluence the behaviour and medication complianceof patients prior to readmissions during or after theirreceiving CTOs.

Method

Community Treatment Order group

Hornsby Ku-Ring-Gai Hospital (HKH) MentalHealth Service, in the northern suburbs of Sydney,with a catchment area of 270 000 people, has acommitment to case management and communitytreatment. Hospital records were examined to iden-tify all patients with a diagnosis of schizophrenia,schizoaffective disorder, schizophreniform disorderand atypical psychosis who received CTOs between1 July 1994 and 1 July 1998. Mean follow up was27.7 months (range = 12–60 months). Medicationand rehabilitative treatment plans were determinedfrom the CTO treatment plans and outcomes were

COMMUNITY TREATMENT ORDERS802

determined from rates of rehospitalisation; instancesof breaches of CTOs or changes to medication weredetermined from patients’ records.

Comparison group

Each patient placed on a CTO was matched with a patient discharged without a CTO who resembledthe CTO patient in gender, age within 5 years, andnumber of previous hospital admissions and who washospitalised as close as possible within 12 months ofthe admission in which the counterpart CTO wasmade (referred to subsequently as the index admis-sion). Features of both groups are shown in Table 1.Most members of both groups were male, single, ona disability allowance and living with their parents.

Readmission to hospital

The duration and level of behavioural disturbanceof patients readmitted during or after discontinuationof a CTO were determined from case records andmental health schedules and compared for the periods

prior to the index admission, and to readmissionsduring and following the CTOs. Periods of theirmedication non-compliance were also assessed frominpatient and outpatient notes. Non-compliance wasexamined both for the whole group and separately forpatients receiving depot injections.

Mental health services before admissions

A rater blind to the purpose of the enquiry countedthe number of outpatient services to patients or theirfamilies from doctors and case managers for each ofthe CTO and comparison patients, for each of 3 con-secutive months prior to the index admission andprior to readmissions during or following terminationof a CTO.

Results

In the 4-year period there were 969 patients admit-ted with a diagnosis of schizophrenia, schizoaffective

K. VAUGHAN, N. MCCONAGHY, C. WOLF, C. MYHR, T. BLACK 803

Table 1. Demographic and clinical details of 123 patients who had at least one Community TreatmentOrder (CTO) and matched group

CTO group Comparison group (n = 123) (n = 123)

Male gender (%) 84 (68) 84 (68)Mean age (SD) 36.82 (20.91) 35.46 (11.06)Marital status

Single 96 102Divorced/separated 12 7Married/de facto 12 14Widowed 3

Living circumstancesAlone 26 29Family of origin 64 58Other 26 30Residential service 7 6

EmploymentDisability pension 63 62Unemployed 38 31Home duties 5 5Full time work 10 14Part time work 3 2Student 4 9

Diagnosis (%)Schizophrenia 102 (83) 101 (82)Atypical psychosis 6 (5) 5 (4)Schizophreniform disorder 6 (6) 8 (7)Schizoaffective disorder 9 (7) 9 (7)

Mean number of admissions prior to index admission (SD) 6.24 (5.57) 5.17 (7.45)Length in days of index admission (SD) 32.59* (20.91) 13.87 (16.89)Involuntary legal status during index admissions (%) 108† (88) 46 (37)

*CTO group > Comparison group (t = 7.73 p < 0.001). †CTO group > Comparison group (χ2 = 66.74, p < 0.001).

disorder or schizophreniform disorder, 533 (55%) ofwhom were admitted as involuntary patients under theMental Health Act. After discharge 74% were casemanaged by the HKH Mental Health Service with theremainder either returning to, or referred to otheragencies usually outside of the HKH catchment area.A total of 133 patients (14% of 969) received an initialCTO, of whom 39 received a second, and 13, a third.Ten of the 133 were referred for management to otheragencies and were excluded from further analysis.

