The principle that people with mental health problems can be given treatment against their will while detained in hospital is well established. In the UK the Mental Health Act 2007 extended this principle by allowing people to be given such compulsory treatment at home through compulsory treatment orders (CTOs).
Leaving aside whether compulsory powers are right or wrong – they aren’t going away anytime soon – you might be surprised to know that unlike physical health (where any of us has a right to refuse treatment unless we lack capacity), the law allows compulsory treatment purely on the basis of mental illness.
While there are arguments that this is unjust, in a world where compulsion is an established fact, are CTOs and forcing people to have treatment in their own homes helpful?
The rationale behind CTOs was to avoid the potentially distressing and dislocating effects of an admission to hospital. Though at the time of their introduction, the evidence for CTOs’ effectiveness was inconclusive, the possibility of delivering treatment at home rather than in hospital struck me as, if not exactly good, then potentially better than the status quo. However, seven years after their introduction there is still uncertainty as to whether they actually help avoid hospital admission. And articles about them are usually critical.
A summary of the OCTET trial, one of most important investigations of CTOs carried out, was published in Psychiatric Bulletin in January and is the largest controlled trial of CTOs ever conducted. It compared 333 people, some of whom had treatment plans involving such orders, and some who didn’t. The short version of their findings is that there was no reduction in hospital admissions for people on CTOs. Both admission rates and length of stay were essentially indistinguishable in the two groups. As someone who thought CTOs were a good idea, this gives me a twinge of unease.
But is the case closed? Not quite. In the face of the Oxford evidence, other contributors to the Psychiatric Bulletin suggested three points to consider.
There may be other indices by which CTOs can be considered helpful – frequency of clinical contact and rates of preventable physical illness are areas where CTOs seem to produce positive effects. Though you may hear the creak of moving goalposts, there is some merit in this. And readmissions may not necessarily be seen as a failure in treatment.
One other potential limitation of the OCTET trial, which lumps together a large and diverse group, is that it does not focus precisely enough on specific sub-groups who may benefit; for example, those on CTOs for a protracted time period. And there have also been been suggestions that the OCTET trial may partly be affected by the participation of clinicians who are lukewarm towards, or outright negative about, CTOs. This could also have affected the results of the trial. In other words, it may not have been a fair test. One suspects angry letters to the journal’s editor are on their way.
So where does this leave us? Critics like Joanna Moncrieff have said that the that OCTET shows that CTOs have failed to meet their intended purposes and should be given the boot. Those taking a more circumspect line argue the evidence is still insufficient for a final decision and further work is needed, especially to establish more precisely if particular groups benefit.
One thing I’m struck by is that inconclusive evidence is seen as a reason to continue with CTOs rather than to suspend, or abandon, them. It’s true that ultimately practice in healthcare must often make policy before the evidence is in, otherwise innovations would never occur. Nonetheless, the evidence in favour of CTOs has been far less convincing than I expected.
It worth reminding ourselves that compulsory powers have a significant effect on people. Having treatment forced on you, especially if the treatment concerned consists of powerful medication or electroconvulsive (ECT) therapy, just add additional trauma to the orignial difficulties.
On balance, the weakness of the evidence has moved me from being a lukewarm supporter of these kinds of orders to a confirmed sceptic.