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Community treatment orders (CTOs) came into effect in Ontario in December 2000 as an attempt to provide the necessary treatment in the least restrictive setting for persons with severe and persistent mental illness (1). In Ontario, the CTO is based on the community treatment plan negotiated between the physician, the patient, the substitute decision maker (if applicable), and the providers of community-based support. The plan clearly states the responsibilities of each person named in it, as well as the consequences of noncompliance. CTOs are in effect for 6 months and may be renewed at any time during that period. CTOs have been in effect in Saskatchewan since 1995. Manitoba and British Columbia have provisions for extended leave. CTOs have been used since the 1970s in the US, where they are currently used in 41 states. They are also used in New Zealand and Australia. Research on the effectiveness of CTOs has occurred predominately in the US (2–26), Australia (27–30), and New Zealand (31,32). The existing literature can be categorized under 2 headings: philosophical discussions (1–14,27,30,32,33–35) and empirical studies (15–26,28, 29,31). The philosophical discussions most often focus on the ethical implications of CTOs. The empirical studies have evolved from small-sample, retrospective, pre- and posttest designs of hospital bed-day use (16,18,21,26,29) to large-sample studies that focus on hospital bed-day use as well as on clinical observations of overall functioning (15,17, 19,20,22–25,28). However, each jurisdiction has its own unique criteria for CTOs, and for this reason, comparing experiences among jurisdictions must be done with caution. To date, there are no available published empirical studies of patients in Canada who have been issued CTOs. Therefore, this study shares the results for patients (n = 25) who were issued CTOs at the Royal Ottawa Hospital, a specialty tertiary care psychiatric teaching hospital in the Champlain District of Eastern Ontario. We examined the profiles of the first patients to be issued CTOs at the Royal Ottawa Hospital to understand their characteristics and the effectiveness of CTOs in changing hospitalization and support service use patterns. MethodA standardized information collection tool was developed by the Champlain District’s CTO coordinators, based on the information required by the Ontario Ministry of Health and Long-Term Care. The tool was completed when a CTO was first issued and then updated to reflect both the patient’s ongoing involvement with the legislation and related clinical outcomes. We examined admission information from other area hospitals to understand each patient’s service use patterns. Patients were notified about ongoing data collection to monitor sociodemographic characteristics and clinical outcomes. We used the date of signing the CTO as the dividing mark between pre- and post-CTO activity. In no case was the person discharged from hospital prior to signing the CTO. We collected data retrospectively for both the pre- and post-CTO use of community services. Community services included crisis services, the hospital outpatient department, medication management clinics, the assertive community treatment team, case management services, addiction services, private psychiatrists, supportive housing services, nonpsychiatric medical care, and community mental health services. The protocol was approved by the Royal Ottawa Hospital’s Research Ethics Board. ResultsSociodemographic Characteristics The patients’ mean age was 45 years (range 20 to 70 years), and 60% of patients were men. Almost three-quarters (72%) were single and never married; only 12% were currently living with a partner. Two-thirds were receiving Ontario Disability Support payments; fewer were supported on CPP Disability Benefits (16%) and Seniors Benefits (12%). Only 4% received no formal monetary support. Almost two-thirds of patients (64%) had been given a diagnosis of schizophrenia (44% of whom had a concurrent diagnosis of substance dependence). Over one-quarter (28%) had received a diagnosis of schizoaffective disorder (29% of whom had concurrent substance dependence); 8% had received a diagnosis of bipolar disorder (50% of whom had concurrent substance dependence). This rate of concurrent disorder is much higher than that reported in the general population (36). Additional concurrent disorders included personality disorder (4%) and