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Guest Editorial
Community Treatment Orders: An Uncertain Step
Gary A Chaimowitz
(PDF)

In Review
Why Are Community Treatment Orders Controversial?
Richard O'Reilly
(PDF)

Involuntary Outpatient Commitment, Community Treatment Orders, And Assisted Outpatient Treatment: What's in the Data?
Marvin S Swartz, Jeffrey W Swanson
(PDF)

Review Paper
The Persistence of Folly: A Critical Examination of Dissociative Identity Disorder. Part I. The Excesses of an Improbable Concept
August Piper, Harold Merskey
(PDF)

Prevalence and Outcomes of Pharmaceutical Industry-Sponsored Clinical Trials Involving Clozapine, Risperidone, or Olanzapine
Ric M Procyshyn, Anthony Chau, Patricia Fortin, Willough Jenkins
(PDF)

Original Research Evaluation of a Children's Temper-Taming Program
Susan Williams, Marjorie Waymouth, Ellen Lipman, Brenda Mills, Peter Evans
(PDF)

Patient Opinions on the Benefits of Treatment Programs in Residential Psychiatric Care
Bruno Biancosino, Corrado Barbui, Valentina Pera, Michela Osti, Denis Rocchi, Luciana Marmai, Luigi Grassi
(PDF)

Client and Community Services Satisfaction With an Assertive Community Treatment Subprogram for Inner-City Clients in Edmonton, Alberta
Pierre Chue, Philip Tibbo, Evelyn Wright, Jelle Van Ens
(PDF)

Stigma Impact on Moroccan Families of Patients With Schizophrenia
Nadia Kadri, Fatiha Manoudi, Soumia Berrada, Driss Moussaoui
(PDF)

Brief Communication
Social Phobia Among University Students and Its Relation to Self-Esteem and Body Image
Ferda Izgiç, Gamze Akyüz, Orhan Doğan, Nesim Kuğu
(PDF)

Hospitalization in the First Year of Treatment for Schizophrenia
David Whitehorn, Julie C Richard, Lili C Kopala
(PDF)

Book Reviews
(PDF)

Psychiatry on Trial: Fact and Fantasy in the Courtroom
Review by
Paul Ian Steinberg

Let Them Eat Prozac
Review by
Dorian Deshauer

Practical Child and Adolescent Psychopharmacology
Review by
MK Nixon

Doctor-Patient Relationship in Pharmacotherapy
Review by
Ronald A Remick

Mastering Forensic Psychiatric Practice: Advanced Strategies for the Expert Witness
Review by
Paul Ian Steinberg

Letters to the Editor
(PDF)

Antidepressant-Induced Sexual Dysfunction Treated with Vardenafil

Reconsidering Pimozide for New-Onset Delusions of Parasitosis

Gabapentin Treatment for Premature Ejaculation

Suspected Propranolol-Induced Delirium

Recognizing Social Anxiety Disorder

A Curious Case of Neuroleptic Malignant Syndrome

Antipsychotic-Induced QTc Interval Prolongation

Using Depression Inventories: Not a Replacement for Clinical Judgment

Treatment With Risperidone and Occurrence of Blurred Vision: A Question of Higher Dosage

Late Onset Neutropenia With Clozapine

In Review

Why Are Community Treatment Orders Controversial?

Richard O'Reilly, MB, FRCPC¹

Few recent issues in psychiatry have polarized the various stakeholders in the mental health system as much as has the propriety of introducing community treatment orders (CTOs). While much of the conflict appears to be based on misunderstanding, some reflects the different philosophical perspectives of the protagonists. This paper outlines the major points of contention and attempts to explain why individuals and groups who share a common concern for the well-being of those suffering from mental illness take such starkly opposing positions on CTOs.

