Implications of community treatment orders

Sir : I should like to comment on some of the points made by Llewellyn-Jones & Donnelly (Psychiatric Bulletin, March 2000, 24, 16-17) in their letter about community treatment orders (CTOs). First, they minimise the importance of the side-effects of medication. These are not only extrapyramidal in nature, but encompass a large number of other undesirable symptoms, which many patients, quiet reasonably, do not wish to experience. Their observation that tardive dyskinesia can occur in patients who have never taken medication is a non-sequitur - would they similarly dismiss the role of smoking in causing lung cancer on the grounds that some people who do not smoke also develop the disease ?

Second, the suggestion that psychiatrists might have a ‘duty’ to enable their patients to comply with treatment in the community is a dangerous one, as it implies that in certain circumstances we are ‘morally obliged’ to go against people's wishes for their own good. This is a familiar argument which has been used to justify various forms of coercive and/or radical treatment (including psychosurgery - see for instance William Sargant's (1967). The Unquiet Mind). No doubt psychiatrists, just as much as doctors in other fields of medicine, would like their patients to comply with the treatment they prescribe and feel that they would be better off as a result. Whether this should be enforced by legislation is another matter.

Compulsory treatment in the community raises important issues, several of them discussed in the original article by Moncrieff & Smyth (Psychiatric Bulletin, November 1999, 22, 544-546). Many mental health workers are justifiably concerned about the implications of CTOs for the relationship between professional and patient as well as for individual patient rights. I do not think that Llewellyn-Jones & Donnelly offer persuasive arguments in their favour.