2. CTOs and ACT: Necessary? Effective? Ethical? CTOs and ACT: Necessary? Effective? Ethical? R. O’Reilly

3. A Successful CTO – Background 27 year old single male 27 year old single male Diagnosis – Paranoid schizophrenia Diagnosis – Paranoid schizophrenia 7 previous hospitalizations 7 previous hospitalizations Several charges Several charges  Assault  Concealed weapon  Possession drugs Threatened GP with knife Threatened GP with knife Abused cannabis & other drugs Abused cannabis & other drugs

4. Successful CTO – Admission Hearing messages from electric wires Hearing messages from electric wires Believed members of a motorcycle gang were going to kill his brother Believed members of a motorcycle gang were going to kill his brother Rambled into brother’s school yelling and threatening to kill people Rambled into brother’s school yelling and threatening to kill people Had a short hospitalization Had a short hospitalization Discharged: assaulted mother and brother Discharged: assaulted mother and brother Readmitted as an involuntary patient Readmitted as an involuntary patient

5. Successful CTO – Hospital Course Believed patients were transmitting the smell of farts to his nose Believed patients were transmitting the smell of farts to his nose Believed the nurses were giving him erections Believed the nurses were giving him erections Very agitated Very agitated Gradually settled on high-dose oral risperidone Gradually settled on high-dose oral risperidone Psychotic symptoms resolved, but no insight Psychotic symptoms resolved, but no insight Adamant that he would not take medication or follow-up with team when discharged Adamant that he would not take medication or follow-up with team when discharged

6. Successful CTO – Treatment Plan Transferred to an ACT team Transferred to an ACT team Placed on a CTO Placed on a CTO Mother substitute decision maker Mother substitute decision maker Treatment Plan Treatment Plan  Take medication as directed  See Dr. O’Reilly monthly  ACT visit home daily for medication observation  Live in area served by the ACT team  Provide urine for random drug screens

7. Successful CTO – Follow-up Initially lived with mother and brother Initially lived with mother and brother GP agreed to take him back (reluctantly) GP agreed to take him back (reluctantly) ACT team did daily medication observation ACT team did daily medication observation ACT team helped patient get identification ACT team helped patient get identification Patient complied, but kept minimal contact Patient complied, but kept minimal contact At 2 nd renewal, mom refused CTO consent At 2 nd renewal, mom refused CTO consent

8. Successful CTO – Outcome Stopped medication when off CTO Stopped medication when off CTO Became symptomatic and threatened family Became symptomatic and threatened family Readmitted to hospital as involuntary patient Readmitted to hospital as involuntary patient Mom again consented to CTO Mom again consented to CTO Patient insisted risperidone be stopped Patient insisted risperidone be stopped Placed on LAI typical antipsychotic Placed on LAI typical antipsychotic

9. Successful CTO – Aftermath Did have 2 subsequent short voluntary admissions associated with heavy drinking Did have 2 subsequent short voluntary admissions associated with heavy drinking In last 6 years, has had no symptoms In last 6 years, has had no symptoms Agreed to take medication without CTO Agreed to take medication without CTO Moved to his own apartment Moved to his own apartment Little motivation, but no legal charges Little motivation, but no legal charges Briefly held a part-time job Briefly held a part-time job

10. An Unsuccessful CTO - Background 27 year old single male 27 year old single male Diagnoses – Diagnoses –  Bipolar disorder type 1  Antisocial and narcissistic personality traits  Polysubstance abuse Dull normal intelligence Dull normal intelligence 4 previous hospitalizations 4 previous hospitalizations Assaultive when manic Assaultive when manic

11. Unsuccessful CTO – Admission Non-adherent to medication Non-adherent to medication Abusing cannabis and cocaine Abusing cannabis and cocaine Became manic with delusions that he was God Became manic with delusions that he was God Evicted from apartment Evicted from apartment Up all night shouting and aggressive in shelter Up all night shouting and aggressive in shelter Hospitalized involuntarily Hospitalized involuntarily

12. Unsuccessful CTO – Hospital Course Treated with sodium valproate and quetiapine Treated with sodium valproate and quetiapine Many assaults and periods in seclusion Many assaults and periods in seclusion Slowly resolved over 8 month admission Slowly resolved over 8 month admission Referred to an ACT team Referred to an ACT team

13. Unsuccessful CTO – Treatment Plan Live in a 24-hour supervised group home Live in a 24-hour supervised group home See Dr. O’Reilly every 2 months See Dr. O’Reilly every 2 months Take medication as prescribed by Dr. O’R Take medication as prescribed by Dr. O’R See ACT workers 3 times weekly See ACT workers 3 times weekly Refrain from using cocaine Refrain from using cocaine Give urine for drug screen on request Give urine for drug screen on request