panic disorder (4%). Over one-half the patients (56%) were assessed as being without capacity to consent to treatment. Of those unable to consent to treatment, 85% had a family member as their substitute decision maker, and 15% had the Public Guardian and Trustee Office. Sociodemographic characteristics of this sample are consistent with characteristics of a sample of patients issued CTOs in the Toronto area in 2001 (37). Psychiatric diagnostic profiles were similar (although concurrent disorders were not recorded), as were age and relationship status and ability to give consent. This suggests that, according to available data, CTOs are being considered for patients with similar sociodemographic backgrounds. Changes Following CTO Involvement We examined patients’ health and support service use patterns following their involvement with a CTO. We recorded changes for use of hospital and support services, as well as housing status. Hospital Use Rates. We compared the number of hospital admissions and the length of hospital stays for patients before and after CTO involvement. There was a significant decrease in the number of hospital admissions between the year prior to the CTO and the year following the CTO (t = 6.56, P < 0.01). In the year prior to first issuance of the CTO, 78% of patients had 2 or more admissions to hospital. The range was 1 to 4 admissions, and the mean was 1.96 admissions. In the year after first issuance, 56% of patients had no admission to hospital. The range was 0 to 3 admissions, and the mean was 0.6 admissions. In addition, the overall number of days spent in hospital in the year prior to CTO involvement decreased significantly in comparison with the number of days spent in hospital following CTO involvement (mean 130, SD 86 vs mean 22, SD 38; t = 6.30, P < 0.01). Thus results demonstrate that CTO involvement was related to a significant decrease in both the number and length of hospital admissions. Use of Support Services. Support services were defined as community-based crisis, mental health, or medical services distinct from hospital services used during an admission. Many persons with severe and persistent mental illness are often disconnected from community-based support services (38). Because the mandate of CTOs is to increase care offered to the patient in the community, we measured the use of such services to compare the change in use rates prior to and following a CTO. Following a CTO, there was a significant increase in the range of services used by patients (P2 = 15.48, P < 0.01). Specifically, the range of services used increased from primarily only hospital outpatient department services to additional supportive services based in the community (over 75% of patients reported using 2 or more services). Again, results demonstrate that a CTO was related to increased access to, and participation in, community-based supportive services. Housing. We recorded the type of housing used by each patient pre- and post-CTO involvement to identify changes from marginalized, inappropriate, or unsupportive arrangements to more supportive arrangements. Housing options measured included private home, subsidized unit, supported housing, domiciliary hostel or shelter, or homelessness (without shelter use). Following CTO involvement, there was a significant change in the type of housing used by patients (P2 = 13.16, P < 0.05), with the most marked increase being in the number of patients in supported housing arrangements. Results demonstrate that CTO involvement for patients was related to increased involvement in supportive housing arrangements. Consent and Capacity Board Activity. A total of 47 CTOs were issued to 25 patients. Prior to issuance of a CTO, patients must receive rights advice and have the opportunity to contest the proposed CTO, regardless of their capacity to consent. No patient in the sample chose to contest the CTO before the Consent and Capacity Board. Legislation requires that a mandatory Consent and Capacity Board hearing occur at the second renewal of a CTO. During the period of time studied, only 2 patients had their CTO renewed a second time. DiscussionThis study examined the population of patients within a specialty psychiatric hospital who were issued CTOs since their introduction in Ontario. More specifically, we examined patients’ sociodemographic characteristics to determine patterns in the profile of who is placed on a CTO and how this patient population compares with