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

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

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

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

5. Is ACT an alternative to CTOs
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 ACT alone has failed because of non-adherence to Rx
Should we try ACT alone first?
CTO can dispense with repeated cajoling
CTO has more procedural justice
CTO renewals can reignite irritation

6. North Carolina RCT Less 3 services per month

7. North Carolina RCT More 3 services per month

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

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

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

11. London ACT/CTO Study Did you use ACT alone before adding CTO Yes 57%
No %
No response 3%

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

13. 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.
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

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

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

16. 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
In contrast, patients with affective disorders on CTO for > 6 months disorders showed no decrease

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

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

19. The Importance of Medication
50% of patients with schizophrenia lack insight
Amador et al 1993
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
Gitlin et al 2001
Mortality increased X 12 after stopping meds
Tiihonen et al 2006

20. 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

21. 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

22. Specifying Residence on a CTO
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
Case of Ms. MBG July 2003

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

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

25. How Long Should a CTO Last?
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
New York study also suggests 6 month minimum
Van Dorn 2010
Iowa study average duration was 4.5 years Rohland et al 2000