14. Unsuccessful CTO – Outcome Took treatment and attended appointments Took treatment and attended appointments Continued to use cannabis, no evidence cocaine Continued to use cannabis, no evidence cocaine Mood remained stable Mood remained stable Good therapeutic relations: occasional tensions Good therapeutic relations: occasional tensions 9 months moved to non-supervised group home 9 months moved to non-supervised group home

15. Unsuccessful CTO – Outcome Quickly non-adherent with medication regimen Quickly non-adherent with medication regimen ACT team instituted daily medication observation ACT team instituted daily medication observation Not available for medication observation Not available for medication observation Started using cocaine Started using cocaine Multiple breaches of CTO with 4 hospitalizations Multiple breaches of CTO with 4 hospitalizations Deterioration of therapeutic relationships Deterioration of therapeutic relationships Gave nurse a cold urine sample – Gave up! Gave nurse a cold urine sample – Gave up!

16. Unsuccessful CTO - Aftermath Attempt to manage with ACT alone Attempt to manage with ACT alone Patient agreed to injections of risperidone Patient agreed to injections of risperidone Re-hospitalized after 6 months with mania Re-hospitalized after 6 months with mania Took injection – limited adherence to oral medications when discharged Took injection – limited adherence to oral medications when discharged Ongoing substance abuse Ongoing substance abuse Further hospitalizations with violence Further hospitalizations with violence Many legal problems Many legal problems Left the catchment area Left the catchment area

18. Why we need CTOs Why we need CTOs Do they work? Do they work? Is ACT an alternative to using CTOs? Is ACT an alternative to using CTOs? Review of ACT and CTOs Review of ACT and CTOs Which patients are suitable for a CTO? Which patients are suitable for a CTO? What care and treatment under a CTO? What care and treatment under a CTO? How long should a CTO last? How long should a CTO last?

19. Why Do We Need CTOs? Deinstitutionalization is a massive public policy experiment Deinstitutionalization is a massive public policy experiment Deinstitutionalization is relocating the locus of treatment to the community Deinstitutionalization is relocating the locus of treatment to the community The authority to treat in hospital settings must be extended to the community The authority to treat in hospital settings must be extended to the community

20. Do CTOs Work? Three randomized controlled trials Three randomized controlled trials New York New York North Carolina North Carolina England & Wales England & Wales Some case-controlled studies Some case-controlled studies Many before-and-after studies Many before-and-after studies A few studies using data-bases A few studies using data-bases

21. Is ACT an alternative to CTOs? If we had sufficient services would not need CTOs Not when there is outright refusal of Rx Not when there is outright refusal of Rx Not when ACT alone has failed because of non-adherence to Rx Not when ACT alone has failed because of non-adherence to Rx Should we try ACT alone first? Should we try ACT alone first?  CTO can dispense with repeated cajoling  CTO has more procedural justice  CTO renewals can reignite irritation

22. North Carolina RCT Less 3 services per month

23. North Carolina RCT More 3 services per month

24. Typical use of ACT and CTOs London, Ontario London, Ontario  Average 17%  Range10-30% Indiana State Indiana State  Median 16%  Range 0-65% Moser 2009

25. Research on ACT and CTOs CTO & ACT compared with ACT alone CTO & ACT compared with ACT alone  Doubled engagement with services  Halved hospitalization Swartz 2010 Swartz 2010 > medication adherence & medication adherence & < admissions after CTO ended:  CTO < 6 months needed ACT  CTO > 6 months persisted without ACT Van Dorn 2010

26. ACT, CTOs and Coercion CTOs increase perception of coercion CTOs increase perception of coercion ACT does not increase perceived coercion ACT does not increase perceived coercion No addition when CTOs & ACT combined No addition when CTOs & ACT combined Galon 2011

27. London ACT/CTO Study Did you use ACT alone before adding CTO Did you use ACT alone before adding CTO Yes 57% No 40% No response3%

28. Reasons ACT Insufficient Patients refused medication Patients refused medication Patients unavailable for Rx and F/U Patients unavailable for Rx and F/U CTO recall powers necessary for timely Rx CTO recall powers necessary for timely Rx Patients had violent potential or Hx Patients had violent potential or Hx