Definitions

A CTO is a legal provision by which a physician may require a person with mental illness who meets specific criteria to follow a course of treatment while living in the community. It is helpful to distinguish between diversionary and preventive CTOs (1). To be placed on a diversionary CTO, a person must meet the jurisdiction’s inpatient committal criteria. In contrast, a person can be placed on a preventive CTO even if he or she does not meet the inpatient committal criteria. The rationale for a preventive CTO is to avert deterioration to the level of the jurisdiction’s inpatient committal criteria, and the criteria for preventive CTOs often include a requirement that the person have a history of involuntary admissions.

Other legal models that require an individual to follow a course of care and treatment in the community include court-ordered outpatient committal, which is available in most jurisdictions in the US (2); conditional leave from hospital, which is available in several Canadian jurisdictions (3); and guardianship legislation, which is available in most Canadian provinces. This article uses the term mandatory outpatient treatment (MOT) when referring to the generic forms of compulsory community treatment. Although there are legal and administrative differences between the various types of MOT, the polemics of the debate on their usefulness and appropriateness are similar.

Arguments For and Against CTOs

Tables 1 and 2 outline the major arguments for and against the use of CTOs. The rationale for the use of CTOs rests primarily on the fact that deinstitutionalisation resulted in the discharge to the community of a cohort of individuals without the insight to recognize that they are ill or that they need treatment. Proponents of CTOs argue that society has a duty to ensure that such individuals receive appropriate care and treatment when, as a consequence of refusing treatment, they are unable to care for themselves or pose a risk to themselves or to others. Proponents claim that research studies provide unequivocal proof of efficacy with no evidence of untoward effects. Opponents object to the coercive nature of CTOs. Opponents also fear that CTOs have unintended negative consequences. They believe that, once available, CTOs will be overused and that there are viable alternatives.

Origins of the Controversy

Philosophical Perspectives
In his classic libertarian thesis, On Liberty, John Stewart Mill stated that “the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or moral, is not sufficient warrant” (4). This statement is often quoted by those who oppose CTOs (5). Seldom mentioned is that Mill, in the next paragraph, went on to say “Those who are still in a state to require being taken care of by others must be protected against their own actions as well as against personal injury.” Herein lies the source of the contemporary tension between those who subscribe to a deontological philosophy and those who are more utilitarian in outlook. Deontologists propose that individual autonomy is absolute and must be respected in all circumstances, whereas utilitarians believe that the negative consequences of allowing patients suffering from psychosis freedom of choice should, in some cases, limit that choice.

This is not a new debate. Freedom of choice for individuals with mental illness was a source of dispute through the 1960s and 1970s, but at that time, the battleground was involuntary inpatient committal and treatment. That battle has largely ended with an affirmation of inpatient civil commitment, although its use is limited by a dramatic reduction in available psychiatric inpatient beds.

In the contemporary debate on compulsory treatment in the community, proponents argue that CTOs prevent involuntary hospitalization and are thus consistent with the principle of providing treatment in the least restrictive setting. This may be a reasonable claim for diversionary CTOs wherein the patient already meets the criteria for inpatient committal, but it cannot be as easily applied to preventive CTOs. Moreover, some critics of CTOs argue that where the coercion occurs is irrelevant: they believe that coercion in any context is noxious (5). There can be little argument that those subjected to MOT experience coercion (6). However, recent research findings indicating that individuals with mental illnesses would prefer a treatment order to involuntary hospitalization (7) support the belief that the concept of least restrictive setting has validity.

Slippery Slope
Critics of CTOs suggest that introducing compulsory treatment in the community is the first step down a slippery slope that will end in widespread coercion forcing adherence to all psychiatric, and perhaps even some medical, treatments. However, even where it has been available for many years, MOT is used sparingly (8,9). MOT use is probably most extensive in some Australian jurisdictions, where reports indicate an annual use for between 20 and 43 persons per 100 000 (10). Thus, clinicians use treatment orders for only a tiny proportion of those individuals who suffer from serious mental illnesses.

Concerns that health professionals may ignore individual rights stem from the lack of civil rights accorded to individuals confined to psychiatric hospitals prior to the 1970s. It may be argued that the early 20th-century lack of rights for those institutionalized with mental illness occurred in a context wherein the philosophy of individual rights had not been fully established. In the last 30 years, Canadian mental health acts have strengthened individual rights by providing various procedural protections, such as access to an appeals process and the right to representation.

