How to Get Help for Someone with Mental Illness? Part 2: Community Treatment Order (CTO)

Last month, I talked about how to get someone who does not want psychiatric care seen by a physician or psychiatrist even if against the person's will.  This does not mean a patient will get treatment, but if appropriate, a Form 1 gives a psychiatrist up to 3 days to assess the need for treatment and  a longer stay in hospital.  This article picks up from here.

After the 72 hours is up, the psychiatrist determines if the patient can become a voluntary patient or if the patient should remain an involuntary patient.  It is common for patients to become voluntary after the form 1 expires and for them to continue with hospital admission, working with the psychiatrist on treatment decisions and a care plan.  Voluntary patients can refuse treatment and leave hospital when they like.

Should a patient be determined to require further involuntary admission by specific criteria (that I will not go into detail here, but is similar to Form 1 criteria), a Form 3 is filled out and this patient remains an involuntary patient for up to 2 weeks.  During this time, certain interventions, like emergency sedation for agitation, can be given to the patient without the patient's consent, but treatment to target the patient's underlying mental illness needs to be discussed and agreed upon between the patient and psychiatrist.  Instances where the patient is not capable to make this decision require a Form 33 to be completed and a substitute decision maker (SDM) designated to make treatment decisions on the patient's behalf.  Of course there are also criteria for how the SDM is chosen, however, I will not go into them here.

At each of these steps, the patient is given an opportunity to challenge the physician's findings, and when this happens, no new treatment can be started until the patient has had their case reviewed by a panel of up to 3 individuals (a lawyer, a psychiatrist and a community member).  Patients also have access to a lawyer if they want.  The panel hears from both sides (patient and psychiatrist) to determine if the psychiatrist has the proper grounds to proceed with involuntary admission and/or treatment.

When a patient does not challenge the Form 3 or 33, the physician is allowed to proceed with treatment for the underlying mental illness.  The most common experiences I have had is that the patient is initially too unwell to challenge the Form 3/33, so treatment is started.  The patient then improves with treatment, insight is regained and he/she/they eventually become voluntary and capable.  The rest of the admission and recovery hopefully goes smoothly from there.

In cases where patients, even when well, do not appreciate they have a mental illness that improves with treatment, a community treatment order, or CTO can be considered.  Most often CTOs are used and only eligible in patients with a pattern of repeatedly stopping treatment, becoming severely unwell as a result and requiring multiple, lengthy hospital admissions.  The community treatment order legally mandates the patient follow-up with a physician and receives treatment.  If the patient does not, the patient is brought to hospital by police for treatment administration and/or psychiatric evaluation.
Patients can challenge the CTO with the same process explained above for Form 3 and 33s.  They can do this at any time and a CTO is automatically up for renewal every 6 months.

There are considerable limitations to implementing a CTO that are worth mentioning.  I hope in describing the process, you can appreciate how a system needs to exist and function reliably for a CTO to be possible.  First, there have to be psychiatrists willing to take on these patients,  patients who are often the most severely unwell and marginalized, so their care needs can be greater and more complex.  Second, there has to be a medication that is enforceable.  What this means is that most CTOs mandate injection medications, and not all patients tolerate or respond to the injection medications available, despite them being the gold standard of care in illnesses like schizophrenia.  Oral medications are effective, but there is no guarantee the patient is taking them.  Injections, on the other hand, are given once or twice monthly by a health care provider.  Third, there has to be all the support persons required to properly execute a CTO.  This includes everyone from the person helping patients who want to challenge the CTO, to the panel, the lawyers, right up to the police officer who brings the patient to hospital when necessary.  It is no surprise then, that not all communities can support CTOs.

Next week I will tackle my own experience with CTOs and the sobering reality of caring for this patient population.