1. The first year of Community Treatment Orders Dr M Claire Royston MB ChB MSc FRCPsych Medical Director Care Principles Lead SOAD, Care Quality Commission 12/24/2015 0 Dr M Claire Royston

2. History of CTOs First appeared in N. America and Australasia during ‘80s CTOs exist in 52 separate jurisdictions across the world: – 41 States in USA – Ontario and Saskatchewan in Canada – All states in Australia – New Zealand – Israel – Scotland – England 12/24/2015 1 Dr M Claire Royston

3. History of CTOs Definition: A legal mechanism by which people with mental health problems who need treatment are compelled to submit to treatment on an outpatient basis Restrictive intervention 12/24/2015 2 Dr M Claire Royston

4. History of CTOs 12/24/2015 3 Dr M Claire Royston Conceptualised in response to number of different pressures on psychiatric services: – Deinstitutionalisation – Homeless mentally ill – Over-representation of mentally ill in prison – Revolving door patients – Dangerous mentally ill in the community

5. History of CTOs Conceptualised as a provision for treatment in a less restrictive environment Outcome measures for ‘success’ –Successful maintenance without harm to self or others 12/24/2015 4 Dr M Claire Royston

6. History of CTOs Over time the concept of the purpose for the CTO has evolved into a legal intervention with ‘health benefits’ A legal intervention designed to benefit persons with serious mental illness who need ongoing psychiatric care and support to prevent relapses, hospital re- admissions, homelessness or incarceration but have difficulty following through with community-based treatments This alters the type of outcome measures Now often considered to be a less restrictive measure 12/24/2015 5 Dr M Claire Royston

7. History of CTOs 14 major studies completed Consistency in the characteristics across all jurisdictions (very different cultural and geographical settings) Typically; male, around 40 years of age, long history of mental illness, previous admissions, suffering from a schizophrenia-like or serious affective illness Likely to be displaying psychotic symptoms, especially delusions at time of inception of CTO Criminal offences and violence not dominant features Often past history of high admission rates, poor medication compliance 12/24/2015 6 Dr M Claire Royston

8. CTOs in England Came into effect with amendments MHA 1983 on 3 November 2008 “Designed for patients who still require treatment for mental disorder, on the ground of their own health or safety or protection of others, but such treatment can be given outside of detention hospital, provided there is a power to recall if clinicians have concerns community arrangements are no longer sufficient” Estimated number ~200 in the first year 12/24/2015 7 Dr M Claire Royston

9. Number of CTO SOAD visit requests 12/24/2015 8 Dr M Claire Royston 3 November 2008 – 31 March 2009, n=1722

10. Number of recalls to hospital206 Number of revocations142 Number of discharges from SCT32 CTO - changes in legal status (n = 2,109) 12/24/2015 9 Dr M Claire Royston

11. Number of CTO requests: region 12/24/2015 10 Dr M Claire Royston

12. Study design From completed CTO second opinions from 3 Nov 2008 to 30 April 2009: 233 records located Records showing some change from treatment plan prioritised, but 111 records showing no change randomly selected. Audited by Lead SOAD following coding. 12/24/2015 11 Dr M Claire Royston

13. History & symptom clusters 12/24/2015 12 Dr M Claire Royston

14. Stated diagnosis Frequency F20 Schizophrenia, schizoaffective or delusional disorder 190 F30-F39 Mood disorders 27 F50-F59 Associated physical/psychological disorders 2 F60-F69 Personality disorders 2 F70-F79 Learning disability 2 F80-F89 Psychological development 3 Non-specific 6 12/24/2015 13 Dr M Claire Royston

15. Assessed risk n = 233 12/24/2015 14 Dr M Claire Royston

16. Categories of drug authorised 12/24/2015 15 Dr M Claire Royston

17. Number of drugs authorised n = 233 12/24/2015 16 Dr M Claire Royston

18. SOAD visits to SCT – BNF limits 12/24/2015 17 Dr M Claire Royston

19. The CTO experience A legal mechanism by which people with mental health problems who need treatment are compelled to submit to treatment on an outpatient basis A legal intervention designed to benefit persons with serious mental illness who need ongoing psychiatric care and support to prevent relapses, hospital re- admissions, homelessness or incarceration but have difficulty following through with community-based treatments 12/24/2015 18 Dr M Claire Royston