Are Treatment Orders Effective?
Much has been written on whether MOT is effective (11–13). Evaluating the clinical effectiveness of MOT is more complex than it first appears, since the measurement of effectiveness depends on the type of MOT, the type of patient, and the desired outcomes. Almost all research studies have used the ability of MOT to reduce hospital use as the primary outcome measure. However, reduced hospitalization is a poor outcome measure (14): some patients who meet criteria for MOT may actually benefit from spending more time in hospital. Indeed, it is clear that hospitalization rates can be lowered by simply closing psychiatric units, without any improvement in patient well-being.

Research on MOT is a somewhat murky area. Reviews of the early studies have noted methodological weaknesses that inflated estimates of its effect (12,13). Two randomized controlled trials (RCTs) have recently been undertaken. One, the New York study, did not find a statistically significant difference in hospitalization between patients on court-ordered outpatient committal and control subjects (15)—probably because there were too few subjects in the study (16). The other, the North Carolina study, was larger, but the reported effectiveness of outpatient committal in maintaining patients in the community was found in post hoc analysis and limited to patients who spent extended periods on MOT (17). This result remains contentious (18).

Researchers have reported other types of improved outcomes for patients on MOT. For example, despite suggestions that coerced treatment in the community may drive patients from the mental health system (19), it has been consistently shown that patients on treatment orders are more likely to follow up with mental health services (20–25). This is an improvement that persists even after MOT is discontinued (20,21). The RCT in North Carolina found that patients on treatment orders were less likely to be victimized (26). Other studies demonstrated a reduction in violent behaviour by patients placed on MOT (24,27). However, of the 2 RCTs (both of which excluded violent patients), the New York study reported no effect on violence (15), while the North Carolina study found that violent behaviour was significantly reduced in those patients who stayed on treatment orders for at least 6 months (28).

It has been suggested that MOT should not be used, pending the results of further RCTs (19). However, further RCTs are unlikely in the near future. They are intrinsically difficult to conduct (29), not least because they require that one group of subjects be excluded from the provisions of a legal statute. Moreover, testing the efficacy of MOT is not the same as testing a new medication. Disparate findings are to be expected when different forms of MOT are compared in different types of patients, with different outcome measures. The North Carolina RCT had sufficient power to start to tease out the specific scenarios in which MOT is most likely to be effective. This study concluded that patients with nonaffective psychosis who were maintained on treatment orders for 6 months or longer and provided with high-intensity clinical service demonstrated the greatest reduction in hospital use (17,30).

Therapeutic Relationship
Some scholars worry that CTOs may adversely affect the therapeutic relationship (19). There has been little formal research on the effect of CTO placement on this relationship. The author recently participated in a study in Saskatchewan that used qualitative methods: several patients who were subject to CTOs stated that the initiation of the CTO adversely affected the relationship with their psychiatrist (Keegan DL, Corring DJ, O’Reilly RL, unpublished). However, patients placed on CTO have often previously failed to follow up with mental health services, and as noted above, MOT increases the likelihood of follow-up. Therefore, the appropriate comparison may not be between a good relationship and a bad one but, rather, between a relationship, however strained, and no relationship at all.

Alternatives to CTOs
Are there alternative legal options that are preferable to CTOs? Guardianship is an alternative that is available in most Canadian provinces and that could in some cases achieve the same purpose as a CTO. However, guardianship requires that an interested party be available to initiate the application and to pay the cost of the court process (about $10 000). Many patients who might benefit from MOT have long been alienated from their relatives or come from families who cannot afford the cost of guardianship. Guardianship is also cumbersome: a court hearing is required both to initiate and to revoke it.

Advance directives have also been proposed as alternatives to CTOs (31). Individuals execute an advance directive when they appoint a proxy decision maker and (or) state treatment preferences for future situations. The Ulysses contract is a specific form of advance directive in which individuals authorize the use of force to ensure that they follow a course of treatment in specific circumstances when they are incapable of making the decision themselves (32).