29. Who is Placed on a CTO? There is remarkable consistency in the characteristics of patients on CTOs across jurisdictions embedded in very different cultural and geographical settings. There is remarkable consistency in the characteristics of patients on CTOs across jurisdictions embedded in very different cultural and geographical settings. The descriptive data indicate that patients are typically males, around 40 years of age, with a long history of mental illness, previous admissions, suffering from a schizophrenia-like or serious affective illness, and likely to be displaying psychotic symptoms, especially delusions, at the time of the CTO. Criminal offences and violence are not dominant features amongst CTO patients. This picture is largely reinforced in the comparative data, which suggest that CTO patients are more likely to be severely mentally ill with high hospital admission rate histories, poor medication compliance, and aftercare needs. The descriptive data indicate that patients are typically males, around 40 years of age, with a long history of mental illness, previous admissions, suffering from a schizophrenia-like or serious affective illness, and likely to be displaying psychotic symptoms, especially delusions, at the time of the CTO. Criminal offences and violence are not dominant features amongst CTO patients. This picture is largely reinforced in the comparative data, which suggest that CTO patients are more likely to be severely mentally ill with high hospital admission rate histories, poor medication compliance, and aftercare needs. The Churchill Report 2007

30. Who Should be on a CTO? ~Geller’s Criteria~ Wants to leave hospital Wants to leave hospital Previously failed in community Previously failed in community Understands treatment order Understands treatment order Can comply Can comply Not dangerous if complies Not dangerous if complies Treatment previously effective Treatment previously effective Treatment meets the patient’s needs and can be delivered by system Treatment meets the patient’s needs and can be delivered by system Treatment can be monitored Treatment can be monitored Outpatient system must be willing partner Outpatient system must be willing partner Inpatient system must be willing partner Geller 1990 Inpatient system must be willing partner Geller 1990

31. Who Does Well on a CTO? Patients refusing Rx who can be convinced Patients refusing Rx who can be convinced Patients with high probability of default Patients with high probability of default Patients who lack insight (incapable) Patients who lack insight (incapable) Patients who respond to the treatment Patients who respond to the treatment Patients with psychotic disorders Patients with psychotic disorders Patients on long-acting injections Patients on long-acting injections Those without Cluster B personality disorder Those without Cluster B personality disorder

32. Who is suitable for a CTO? ~North Carolina RCT~ Patients with psychotic disorders who were placed on a CTO for > 6 months showed a 72% decrease in hospitalization Patients with psychotic disorders who were placed on a CTO for > 6 months showed a 72% decrease in hospitalization In contrast, patients with affective disorders on CTO for > 6 months disorders showed no decrease In contrast, patients with affective disorders on CTO for > 6 months disorders showed no decrease

33. Why Psychotic > Mood? Most mood disorder patients fully recover Most mood disorder patients fully recover Most mood disorder patients have insight Most mood disorder patients have insight More mood disorder patients have PD? More mood disorder patients have PD? Mood disorder patients take oral meds Mood disorder patients take oral meds

34. What Care and Treatment? Medication Medication Clinical monitoring Clinical monitoring Stable residence Stable residence Laboratory tests Laboratory tests Counselling/therapy Counselling/therapy Refrain from substances Refrain from substances

35. 50% of patients with schizophrenia lack insight 50% of patients with schizophrenia lack insight Amador et al 1993 74% of patients with schizophrenia non- adherent within 2 years of discharge 74% of patients with schizophrenia non- adherent within 2 years of discharge Weiden & Olfson 1995 When LAIs stopped in 1st episode patients, 78% relapsed within 1 year and 96% within 2 years When LAIs stopped in 1st episode patients, 78% relapsed within 1 year and 96% within 2 years Gitlin et al 2001 Mortality increased X 12 after stopping meds Mortality increased X 12 after stopping meds Tiihonen et al 2006 The Importance of Medication

36. Long-acting Injections Modest evidence for superior effectiveness Naturalistic studies stronger than RCTs Zhornitsky & Stip 2012 Better treatment adherence independent of being on a CTO Swartz et al 2001 NSW < admissions on CTO with depot vs. oral Vaughan et al 2000

37. Specifying Residence on a CTO “Treatment can be monitored” Geller 1990 Observe medication Daily monitoring of symptoms Nighttime supervision Limits drug use Three square meals

38. Specifying Residence on a CTO PG&T will give consent PG&T will give consent   The individual will reside in a group home or residential setting which, by program design, supports the development of life skills and promotes treatment adherence CCB has upheld the practice CCB has upheld the practice  Case of Ms. MBG July 2003

39. Laboratory Tests Monitoring mood stabilizers Tests for specific medical indications Segal 2006 Kisely 2013 Screening for drugs of abuse

40. What Care and Treatment? Medication Clinical monitoring Stable residence Laboratory tests Counselling/therapy Refrain from substances