other available Canadian profiles. In addition, we examined changes in hospital use patterns and use of support services, as well as changes to housing status, following the issuance of a CTO. We found that all these CTOs were initiated in the hospital, and none were contested. Findings of this study also suggest that persons placed on a CTO experience a serious and persistent mental illness and that most have a concurrent substance dependence disorder. Our study findings are consistent with studies in the US and Australia that demonstrate reduced hospital use and increased use of other supportive services. However, our study had a small sample size and measured a limited number of outcomes. Further, Geller’s work has confirmed that regression plays some role in the positive outcomes of mirror image studies (20). Therefore, the generalizability of these effectiveness findings is restricted. Expansion of both the sample and the range of outcomes will permit more conclusions to be made about the effectiveness of CTOs in patients’ lives. The legislation allows for CTOs to be initiated in the community, but it has been our experience that most, or in the case of this study all, CTOs are initiated in the hospital. The patients for whom CTOs are intended are those who do not voluntarily engage in follow-up. The criteria for issuing a CTO in the community are such that patients must meet Form 1 criteria and be without capacity to consent to treatment. These patients have most likely been noncompliant with treatment for some time prior to contact with psychiatry services. Therefore, an inpatient admission for assessment and stabilization is indicated before a CTO is organized. The lack of Consent and Capacity Board activity needs to be explored further; it is our assumption that these orders are not contested because they are reasonable. They contain nothing more intrusive than treatment routinely advised upon discharge from hospital. Most patients have experienced a recurrence of symptoms caused by noncompliance that has resulted in involuntary readmission to hospital. The CTO acknowledges this possibility and provides a strategy to avoid it. Future studies need to systematically evaluate the efficacy of all aspects of the CTO plan to determine the critical elements of their success from the perspective of both patients and health care professionals. Finally, the optimal match between patient characteristics and the multidimensional aspects of care mandated by CTOs must be examined. AcknowledgementsThe authors acknowledge the collaboration of Sylvie Faulkner, Elda Lansfield, and Elizabeth Shannon in the development of the information collection tool. We also gratefully acknowledge the assistance of Dr Robert Bialik with the original data analysis. References1. Ministry of Health and Long-Term Care: Brian’s law (mental health legislative reform) Toronto: Queens Printer; 2000. 2. Swartz MS, Monahan J. Special section on outpatient commitment. Psychiatr Serv 2001;52:323–4. 3. Mulvey E, Geller J, Roth L. The promise and peril of involuntary outpatient commitment. Am Psychol 1987;42:571–84. 4. Swanson JW. Interpreting the effectiveness of involuntary outpatient commitment: a conceptual model. J Am Acad Psychiatry Law 1997;25:5–16. 5. Allen M, Smith Fox V. Opening Pandora’s Box: the practical and legal dangers of involuntary outpatient commitment. Psychiatr Serv 2001;52:342–436. 6. Swartz M, Swanson JW, Wagner HG, Hannon MJ, Burns BJ, Shumway M. Assessment of four stakeholder groups’ preferences concerning outpatient commitment for persons with schizophrenia. Am J Psychiatry 2003;160:1139–46. 7. Geller JL. A biopsychosocial rationale for coerced community treatment in the management of schizophrenia. Psychiatr Q 1995;66:219–35. 8. Geller JL. Rights,wrongs, and the dilemma of coerced community treatment. Am J Psychiatry 1996;143:1259–68. 9. Appelbaum PS. Thinking carefully about outpatient commitment. Psychiatr Serv 2001;52:347–50. 10. Swartz MS, Burns B, George LK, Swanson J, Hiday VA, Borum R, and others. The ethical challenges of a randomized controlled trial of involuntary outpatient commitment. J Ment Health Admin 1997;24:35–43. 11. Geller J. The quandaries of enforced community treatment and unenforceable outpatient commitment statutes. The Journal of Psychiatry and the Law 1986;14:149–58. 12. Swartz MS, Burns B. New directions in research on involuntary outpatient commitment. Psychiatr Serv 1995;46:381–5. 