Letters to the Editor
Authors Should Have Gotten the Facts Right on Community Treatment Orders
Dear Editor: I wish to correct just 2 of the factual errors in O’Brien and Farrell’s recently published article on community treatment orders (CTOs) (1). The authors refer (twice) to Australian studies: in the first reference, they describe the paper by Preston and others (2) as a small-sample retrospective study of hospital bed-day use; in the second (1), they state that Australian studies demonstrated reduced hospital use by patients on CTOs.
As one of the authors of the paper by Preston and others, I can assure readers that it was neither a small-sample retrospective study of hospital bed-day use nor a vindication of the effectiveness of CTOs (2). We used contemporaneously collected routine administrative data from all community-based and inpatient psychiatric services in Western Australia, covering a population of 1.7 million. We undertook an epidemiologic study with a before-and-after, 2-stage design of matching and multivariate analysis, controlling for sociodemographic variables, clinical features, and psychiatric history. We had a sample size of 456 subjects and control subjects. Our results showed no difference in hospital admissions or time spent in hospital between subjects on CTOs and control subjects. These results were confirmed in a later paper where we were able to adjust for forensic history (3).
Our paper’s methodology is consistent with the criteria that the Effective Practice and Organisation of Care (EPOC) group of the Cochrane Collaboration use for inclusion in Cochrane reviews (4). These include contemporaneous data collection (n = 456) and the use of appropriate control groups. I rather suspect that the data from O’Brien and Farrell’s sample (n = 25), collected retrospectively and without blinding or control subjects, would not be consistent with these criteria. Given these methodological problems, their results cannot support their sweeping claims that CTOs are effective tools for allowing patients to live in the least restrictive setting or that CTOs reduce rates and lengths of readmission.
I am aware of only one other Australian study that compared patients on CTOs with control subjects (5). In it, the authors were clearly more circumspect than O’Brien and Farrell in the interpretation of their findings. In the light of problems with matching their CTO groups and control subjects, Vaughan and others state that “Evidence of lower severity of illness in the comparison patients prevented meaningful evaluation of the readmission rates of the 2 groups” (5, p 801).
If O’Brien and Farrell wish to incorrectly interpret their own results to favour a particular viewpoint, they should at least have the courtesy to report others’ results accurately. In this case, evidence appears to be in the eye of the beholder.
References
1. O’Brien A, Farrell S. Community treatment orders: profile of a Canadian experience. Can J Psychiatry 2005;50:27–30.
2. Preston NJ, Kisely S, Xiao J. Assessing the outcome of compulsory psychiatry treatment in the community: epidemiological study in Western Australia. BMJ 2002;324:1244–6.
3. Kisely SR, Xiao J, Preston NJ. Impact of compulsory community treatment on admission rates: survival analysis using linked mental health and offender databases. Br J Psychiatry 2004;84:432–8.
4. The Cochrane Effective Practice and Organisation of Care (EPOC) Group. Resources. Available: http://www.epoc.uottawa.ca/resources.htm. Accessed 10 February 2005.
5. Vaughan K, McConaghy N, Wolf C, Myhr C, Black T. Community treatment orders: relationship to clinical care, medication compliance, behavioural disturbance and readmission. Aust N Z J Psychiatry 2000;34:801–8.
Steve Kisely MD, MSc, FRANZCP, FAFPHM, FRCPC
Halifax, Nova Scotia
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