How to Get Help for Someone with Mental Illness? Part 3: "Care" on a CTO, a review of the process

I am often very grateful and impressed to live in a society where a community treatment order (a CTO) can exist.  To review, a CTO legally allows a psychiatrist to administer treatment to a patient against his/her will over a longer period of time.  When they work, the CTO is a lifeline in a chaotic, dizzying and scary place.  It is a ray of hope for family members looking to get their loved one's back from a severely compromised mental state.  Patients can be so far from their normal selves that they are at risk of significant harm to themselves and others.  I support the use of a CTO as a necessary bridge for many patients back to wellness.   I am fortunate enough to say that I have seen patients first hand recover and benefit from a CTO.  They regain their senses and look back in shock at what they had been through and what they had put their loved ones through.  I have seen them grateful for the CTO and struggle with what this all means for their lives going forward as they try to stay stable.  Many of these patients would not have had a second or third chance at the lives they want to live without an intervention like a CTO.  I do believe the CTO is an important and vital part of mental health care.

That being said, how a CTO is managed in the real world sometimes makes me wonder if it is more trouble than it is worth.  From my personal experience and from a review of the literature, those whose lives continue an onward and upward trajectory after being on a CTO are in the minority of CTO patients.

First a comment on the process of keeping someone on a CTO.  In the real world, a CTO is renewed every 6 months or at any time the patient asks for the CTO to be challenged.  In the real world, the CTO is a legal document and prioritizes due process over good clinical care.  For example, we have had CTOs stopped not because the mental health criteria were not met, but because the legal ones were not.  And patients are given lawyers to defend their cases.  An example of what might get a CTO stopped is having the wrong time on a certain form.  And though I recognize how important it is to have due process without error, I would like to remind readers that psychiatrists are not lawyers, we can not keep up with what is legally demanded from us as it changes.  I know I value staying on top of my clinical knowledge more and I have very limited time.  All to say, the process of maintaining a CTO is very inconvenient and cumbersome for any psychiatrist.  So finding enough psychiatrists willing to take these cases on is a challenge.

Ideally, a CTO helps a patient recover and part of that recovery is to regain insight so that the patient can become capable once more to look after his own mental health.  How the CTO is set up, with the frequent reviews, is that it is meant to be temporary.  In real life, this is simply not the case.  Many psychotic illnesses result in a permanent loss of insight, and so even when acute symptoms have subsided, patients do not believe they have an illness that will relapse and that needs treatment.  It would be a more sensible process if patients where permanent loss of insight and incapacity for treatment decisions have been established, have their CTOs reviewed annually or even less frequently, so long as they are stable on treatment.  I would question the psychiatrist's role at this point and suggest that the task of renewing CTOs in these patients be outsourced to a more appropriate, less costly alternative.

Ideally, the psychiatrist tasked with looking after patients on CTOs can still develop a therapeutic alliance with these patients and that the patients are then subjectively and objectively better, happier and more productive.  In real life, because the CTO must be discussed and patient's insight and capacity evaluated every 6 months or less, rapport is very difficult to establish and maintain.  These patients are angry that they are forced to participate in psychiatric care and so these relationships, in my experience, are tense and unrewarding for all involved making the assessments unreliable.  This is why I question a psychiatrist's role in maintaining CTOs in chronically unwell patients.  In these cases, the psychiatrist has not earned the patient's trust and in fact, the psychiatrist is seen as a perpetrator.  In addition, research on CTOs have found little benefit from them.  In research from England, where they have a longer history with CTOs, CTOs do not reduce the cost of care for patients, nor do they improve quality of life.   CTOs also do not improve psychiatric outcome measures like time to readmission to hospital or time to relapse.  Important to mention is that the articles I have read specifically address patients with psychosis who are on CTOs which is the most common patient population to find themselves on CTOs, and also reflects my clinical practice.

So there you have it, this article concludes the series on how to get help for someone with a mental illness.  As you can see, though there are many options, there also significant limitations and the outcomes are as varied as the patients themselves.