Community treatment orders do not reduce hospital readmissions

Author: Ingrid Torjesen

Community treatment orders (CTOs) are associated with an increased risk of readmission as well as increased time spent in psychiatric hospitals, the first large, observational study* with a control group in England and Wales to look at their effectiveness has found.

The researchers said that their results, which conflict with those from previous uncontrolled studies which have backed use of the orders, should be considered in future reforms to the UK Mental Health Act.

CTOs were introduced in England and Wales under the 2007 amendment to the Mental Health Act (1983). They are a legal order for compulsory monitoring and treatment of people discharged from psychiatric hospitals with serious mental disorders within a community care setting. They also allow quicker readmission to hospital, if necessary, following suspected relapse. Their use has exceeded initial expectation and 5,000 are now used in England each year on average.

For this study, researchers compared 830 patients who were discharged on a CTO with 3,659 patients discharged to voluntary community mental healthcare. The results, published in BMJ Open, show that in the two years following discharge from psychiatric hospital, patients on CTOs spent, on average, 17.3 additional days in hospital and had a 60% greater rate of readmission compared to patients receiving voluntary care. The study also found that the average CTO lasted three years, more than four times longer than initial government projections of nine months.

Lead author Dr Rashmi Patel, MRC UKRI health data research UK fellow at the Institute of Psychiatry, Psychology and Neuroscience at King's College London, said: "[CTOs] were designed to prevent relapse and readmission to hospital for people with serious mental illnesses. In fact, our study suggests that they have the opposite effect, with people on CTOs being more likely to be readmitted and spending longer in hospital. In light of these findings, we need to think carefully about what role (if any) CTOs should play in providing care to people with serious mental illnesses".

Some previous uncontrolled observational studies have reported a reduction in readmission rates in patients on CTOs, however the addition of a control group of patients discharged without a CTO allowed outcomes to be compared more robustly than in previous studies. The researchers said the findings could be due to the tendency for patients with CTOs to have historic relapses and severe symptoms, or to the ease of readmission through the CTO pathway.

Co-author Dr Alexis Cullen, research fellow at the Institute of Psychiatry, Psychology and Neuroscience at King's College London said, "Our findings concur with smaller randomised controlled trials from the UK in showing that readmission rates are not reduced. Importantly, our inclusion of patients treated in forensic psychiatric settings (who have been excluded from previous studies) means that our sample is more reflective of the patients who typically receive these treatments."

*Barkhuizen W, Cullen AE, Shetty H, et al. Community treatment orders and associations with readmission rates and duration of psychiatric hospital admission: a controlled electronic case register study. BMJ Open 2020;10:e035121. doi: 10.1136/bmjopen-2019-035121