The present cohort is composed of the remaining123 patients. The mean continuous CTO length was288 days (SD = 210 days). The matching procedureresulted in two groups equivalent in age, gender,marital status, living circumstances, employment,diagnosis and number of previous admissions. How-ever, the index admission of the 123 CTO pa-tients was more frequently involuntary (χ2 = 66.74,p < 0.001) and longer (t = 7.73, p < 0.001).

Readmission in the Community Treatment Orderand comparison group

Timing of readmissions to hospital of patients whoreceived CTOs and comparison group is reported inTable 2.

Fifty-nine patients (48%) were readmitted in theCTO group and 45 (37%) in the comparison group(χ2 = 3.26, p = 0.07). Almost half of the readmissionsin both the CTO and comparison groups occurred inthe first 3 months (see Table 2). Thirty-six (61%)readmissions in the CTO group were involuntarycompared with 15 (33%) involuntary admissions inthe comparison group (χ2 = 7.8, p = 0.005).

The length of the initial readmission in bothgroups was similar: a mean of 18.4 days (SD = 17.9)in the CTO group and 19.04 days (SD = 20.9) in the

comparison group. Total length of hospitalisation of theCTO patients in the one year prior to and following the making of the CTO was compared in two ways.The number of days the patients spent in hospitalduring the year that followed the date the CTO wasissued and the patient discharged (mean = 12.6 days,SD = 27.9) was significantly less (t = 8.7, p < 0.001)than the number of days (mean = 44.5 days, SD =29.6) they spent in hospital during the year prior tothat date. The latter number of days included the dura-tion of the index admission. When the length of theindex admission was excluded, by determining themean number of days of hospitalisation in the yearimmediately prior to that admission, the number wassubstantially reduced (mean = 9.2, SD = 20.5), butdid not differ significantly (t = 1.22, p = 0.23) fromthe number of days they were hospitalised in the yearthat followed the awarding of the CTO.

Readmission during and after discontinuation ofCommunity Treatment Orders

In the CTO group 38 patients were readmittedduring the CTO and 21 of the remaining 85 werereadmitted after its elective discontinuation. Noadmissions occurred during the first 3 months afterthe discontinuation and only two within 3–6 months.Ten (12%) occurred within 6–12 months of discon-tinuation. Five (6%) occurred within the second yearand 4 (4%) were after 2 years. Perhaps the low re-admission rate (two patients) in the first 6 monthsafter elective discontinuation of CTOs implies thatsome benefits of the CTO are slow to accrue, butmay persist beyond the length of the CTO. After the6-month period following discontinuation, the re-admission rate climbed again.

Readmission and medications

At the start of their period on a CTO, 76 patientswere prescribed depot neuroleptics and 47 oral medi-cations (see Table 3). During the course of the CTO18 (24%) of those receiving depot medications weresubsequently readmitted to hospital compared with20 (43%) of the 47 patients who were prescribed oralmedications (χ2 =4.84, p = 0.03). There was no sig-nificant difference in the readmission rate of thosereceiving typical as compared with atypical oralantipsychotics: 7 (50%) of the former and 13 (39%)of the latter.

Within the comparison group, only 13 patients(11%) were prescribed depot medications of whomsix (46%) were readmitted. This was a similar


Table 2. Timing of readmission in the CommunityTreatment Order (CTO) and comparison groups

after CTO is made

CTO group Comparison groupn (%) n (%)

0–3 months 28 (23) 21 (17)3–6 months 5 (4) 7 (6)6–12 months 14 (11) 7 (6)12–18 months 3 (2) 8 (7)18–24 months 5 (4) 2 (2)24 months + 4 (3) 0Total 59 (48) 45 (37)

readmission rate to that of patients given oral medi-cations (39 admissions, 35%). The trend for a higherreadmission rate with depot medications in the com-parison group compared with the CTO group failedto reach statistical significance (χ2 = 2.84, p = 0.09).