13. Geller JL. Clinical guidelines for the use of involuntary outpatient treatment. Hosp Community Psychiatry 1990;41:749–55. 14. Monahan J, Bonnie, RJ, Appelbaum PS, Hyde PS, Steadman HJ, Swartz MS. Mandated community treatment: beyond outpatient commitment. Psychiatr Serv 2001;52:1198–205. 15. Steadman HJ, Gounis Kostas, Dennis D, Hopper K, Roche B, Swartz M, and others. Assessing the New York City involuntary outpatient commitment pilot program. Psychiatr Serv 2001;52:330–6. 16. Munetz M, Grande T, Kliest J, Peterson G. The Effectiveness of outpatient civic commitment. Psychiatr Serv 1996;47:1251–3. 17. Van Putten RA. Involuntary outpatient commitment in Arizona: a retrospective study. Hosp Community Psychiatry 1988;39:953–58. 18. Hiday VA, Scheid-Cook TL. A follow-up of chronic patients committed to outpatient treatment. Hosp Community Psychiatry 1989;40:52–9. 19. Fernandez GA, Nygard S. Impact of involuntary outpatient commitment on the revolving door syndrome in North Carolina. Hosp Community Psychiatry 1990;41:1001–4. 20. Geller J, Grudzinskas AJ, McDermeit M, Fisher WH, Lawlor T. The efficacy of involuntary outpatient treatment in Massachusetts. Admin Policy Ment Health 1998;25:271–84. 21. Rohland BM, Rohrer J, Richards C. The long-term effect of outpatient commitment on service use. Admin Policy Ment Health 2000;27:383–94. 22. Swanson JW, Swartz M, Borum R, Hiday VA, Wagner HR, Burns BJ. Involuntary out-patient commitment and reduction of violent behavior in persons with severe mental illness. Br J Psychiatry 2000;176:324–31. 23. Swartz MS, Swanson JW. Can involuntary outpatient commitment reduce hospital recidivism? Am J Psychiatry 1999;156:1968–75. 24. Swanson J W, Borum R, Swartz MS, Hiday VA, Wagner HR, Burns BJ. Can involuntary outpatient commitment reduce arrests among persons with severe mental illness? Criminal Justice and Behavior 2001;28:156–89. 25. Swartz MS, Swanson JW, Hiday VA, Wagner HR, Burns BJ, Borum R. A randomized controlled trial of outpatient commitment in North Carolina. Psychiatr Serv 2001;52:325–9. 26. Zanni G, de Veau L. Inpatient stays before and after outpatient commitment. Hosp Community Psychiatry 1986;37:941–2. 27. Dawson J, Romans S, Gibbs A. Ambivalence about community treatment orders. Int J Law Psychiatry 2003;26:243–55. 28. Vaughan K, McConaghy N, Wolf C, Myhr C, Black T. Community treatment orders: relationship to clinical care, medication compliance, behavioral disturbance, and readmission. Aust N Z J Psychiatry 2000;34:801–8. 29. Preston NJ, Kisely S, Xiao J. Assessing the outcome of compulsory psychiatric treatment in the community: epidemiological study in Western Australia. BMJ 2002;324:1244. 30. Power P. Community treatment orders: the Australian experience. The Journal of Forensic Psychiatry 1999;10:9–15. 31. Dawson J, Romans S. Uses of community treatment orders in New Zealand: early findings. Aust N Z J Psychiatry 2001;35:190–5. 32. Dawson J. Community treatment orders. Otaga Law Review 1991;l7:410–25. 33. O’Reilly RL. A survey of the use of community treatment orders by psychiatrists in Saskatchewan. Can J Psychiatry 2000;45:79–81. 34. O’Reilly RL. Does involuntary out-patient treatment work? Psychiatr Bull 2001;25:371–4. 35. Boudreau F, Lambet P. Compulsory community treatment? Ontario stakeholders’ responses to “Helping Those Who Won’t Help Themselves” Can J Commun Ment Health 1993;12:57–96. 36. Gou S, Bidel D, Johnsen J, Dyches H. Assessing the impact of community-based mobile crisis services on preventing hospitalization. Psychiatr Serv 2001;52:223–8. 37. Canadian Mental Health Association and Center for Addiction and Mental Health. [Community Treatment Order Project Update, 2002]. Located at Canadian Mental Health Association and Center for Addiction and Mental Health, Toronto, Ontario. 38. Health Canada. Best practices: concurrent mental health and substance use disorders. Ottawa (ON): Health Canada; 2001. Author(s)Manuscript received February 2004, revised, and accepted June 2004. 1. Community Treatment Order Coordinator, Royal Ottawa Hospital, Ottawa, Ontario, 2. Psychologist, Royal Ottawa Hospital, Ottawa, Ontario; Clinical Professor, School of Psychology, University of Ottawa, Ottawa, Ontario; Affiliate Scientist, Institute of Population Health, University of Ottawa, Ottawa, Ontario. Address for correspondence: A-M O’Brien, The Royal Ottawa Hospital, 1145 Carling Ave, Ottawa ON K1Z 7K4 e-mail: aobrien@rohcg.on.ca
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