Community Treatment Order: Identifying the need for more evidence based justification of its use in first episode psychosis patients
Introduction
The early phase of psychotic disorders has received increasing attention over the last decades (Marshall and Rathbone, 2011). Different intervention programs that target this early phase of the illness have been developed and assessed (Garety et al., 2006, Gleeson et al., 2013, Petersen et al., 2005). One of the main aims of such programs is to reduce the duration of untreated psychosis (DUP), because of the association between a longer DUP and poorer outcome (Boonstra et al., 2012, Golay et al., 2016, Penttila et al., 2014). Disengagement from services and poor adherence to treatment has been identified as factors that are likely to limit the effect of early intervention programs (Conus et al., 2010c, Garety et al., 2006).
There is an absence of evidence regarding the effectiveness of Community Treatment Orders (CTOs) (Kisely and Campbell, 2014). Studies that addresses the topic have been questioned because of specific bias such inclusion criteria or protocol violation (Burns et al., 2013a). In this context, CTOs are often considered by specialists as useful tools to reduce disengagement and improve adherence to treatment (Mustafa, 2015). As a reminder, the concept of a CTO was developed in several jurisdictions and was first commonly used in the US in the 1960s and 70s. They were quickly adopted by other countries, especially in the English speaking world (Hiday, 2003). By authorizing outpatient care within the structure of a CTO, the aim was to offer a less restrictive alternative to involuntary hospitalization. It was hoped that CTO would make it possible to keep people in care outside of hospital, to avoid any decline in their state of health and their social situation, and crucially, to limit recourse to institutional placements (least restrictive CTO). Several jurisdictions like most of the US states, Australia or New Zealand further adapted their legislation to authorize the use of CTO on a preventative basis (preventative CTO).
Victoria was the first Australian state to introduce CTO in 1986 (Power, 1999). This new form of compulsion has been implemented in the context of deinstitutionalised services and well-developed networks of community mental health teams (Churchill et al., 2007). The criteria for a CTO required that: (a) the person suffered a mental illness; (b) a risk to self or other people existed; (c) the person refused treatment or his or her consent was unavailable; (d) there was no less restrictive alternative for treatment; and (e) immediate and adequate community treatment or care was available (Dawson, 2005).
To our knowledge, the use of CTOs for first episode psychosis (FEP) patients involved in a specialized youth-specific early intervention program has never been studied. Considering the importance of the restriction it imposes on patients, it is crucial to study if it has a positive impact on patients' outcome. The aims of the study were to: (i) determine the frequency of CTOs in a large representative sample of FEP patients; and (ii) to compare pre-treatment, treatment and outcome characteristics of FEP patients who were put on a CTOs during treatment at a specialized early intervention program with those of patients who were not exposed to CTOs.
Section snippets
Patient sample
This paper is based on a file audit study (FEPOS; First Episode Psychosis Outcome study) (Conus et al., 2007). The initial sample comprised a population-based cohort of all the 786 FEP patients consecutively treated at the Early Psychosis Prevention and Intervention Centre (EPPIC) between January 1998 and December 2000. EPPIC is a comprehensive program for young people aged between 15 and 29 years and experiencing their first episode of psychosis (McGorry et al., 1996). The catchment area
Frequency of CTO
19.2% (n = 127) of the patients were placed under CTO at some point during the 18 months of treatment.
Pre-treatment variables
Pre-treatment variables are presented on Table 1. Patients under CTO were significantly more likely to be male (OR = 1.62, p = 0.030) and had fewer years of education (OR = 0.83, p = 0.005). They showed a lower premorbid functioning (OR = 0.96, p < 0.001) and a longer duration of untreated psychosis (OR = 1.33, p = 0.007). Patients under CTO were less likely to have a history of suicide attempt (OR = 0.90, p =
Discussion
To the best of our knowledge, this is the first study exploring the use of CTOs among FEP patients. Our data analyses led to four main findings.
First, the percentage of patients who were under CTO at least once over the 18 months treatment period was relatively high. Indeed, the 19.2% rate that we observed in our sample contrasts with the significantly lower rates recorded over the same period by the Victorian Psychiatric Case Register where information about all psychiatric inpatient admissions
Contributors
M Lambert and P Conus designed the study and wrote the protocol.