Readmission and medications afterdiscontinuation of Community Treatment Orders

Of the 58 patients on depot medications at termi-nation of the CTO, seven patients moved out of area,12 patients were transferred to atypical antipsychoticmedications, and two patients suicided. Of the 37remaining on depot medication, 14 (38%) were read-mitted to hospital. Seven of these readmissionsoccurred within 8 weeks of abrupt cessation of medi-cations against medical advice. Of the 27 patients onoral medications not readmitted during the CTO,seven (26%) were readmitted following it. Although13 (39%) of the 33 patients receiving atypical anti-psychotics were readmitted while on a CTO, onlyfour (20%) of the remaining 20 were readmitted afterdiscontinuation of the CTO. This could indicate abetter longer-term outcome with these medicationsonce treatment becomes established. Readmissionoccurred only in one of eight patients taking cloza-pine after their CTOs were terminated and it followedimmediately after the clozapine was discontinuedbecause of neutropenia.

Adherence to Community Treatment Orders

Compliance with depot medications while patientswere on CTOs was high. Of the 76 patients prescribeddepot medication, only four were taken off depotmedication. All four were readmitted. In two patients,discontinuation of depot medications was medicallysupervised; one was changed to clozapine to combatnegative symptoms, and haloperidol decanoate was

stopped for another patient who developed thrombo-cytopenia. Two further patients moved out of area toavoid the CTO. Fifty-eight patients were still on depotmedications at the termination of their CTO. Com-pliance with oral medications could not be accuratelydetermined from the case notes. When patients’symptoms increased, clinicians tended to query com-pliance, but patients usually reported they were contin-uing to take their medication.

Community Treatment Order breaches

Orders were breached for three patients during thecourse of the CTO. All three were on a depot medi-cation and although their condition had not deteri-orated, they were brought to the hospital on oneoccasion, where they were given a depot injection,but were not re-admitted.

Level of disturbed behaviour before and duringhospitalisations

The level of disturbed behaviour before hospitalisa-tions was difficult to reliably quantify from case notes,but may be reflected in the need for involuntary admis-sion. The readmissions of the 38 patients while theywere on CTOs compared with their index admissionswere more likely to be voluntary (19 vs 0, χ2 = 22.9,p < 0.001), and showed a trend to require less policeinvolvement (10% vs 29%, NS). They were also morelikely to be of shorter duration (means of 19.4 dayscompared with 34.1 days, t = 2.78, p = 0.007).

Length of noncompliance and disturbedbehaviour associated with the CommunityTreatment Order

The mean number of days of behavioural distur-bance and of non-compliance with medication before


Table 3. Readmission rate in relation to medication prescribed for the 123 patients during the CommunityTreatment Order (CTO) or after termination of CTO

Medication type (n) Readmission during CTO Readmission after termination of CTO*(n = 38) (n = 21)

Oral traditional antipsychotic medications (14) 7 (50%) 3 (43%)Risperidone (11) 3 (27%) 3 (38%)Olanzapine (8) 4 (50%) 0Clozapine (14) 6 (43%) 1 (13%)Depot neuroleptics (76) 18 (24%) 14 (24%)

*Patients readmitted during CTO are not included in the rest of the study. Percentages in this column are of patients remain-ing in the study after termination of CTO.

the index admission and the readmissions during andfollowing the CTO are reported in Table 4.

Prior to the index admission, non-compliance withmedication significantly preceded the onset of dis-turbed behaviour. The duration of both non-complianceand disturbed behaviour occurred for significantlylonger periods prior to those admissions than prior tothe readmissions occurring during the CTOs. In re-admissions occurring during the CTO, non-complianceand disturbed behaviour commenced around the sametime. Prior to the readmissions after discontinuationof the CTO, the period of non-compliance and theperiod of disturbed behaviour increased, with theonset of non-compliance again significantly preced-ing that of disturbed behaviour.

