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Question
Question: Are community treatment orders more effective than Section 17 leave in reducing hospital readmissions in people with psychosis?
Patients: In total, 336 adults (aged 18–65 years) involuntarily hospitalised for psychosis. Eligible participants were those who could give informed consent and were suitable for supervised outpatient care.
Setting: Thirty-two National Health Service Mental Health Trusts, UK; recruitment November 2008–February 2011.
Intervention: Hospital discharge on a community treatment order (CTO) or Section 17 leave. CTOs require patients to agree to clinical monitoring and patients can be recalled for up to 72 h for assessment without readmission procedures. Section 17 leave permits patients to leave hospital for hours, days or weeks subject to readmission without further legal procedures.
Outcomes: Hospital readmission over 12 months. Secondary outcomes: time to readmission, total number of readmissions, total days of hospitalisation and clinical symptoms measured with the Global Assessment of Functioning (GAF) and Brief Psychiatric Rating Scale (BPRS).
Patient follow-up: At 12 months, 99% of participants were analysed for the primary outcome and 72% for secondary outcomes.
Methods
Design: Randomised controlled trial.
Allocation: Concealed.
Blinding: Unblinded.
Follow-up period: Twelve months.
Main results
In total, 167 patients were randomised to CTO and 169 to Section 17 leave. There were five deaths during follow-up (three suicides, one accidental drug overdose and one death due to natural causes). At 12 months, there was no significant difference between CTO and Section 17 in the number of patients readmitted to hospital (36% vs36%, RR 1.00, 95% CI 0.75 to 1.33). There were no significant differences between CTO and Section 17 in the time to first hospital readmission (mean 246 days vs 241 days, p=0.755), number of readmissions (mean 1.2 vs 1.4; incident density ratio 0.82, 95% CI 0.58 to 1.16) or total days of hospitalisation (mean 82.2 vs 90.9; incident density ratio 0.90, 95% CI 0.65 to 1.26). The CTO group had more days of total compulsory treatment compared with the Section 17 group (median 255 days vs 102 days, p<0.0001), and more days in the community under legal compulsion compared with the Section 17 group (median 183 days vs 8 days, p<0.0001). There were no significant differences between groups in the mean number of service contacts per month (3.0 under CTO vs 3.9 under Section 17; RR 0.77, 95% CI 0.47 to 1.26). At 12 months, there were no significant differences between groups in GAF (adjusted mean difference −0.86, 95% CI −2.93 to +1.20) or BPRS (adjusted mean difference −1.09, 95% CI −3.25 to +1.07) scores.
Conclusions
For people hospitalised with psychosis, discharge under a CTO does not reduce the rate of hospital readmission within 12 months compared with discharge under Section 17.
Abstracted from
Commentary
The administration of involuntary supervision in community care shows greater within than between variation across jurisdictions and title — eg, “Conditional Release,” “Section 17,” “Community Treatment Order (CTO)” or “Assisted Outpatient Treatment”. Community treatment orders (CTOs) in England and Wales are legal alternatives to Section 17 orders; both are conditional releases offering the same services. CTOs specify a 6 month fixed period of supervision, renewable for 1 year; Section 17 orders provide a discretionary period of supervision. Burns and colleagues evaluated the effects of fixed-period CTO supervision versus Section 17 discretionary-supervision on readmission, community tenure, brief psychiatric rating scale and global assessment of functioning scores over 12 months. The authors found no differences between the conditions on these measures at 12 months and concluded: CTOs are not an effective intervention since they involve more days under involuntary supervision (median=255 vs 102) – the latter not being one of the criteria they tested but a characteristic of the order as implemented.
The authors’ hypotheses derive from legislative claims that CTOs potentially reduce and prevent admissions and increase community tenure; not from previous research findings, which fail to support such claims making them unlikely to be sustained. Unfortunately, this study failed to address research supported hypotheses indicating that CTOs reduce the duration of hospital episodes preceding release, reduce victimisation and mortality.1 ,2 This study also allowed “those [psychiatrists] committed to a routine use of protracted Section 17”1 to not enrol patients, thus selecting for psychiatrists supporting rapid release and perhaps, those patients more appropriate for short-term supervision. This changes the study question: testing long-fixed-term CTOs versus discretionary-short-term Section 17s; making the longer fixed period of CTO involuntary care a foregone conclusion. Given a 25% crossover to each condition, one also wonders if the patients knew the legal difference between the conditions and viewed themselves as involuntary throughout the period. Given these design issues, the authors’ conclusions that ‘CTOs do not confer benefits on patients’ is premature and potentially harmful.
This study refocuses research on the components of successful involuntary supervision, the need to consider reduced fixed supervision periods combined with better specified discretionary approaches. The generalisability of the results are limited, perhaps to the study districts and, given the selected nature of participation in the ‘discretionary’ condition, to the selected group of clinicians choosing to participate.
Supplementary materials
Supplementary Data
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Footnotes
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Sources of funding: National Institute of Health Research
Footnotes
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Competing interests: None.
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