Advance directives that outline treatment preferences are most suitable when a person has previously experienced the illness (33). Clinicians recommend MOT for individuals who have chronic illness associated with lack of insight (1). Use of an advance directive requires a period of planning during which the patient is capable of assessing the need for coercion in various circumstances that may or may not occur in the future. However, for many individuals with illnesses such as schizophrenia that starts in adolescence or early adult life and is often associated with premorbid cognitive abnormalities and permanent lack of insight thereafter, there is no opportunity to do this type of sophisticated planning.

Treatment Capacity
All antipsychotic medication can cause side effects. Some side effects, such as parkinsonism or weight gain, may affect an individual’s quality of life; others, such as the disruption of glucose metabolism and elevation of lipid levels, can actually shorten life. It is hardly surprising that some patients prefer to hear voices than to experience these side effects. Opponents of CTOs fear that patients on treatment orders will be compelled to take medications that cause intolerable side effects.

When a person is capable of weighing the risks and benefits of treatment and the consequences of refusing treatment, that person has the right to make his or her own treatment decisions. The exception may be a person who has been involuntarily hospitalized. Some scholars argue that, when the state deprives a person of liberty because of mental illness, the state has a further duty to provide standard treatment that is often the only key to liberty (3). However, this argument does not apply to compulsory treatment in the community, where the patient is not confined. Several jurisdictions, including Saskatchewan (34) and Victoria, Australia (10), stipulate that CTOs are only to be used when a person is incapable of consenting to his or her own treatment. The Canadian Psychiatric Association has also adopted this position (1).

The procedure for authorizing treatment when a patient is found to be incapable varies greatly among Canadian jurisdictions (35). In some provinces, the treating physician decides for the patient. However, it seems preferable that a second responsible person also be involved in deciding the appropriateness of treatment for a patient whom the physician has deemed incapable of consenting to treatment. This would provide some assurance that clinical alternatives, including the possibility of foregoing treatment, are fully considered in cases where patients experience substantial side effects.

Unwarranted Focus on Violence
In public debates on CTOs, the media have tended to focus on their potential for reducing violence perpetrated by persons with mental illness. Indeed, it is often the risk of violence to the general public, rather than any potentially inherent benefit to individuals suffering from mental illness, that galvanizes political will to introduce CTOs. This was exemplified by the public debates on MOT that occurred simultaneously in Ontario and New York State. In both jurisdictions, the major catalyst for the introduction of MOT legislation was the death of young women—Kendra Webdale in New York and Charlene Minkowski in Ontario—who were pushed in front of subway trains by individuals with mental illness. New York State named its new legislation “Kendra’s Law”; Ontario called its legislation “Brian’s Law,” after Brian Smith, a popular sports commentator shot dead by a man with schizophrenia. The focus on violence, especially the naming of legislation after individuals who have been victims of violent acts, perpetuates the association of violence and mental illness in the public mind and leads to further stigmatization of persons with mental illness.

There have long been arguments about whether a relation exists between mental illness and violence (36) or even whether persons with mental illness are less likely to be dangerous (37). However, recent empirical evidence indicates that mental illness is associated with increased violent behaviour (38), mostly accounted for by patients with active symptoms (39) who are not adhering to treatment (40). Research also indicates that the use of various forms of MOT may reduce the risk of violent behaviour (27,28). However, the low proportion of violent acts by people with mental illness (41) and the low use of MOT mean that introducing treatment orders is unlikely to lead to substantially reduced rates of community violence. Thus, the introduction of MOT is more appropriately debated in the context of the potential benefits to individuals who suffer from severe mental illness.

Duration of CTOs
While CTOs and inpatient civil committal can be renewed indefinitely, the reduced availability of psychiatric beds has increasingly forced doctors to discharge hospitalized patients, even when many of these patients continue to meet committal criteria (42). There is, however, no such pressure to end the commitment of patients who are on an outpatient commitment order. This has led to fears that people will be left on CTOs longer than necessary (43).