Because the assessment of non-compliance usingoral medications depends greatly on patient andfamily reports and so could be invalid, the same dataas reported in Table 4 for all 59 readmitted patientswere investigated for the 32 patients readmittedwhile receiving depot medication. In patients admit-

ted during the CTO, behaviour disturbance precededthe date where the depot injection was due. Theyshowed a mean of 12.8 (SD = 16.6) days behaviourdisturbance before admission compared with 6.3(SD = 12.6) days non-compliance. Duration of theirmedication non-compliance was much greater beforethe CTO (mean = 117.7, SD = 125.9 days, p < 0.001),as was duration of behaviour disturbance (mean =38.2, SD = 47.4 days, p < 0.01). After discontinua-tion of the CTO the duration of their non-complianceagain significantly increased (mean = 58.9, SD = 50.3days, p < 0.01) and the duration of their behaviourdisturbance showed a trend in the same direction(mean = 25, SD = 27.6 days, NS).

Frequency of consultations prior tohospitalisations prior to, during and followingCommunity Treatment Orders

Table 5 shows that there was a statistically signifi-cant increased mean number of services in the


Table 4. Length of medication non-compliance (MNC) and behavioural disturbance (BD) of readmittedpatients on Community Treatment Orders (CTO) prior to index admissions (pre-CTO), readmissions during

the period of the CTO (CTO) and readmissions after discontinuation of the CTO (post-CTO)

Pre-CTO CTO Post-CTO(n = 59) (n = 38) (n = 21)

Mean number of days of BDbefore admission (SD) 38.27 (47.42) 9.71 (13.75) 26.18 (29.65)Mean number of days of MNCbefore admission (SD) 66.86 (107.73) 9.18 (11.35) 53.47 (47.47)

Significant pre-CTO MNC > pre-CTO BD (t = 3.52, p < 0.001). Significant pre-CTO BD > CTO BD (t = 4.6, p < 0.001).Significant pre-CTO MNC > CTO MNC (t = 7.68, p < 0.001). Significant post-CTO BD > CTO BD (t = 2.61, p = 0.01).Significant post-CTO MNC > CTO MNC (t = 4.85, p < 001). Significant post-CTO MNC > post-CTO BD (t = 4.75, p < 0.001).

Table 5. Frequency of services (mean) during the 3 months preceding hosptialisations, before, duringand after Community Treatment Orders (CTOs)

Outpatient services Outpatient services Outpatient servicesper month before per month before per month beforeindex admissions readmissions readmissions

(SBCTO) during CTOs (SDCTO) after CTOs (SACTO)3 months before (–3) (SD) 1.72 (2.94) 3.2 (3.65) 2.3 (2.43)2 months before (–2) (SD) 1.58 (2.59) 5.67 (3.65) 2.25 (1.73)1 month before (–1) (SD) 3.02 (4.58) 7.93 (5.94) 3.55 (2.36)

Significant –2.SDCTO > –2.SBCTO (t = 6.49, p < 0.001). Significant –1.SDCTO > –1.SBCTO (t = 4.61, p < 0.001).Significant –2.SDCTO > –2.SACTO (t = 4.04, p < 0.001). Significant –1.SDCTO > –1.SACTO (t = 3.25, p < 0.01). Significant –1.SDCTO > –3.SDCTO (t = 3.6, p = 0.007).

2 months before hospitalisations during CTOs ascompared with those before or after CTOs. The CTOgroup showed a significant increase in the number ofconsultations received for each month from the thirdto the first month before readmission. Trends for anincrease in number of consultations in the 3 monthsbefore the index admission and that following a CTOdid not reach statistical significance.

Frequency of outpatient services in CommunityTreatment Order group compared withcomparison group

There was a trend for CTO patients to receive alower number of consultations in the 3 months beforetheir index admission compared with the numberreceived by the comparison group in the equivalentperiod (mean = 2.1, SD = 3.3 vs mean = 3.9, SD =6.89 services monthly, t = 1.7, p = 0.08). The numberof services received by patients monthly for the 3 months prior to hospitalisations while on CTOswere non-significantly greater than those received bythe comparison group prior to the equivalent hos-pitalisations (mean = 5.6, SD = 4.4 vs mean = 3.9,SD = 6.8, t = 1.77, NS). The level of service whenreadmission was not imminent was assessed for thefirst 3 months of CTOs compared with the corre-sponding period for patients not on a CTO. Afterpatients who were readmitted within the first 6 monthswere excluded, the mean number of consultationsreceived monthly by the remaining patients in thefirst 3 months of CTOs was 4.8. The mean numberreceived monthly by the comparison group in the 3 months following their discharge was 5.2 (NS).