S Morandi managed the literature searches and analyses.
P Golay and SM Cotton undertook the statistical analysis, and.
S Morandi and P Golay wrote the first draft of the manuscript.
S Morandi, P Golay and P Conus revised the manuscript.
All authors contributed to and have approved the final manuscript.
Role of the funding source
FEPOS was supported by an unrestricted investigator initiated grant from Eli Lilly Australia.
Conflict of interest with respect to the study and manuscript
Prof. Dr. Martin Lambert: Data of the present paper were collected within a large outcome study in first-episode psychosis at the Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne Australia. One part of the study was the comparison of Olanzapine and Risperidone in first-episode psychosis, which was financially supported by Eli Lilly Company Australia with 60.000 Australian Dollar for Prof. Dr. Martin Lambert as primary investigator of the study. Therefore, Eli Lilly
Acknowledgment
Prof. Cotton is supported by a National Health and Medical Research Council Career Development Fellowship (APP1061998).
References (36)
- et al.
Duration of untreated psychosis and negative symptoms - a systematic review and meta-analysis of individual patient data
Schizophr. Res.
(2012) - et al.
A cluster analysis of people on community treatment orders in Victoria, Australia
Int. J. Law Psychiatry
(2006) - et al.
Community treatment orders for patients with psychosis – authors' reply
Lancet
(2013) - et al.
Community treatment orders for patients with psychosis (OCTET): a randomised controlled trial
Lancet
(2013) - et al.
Rate and predictors of service disengagement in an epidemiological first-episode psychosis cohort
Schizophr. Res.
(2010) - et al.
Duration of untreated psychosis: impact of the definition of treatment onset on its predictive value over three years of treatment
J. Psychiatr. Res.
(2016) Diagnostic and Statistical Manual of Mental Disorders
(1994)- et al.
Do community treatment orders for mental illness reduce readmission to hospital? An epidemiological study
Soc. Psychiatry Psychiatr. Epidemiol.
(2006) - et al.
- et al.
The first-episode psychosis outcome study: premorbid and baseline characteristics of an epidemiological cohort of 661 first-episode psychosis patients
Early Interv. Psychiatry
(2007)
Pretreatment and outcome correlates of past sexual and physical trauma in 118 bipolar I disorder patients with a first episode of psychotic mania
Bipolar Disord.
Pretreatment and outcome correlates of sexual and physical trauma in an epidemiological cohort of first-episode psychosis patients
Schizophr. Bull.
Community Treatments Orders: International Comparisons
Psychiatric diagnostics according to the 10th revision of the International Classification of Diseases (ICD-10)
Nervenarzt
Early psychosis in the inner city: a survey to inform service planning
Soc. Psychiatry Psychiatr. Epidemiol.
Specialised care for early psychosis: symptoms, social functioning and patient satisfaction - randomised controlled trial
Br. J. Psychiatry
A randomized controlled trial of relapse prevention therapy for first-episode psychosis patients: outcome at 30-month follow-up
Schizophr. Bull.
ECDEC Assessment Manual for Psychopharmacology, Revised
Cited by (7)
Rates, determinants and outcomes associated with the use of community treatment orders in young people experiencing first episode psychosis
2019, International Journal of Law and PsychiatryCitation Excerpt :Few studies have assessed CTO usage in younger people in the early stages of emerging mental health disorders. A study of youth aged 15–29 presenting to a Victorian early psychosis service with first episode psychosis (FEP) found a high rate of CTO use, with 19.2% of the individuals subject to a CTO during an 18-month period, however this study included individuals who attended services in 1998 to 2000 (Morandi et al., 2017). Given the significant impact involuntary treatment can have on an individual's autonomy, the high CTO rate identified in this study reiterates the need for further, more current, information in this population.
Community Treatment Orders use Among Persons With a First Episode of Psychosis in Quebec
2023, Canadian Journal of PsychiatryA systematic review and meta-analysis of predictors and outcomes of community treatment orders in Australia and New Zealand
2021, Australian and New Zealand Journal of PsychiatryCommunity treatment orders: The evidence and the ethical implications
2018, Critical Perspectives on Coercive Interventions: Law, Medicine and Society