For how long is it reasonable to require a person living outside hospital to adhere to a plan of treatment? Many patients with psychotic disorders such as schizophrenia have permanently impaired insight: they never come to understand that they are ill and need treatment (44). It therefore seems likely that some of these individuals will need ongoing compulsion or inducement to adhere to clinical treatment, which probably explains why several research studies have shown that MOT is most likely to be effective when it is used over extended periods of time (17,23,26,28). Considering the persistence of symptoms in patients who are typical candidates for MOT and the research on MOT duration, it is surprising, and perhaps disconcerting, to find that most patients are maintained on MOT for brief periods (8,9).

An interesting clinical dilemma is raised by patients with a stormy clinical history who settle and remain stable while on a CTO (45). Is this stability a measure of the success of the CTO and an indication that it should be continued—or is it an indication that the patient has improved and that the CTO is no longer warranted? One germane piece of research found that, when treatment orders are withdrawn for stable patients, approximately one-half do well and the other one-half have poorer outcomes (46).

Resources and CTOs
It has been suggested that there would be no need for CTOs if governments provided adequate community services (47). Unfortunately, this assertion must now be discounted: we know that a small cadre of patients who are provided with high-intensity service by assertive community treatment teams persistently refuse treatment and follow-up, owing to their lack of insight (22).

It is less easy to dismiss concerns that governments struggling with budgetary deficits may be tempted to rely on coercion to ensure adherence to medication treatment as an alternative to providing a comprehensive package of services that include case management, vocational training, and supportive housing. The limited research relevant to this issue suggests that such a strategy would not be successful. In the North Carolina RCT, reduced violence and hospitalization occurred only in those patients for whom sustained MOT was combined with high-intensity services (28,30).

Several Canadian provinces have attempted to ensure adequate services for patients on CTOs or conditional leave by requiring in their statutes that services to support the CTO (or conditional leave) must be available in the community. It remains to be seen whether this is sufficient leverage to ensure that services are actually provided.

A CTO commits physicians and other professionals to provide care and treatment in the community just as much as it commits patients to accept the care and treatment provided. When physicians and other clinicians agree to monitor a patient on a CTO, they commit to assisting the patient even if the patient has little interest in following a treatment plan. Formerly, such patients were too often allowed to simply to drop out of treatment and decompensate out of sight.

Critics worry that MOT siphons resources away from patients who voluntarily seek help (19). This argument might have more validity if more patients were being placed on MOT. Even for the few patients placed on treatment orders, however, it is important to bear in mind that MOT is used because they have severe and debilitating illnesses. In other areas of health care, individuals with the most severe illness are given priority access to scarce resources.

Difficulty Monitoring Rights in a Community Setting
Many hospitals have in-house rights advisors and advocates who can easily provide rights advice and monitor the care of individuals concentrated in a hospital. It is more difficult, but still possible, to regulate care and treatment provided to patients dispersed into the community (48). It is interesting to note that, for most of the 20th century, society fretted about the difficulties in monitoring what was happening “behind the walls” of large institutions. The introduction of various forms of MOT has highlighted the remarkable progress that has occurred in making the activities of these institutions transparent.

Summary

Deinstitutionalisation is an ongoing process, not a historical event. In the coming years we will be obliged to care for larger numbers of even more challenging patients in community settings. It is difficult to conceive how this can be successfully achieved without transferring to the community some components of the legal authority that has been necessary to provide adequate care and treatment in hospitals. The challenge will be to ensure that patients who have no understanding that they suffer from a mental illness and require treatment receive necessary treatment and care in the community, while at the same time ensuring that coercion is kept to a minimum and that civil rights are respected.

References

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Author(s)

Manuscript received and accepted May 2004.

1. Professor, Department of Psychiatry, The University of Western Ontario, London, Ontario.

Address for correspondence: Dr R O’Reilly, Regional Mental Health Care, 850 Highbury Avenue North, PO Box 5532, Station A, London, ON N6A 4H1

e-mail: roreilly@uwo.ca

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