Discussion

Community Treatment Orders were issued for 14%of patients hospitalised with a schizophrenia-relateddiagnosis. They were used mostly for male, unmar-ried patients. Of 123 patients given CTOs in thepresent study, 31% were readmitted while the CTOswere active and a further 17% following their termin-ation. Community Treatment Orders were maintainedon average for just over 9 months. During the CTOvery high compliance was found with depot medi-cations. Formal breaching was seldom necessarysuggesting that the threat of breaching was sufficientto promote compliance in most cases. Depot medi-cations conferred significant advantage in terms ofrehospitalisation compared with oral medicationsduring the CTO. However, during the post-CTO

period this advantage was lost due to a lower rate ofrelapse in the oral medication group.

Rehospitalisations occurring during a CTO wereshorter, with less police involvement and involuntaryadmission than the index hospitalisations, suggestingthe patients were admitted at an earlier stage of relapsewhen they were more amenable to treatment. Thisconclusion is supported by the most significant findingof the study that duration of non-compliance and dis-turbed behaviour was reduced in the period prior tohospitalisations during CTOs in the comparable periodprior to the index admissions. After termination ofCTOs admissions once again reverted to the pre-CTO pattern of a longer period of non-compliance and disturbed behaviour prior to hospitalisation. In the 2 months prior to hospitalisation, the number of psy-chiatric services used increased to a significant extentfor patients when on CTOs compared with prior to orafter CTOs. It would seem likely that CTOs enablecloser monitoring of patients and establishment ofmore clinical contact as symptoms of relapse becameapparent. In the patients on CTOs receiving depotmedication who were readmitted, disturbed behaviourpreceded medication non-compliance, indicating thelatter was not a factor in relapse.

Although the comparison group was well matchedto the CTO group in terms of demographic variables,they differed in regard to important clinical variables.Their illness was presumably less severe, in view ofthe shorter duration of their index admissions. Themuch higher percentage having voluntary status atthat admission, consistent with the decision not toapply for a CTO for their management after discharge,indicated that they appeared more insightful andaccepting of a therapeutic alliance.

There was a trend for the CTO group comparedwith the comparison group to receive less care in the3 months prior to the index admission, but not in the3 months prior to the following readmission whenthe former group were on CTOs. This difference pos-sibly resulted from the non-compliance of the CTOgroup prior to receiving CTOs. Interestingly, ofpatients not at imminent risk of relapse, those onCTOs received slightly less services than the com-parison group, at least in the first 3 months after dis-charge from the index admission.

The 6-month readmission rate of 27% in the groupgiven CTOs was comparable to the 23% in the com-parison group and also to the readmission rate of28% in 71 consecutive patients with chronic schizo-phrenia recently reported by Bergin et al. [8]. How-ever, 48% of patients were hospitalised at least once


during or following CTOs as compared with 37% ofthe comparison patients. It is possible a randomisedcontrol group not given a CTO would have a signifi-cantly higher rate of rehospitalisation than the less-severely ill comparison group. The procedure [9–11]of evaluating CTOs by comparing the period patientsspent in hospital following a CTO with the equivalentperiod immediately prior to receiving a CTO appearsquestionable methodologically. A long period of hos-pitalisation is a likely factor determining the seekingof a CTO. In the present study the mean period spentin hospital by patients who subsequently were givena CTO was nearly three times longer than that of thecomparison group and twice as long as the meanperiod of their readmissions following the CTO. Thelonger hospitalisation indicates a more severe phaseof illness, so that some regression towards the meanin the severity of a subsequent episode is possible. Inthe present study when the duration of the indexadmission was included in the duration of hospitali-sation in the year prior to the CTO, the total durationwas significantly greater than the duration of hospitali-sation in the year following the CTO. When it wasexcluded, there was no significant difference.

