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Compulsory supervision failed to reduce readmission rates in psychotic patients

Legislation in the United Kingdom that allows specific conditions to be imposed on mentally ill patients who are at risk for hospital readmission — known as community treatment orders — did not lower the rate of readmission among patients with psychosis.

“There is currently no justification for using [community treatment orders] or mandated community treatment, and we should probably stop doing it,” study researcher Tom Burns, MD, DSc, FRCPsych, of the University of Oxford, told Psychiatric Annals.

 

Tom Burns

Community treatment orders (CTOs), introduced in 2008 in England and Wales, give clinicians and mental health care providers the power to monitor at-risk patients whom they suspect likely to relapse after leaving the hospital and to even recall patients for up to 72 hours for assessment without formally readmitting them. Similar legislation has been introduced in the United States, Australasia and Canada. A number of patient advocacy groups and other organizations have resisted CTOs on the basis that they violate patients’ civil liberties and for the lack of evidence that compulsory supervision actually works.

CTOs differ from the “leave of absence” provision in Section 17 of the UK’s Mental Health Act in that the supervisory periods last for much longer periods of time and the clinician can impose certain conditions on the patient’s discharge, including taking medication and attending assessments.

Burns and colleagues conducted the OCTET trial to test the efficacy of CTOs in reducing hospital readmission rates among 333 patients with a diagnosis of psychosis. Approximately half of the patients received CTOs while the other half was released under Section 17 leave of absence. Both groups received equal treatment for their illness, but patients in the CTO group had an average of 183 days of compulsory supervision vs. 8 days in the Section 17 group.

Results indicated that at 12 months, there was no difference in the number of patients readmitted between the CTO (36%) and Section 17 (36%) groups (adjusted RR=1.0; 95% CI, 0.75-1.33), nor in the time to readmission or the duration of readmissions.

The findings are consistent with two other randomized trials of CTOs. However, the current study represents the largest trial to date.

“The evidence is now strong that the use of CTOs does not confer early patient benefits despite substantial curtailment of individual freedoms,” the researchers wrote.

Disclosure: The researchers report no relevant financial disclosures.