November 28, 2014
Forced psychiatric treatment under Community Treatment Orders (CTOs), also referred to as forced or assisted outpatient treatment, provides “no clinical advantage” to patients on any measures of any kind, according to a meta-analysis of the scientific literature published in Social Psychiatry and Psychiatric Epidemiology. “If clinicians are to take a strictly evidence-based approach, then they cannot continue to use CTOs in their current form,” wrote the team of researchers from the UK, Norway and New Zealand.
“Community Treatment Orders require outpatients to adhere to treatment and permit rapid hospitalisation when necessary,” explained the researchers. “They have become a clinical and policy solution to repeated hospital readmissions despite some strong opposition and the contested nature of published evidence.”
The researchers reviewed all of the studies of every kind done on CTOs around the world, as well as other systemic reviews that have been done, with sample sizes ranging from 50 to 128,427. They placed particular emphasis on studies published since 2006 when the last major systematic review was done.
The researchers noted that qualitative studies have found that “clinicians prefer to work in systems where CTOs are available, that views among psychiatrists often get more positive over time, and that many believe CTOs to have positive clinical outcomes.” They also found that “family members find CTOs necessary or helpful but consider the community services offered to be inadequate,” while “patients reportedly hold ambivalent views, some finding aspects of the order helpful, while also restricting their lives in ways experienced as problematic.” All three groups felt the main objective of CTOs was to reduce hospital readmissions.
The researchers found, though, that the non-randomised outcome studies showed “conflicting results,” with some showing decreases and others showing increases in hospital admissions. One of the confounders frequently seen in these studies was that different types of community support services, such as those provided through assertive community treatment programs, were often provided in conjunction with the CTOs. “In contrast,” they wrote, “all three randomised controlled trials conducted concur in their findings that CTOs do not impact on hospital outcomes.”
One of the RCTs also showed that patients on CTOs ended up being forcibly treated for far longer than the control group. The researchers commented that this “raises the ethical question whether such a significant imposition on personal liberty can be justified in the absence of significant clinical benefits.”
“CTOs do neither appear to reduce relapse and readmission nor, overall, to reduce coercion,” concluded the researchers. “If clinicians are to take a strictly evidence-based approach, then they cannot continue to use CTOs in their current form.”
In their discussion, the researchers argued that “the lack of evidence for patient benefit, particularly when combined with restrictions to personal liberty, is striking and needs to be taken seriously. Clinicians have a duty to provide their patients with treatment in the least restrictive environment. The paucity of rigorous experimental research evidence for such an invasive intervention that has been in use for over three decades is quite remarkable. It raises a question of whether this would have been accepted in other branches of medicine. Surely major, intrusive interventions in community psychiatry should be expected to conform to the highest standards of evidence.”
(Abstract) CTOs: what is the state of the evidence? (Rugkåsa, Jorun et al. Social Psychiatry and Psychiatric Epidemiology. December 2014, Volume 49, Issue 12, pp 1861-1871. DOI: 10.1007/s00127-014-0839-7)
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