Community Treatment Orders in this study appearassociated with possibly contrary effects: hospitali-sations appear to have been reduced by the CTOensuring medication delivery particularly of depotmedications, but may have been brought forward oreven increased by earlier intervention during exacer-bations in disturbed behaviour. A great advantage ofCTOs is their ability to reduce the period of thepatient’s disturbed behaviour as it is not necessary to wait until the patient is sufficiently ill to justifyinvoluntary admission. Shorter periods of disturbancebefore readmission may provide benefit by reducingthe associated level of psychosocial havoc includingdamage to key relationships, demonstrated to be amajor determinant of expressed emotion [12], anestablished risk factor for future relapse.

Increased delivery of prophylactic medicationsmay not be the only mechanism that could allowCTOs to reduce rehospitalisations. Remissions maybe made more robust by encouraging patients toaccept social skills training, psycho-education,family therapy, personal therapy, assertive training,stress management, or improved problem solving andother interventions that enhance recovery.

It could be argued that this investigation simplydemonstrates the benefits associated with assertivecase management. But this study suggests that beforeCTOs, patients reduced the frequency of, or withdrew

from, seeing their case managers and doctors, soreducing the efficacy of assertive case management.When patients refused to see mental health workers,they were obliged to withdraw until the level of thepatients’ disturbance resulted in a risk or harm tothemselves or others such that they required involun-tary admission under the Mental Health Act.

This study has all the limitations of a retrospectiveanalysis from case notes and replication in a prospec-tive study would seem of value. The influence of CTOson rate of rehospitalisation could not be determineddue to the lack of comparability of the comparisongroup. It would seem this determination would requirea prospective study using a random allocation design.

Acknowledgements

We are grateful to Tom Burns for his very helpfulcomments on an earlier draft of this paper and for thestatistical advice from Kar Kiat Yeo.

References

1. Mulvey EP, Geller JL, Roth LH. The promise and peril ofinvoluntary outpatient commitment. American Psychologist1987; 42:571–584.

2. Swartz MS, Burns BJ, Hiday VA, George LK, Swanson J,Wagner HR. New directions in research on involuntary outpatient commitment. Psychiatric Services 1995;46:381–385.

3. American Psychiatric Association. Involuntary commitmentto outpatient treatment. Report of the task force on involuntary outpatient commitment. Washington: AmericanPsychiatric Association, 1987.

4. Holloway F. Supervised discharge – paper tiger? PsychiatricBulletin 1996; 20:193–194.

5. Swartz MS, Swanson JW, Wagner HR, Burns BJ, Hiday VA,Borum R. Can involuntary outpatient commitment reducehospital recidivism? Findings from a randomized trial withseverely mentally ill individuals. American Journal ofPsychiatry 1999; 156:1968–76.

6. Hanbridge J, Watt N. Involuntary community treatment in NewSouth Wales, Australia. Psychiatric Bulletin 1995; 19:45–47.

7. McIvor R. The Community treatment order: clinical andethical issues. Australian and New Zealand Journal ofPsychiatry 1998; 32:223–228.

8. Bergin J, Hunt G, Armitage P, Bashir M. Six month outcome following a relapse of schizophrenia. Australian and New Zealand Journal of Psychiatry 1998; 32:815–822.

9. Fernandez G, Nygard S. Impact of involuntary outpatientcommitment on the revolving-door syndrome in NorthCarolina. Hospital and Community Psychiatry 1990;41:1001–1004.

10. Zanni G, deVeau L. Inpatient stays before and after outpatient commitment. Hospital and CommunityPsychiatry 1986; 39:941–942.

11. Bursten B. Post hospital mandatory out-patient treatment.American Journal of Psychiatry 1986; 143:1255–1258.

12. Brown G, Birley A, Wing J. Influence of family life on thecourse of schizophrenic disorders: a replication. BritishJournal of Psychiatry 1972; 121:241–258.


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Community Treatment Orders: relationship to clinical care, medication compliance, behavioural disturbance and readmission