41. How Long Should a CTO Last? North Carolina study reported positive outcomes when CTO was continued > 6 months North Carolina study reported positive outcomes when CTO was continued > 6 months Actually found that the longer the CTO, the better the outcomes Swartz et al 1999 Actually found that the longer the CTO, the better the outcomes Swartz et al 1999 New York study also suggests 6 month minimum New York study also suggests 6 month minimum Van Dorn 2010 Iowa study average duration was 4.5 years Rohland et al 2000 Iowa study average duration was 4.5 years Rohland et al 2000

43. A Successful CTO – Background 58 year old separated male 58 year old separated male Diagnosis – Paranoid schizophrenia at 45 Diagnosis – Paranoid schizophrenia at 45 Destroyed property when living with family Destroyed property when living with family 3 previous hospitalizations 3 previous hospitalizations Past delusions about poison injected up nose Past delusions about poison injected up nose He surgically removed a polyp from his nose He surgically removed a polyp from his nose Severe hemorrhage Severe hemorrhage Refused to take thyroid hormone post-surgery Refused to take thyroid hormone post-surgery

44. Successful CTO – Admission Delusions that sister was poisoning family Saved his vomitus for analysis Went to the police to press charges Hoarding and eating rotten food Increasingly irascible Admitted as an involuntary patient

45. Successful CTO – Hospital Course Adamant that he had no mental illness Adamant that he had no mental illness Refused medication Refused medication Attributed all physical discomfort to meds Attributed all physical discomfort to meds Deemed treatment incapable Deemed treatment incapable Daughter SDM Daughter SDM Started on injectable antipsychotic Started on injectable antipsychotic Plan to discharge to a group home Plan to discharge to a group home Gradually became less paranoid Gradually became less paranoid Referred to ACT team Referred to ACT team Ex-wife agreed to his return to family home Ex-wife agreed to his return to family home

46. Successful CTO – Treatment Plan Treatment Plan Treatment Plan  Take medication as directed  See Dr. O’Reilly monthly  Daily visits for medication observation  Provide blood or urine for laboratory tests on request

47. Successful CTO – Follow-up Initially unrealistic with bizarre behaviour Initially unrealistic with bizarre behaviour Continued to attribute discomfort to meds Continued to attribute discomfort to meds Applied to the CCB every 6 months Applied to the CCB every 6 months Reluctant to have a cystoscopy Reluctant to have a cystoscopy Gradually became less bizarre and ornery Gradually became less bizarre and ornery Good relationship with wife and children Good relationship with wife and children Good relationship with ACT team Good relationship with ACT team Mother died: I was able to help with will Mother died: I was able to help with will

48. An Unsuccessful CTO - Background 31 year old single male 31 year old single male Diagnosis – Diagnosis –  Paranoid schizophrenia with polysubstance abuse 15 previous hospitalizations 15 previous hospitalizations

49. An Unsuccessful CTO - Admission Non-adherence to medication Non-adherence to medication Psychotic & jumped from 5th floor window Psychotic & jumped from 5th floor window Fractured ribs and humerus; Fractured ribs and humerus; lacerated liver and spleen; pneumothorax

50. Unsuccessful CTO – Hospital Course Mother agreed to be SDM Mother agreed to be SDM ACT agreed to serve patient outside area ACT agreed to serve patient outside area Plan to manage patient on a combination of LAI and oral antipsychotic Plan to manage patient on a combination of LAI and oral antipsychotic

51. Unsuccessful CTO – Treatment Plan See Dr. O’Reilly at least every 3 months See Dr. O’Reilly at least every 3 months Take medication as prescribed by Dr. O’R Take medication as prescribed by Dr. O’R See ACT workers weekly See ACT workers weekly Give urine for drug screen on request Give urine for drug screen on request ACT must agree to change of residence ACT must agree to change of residence

52. Unsuccessful CTO – Outcome ACT had problems from the beginning ACT had problems from the beginning Often unavailable for home visits Often unavailable for home visits Drug tests positive for cocaine and opiates Drug tests positive for cocaine and opiates I refused to prescribe Concerta I refused to prescribe Concerta Refused to see me – two Form 47s Refused to see me – two Form 47s Evicted from his apartment Evicted from his apartment Left catchment area to live with father Left catchment area to live with father Had fight with father - superficial stab wound: father ruptured spleen Had fight with father - superficial stab wound: father ruptured spleen

53. Unsuccessful CTO – Aftermath Lived with various relatives Lived with various relatives Stole from relatives to support drug habit Stole from relatives to support drug habit Charged with assault, but no conviction Charged with assault, but no conviction Had to call Security during an office visit Had to call Security during an office visit ACT team still believes that ensuing treatment is worth the cost ACT team still believes that ensuing treatment is worth the cost