Paliperidone – a costly option for schizophrenia

Lepping & Malik’s analysis ¹ of the conditions placed on patients subject to a community treatment order (CTO) in England and Wales, and suggestions for improving their robustness, is timely. We have only recently seen the results of the OCTET study published in The Lancet, ² which showed that CTOs are no more effective in reducing rates of readmission to hospital than Section 17 leave. The study also found that CTOs confer no greater benefits for patients in terms of clinical or social functioning. In the authors’ words, ‘their current high usage should be urgently reviewed’.

There are two points made by Lepping & Malik that might be elaborated on.

The first is that CTOs ‘have been very popular with treating teams and clinicians’. This suggests all psychiatrists are in favour of CTOs. In fact, the use of CTOs has varied considerably, and one consultant psychiatrist has gone on record saying: ‘I have not used CTOs in my practice despite having a large community caseload, and have removed CTOs if patients are transferred to my care on them. I justify this because they lack an evidence base’. ³ We should not forget either that there have been occasions when approved mental health professionals (AMHPs) - often forgotten in this whole debate - have vetoed clinicians’ applications.

Second, the authors suggest that CTOs ‘have been used more than anticipated’. Certainly, their use has been higher than the Department of Health estimated at the time. However, estimates have been published by the King’s Fund, based on my own analysis, ⁴ which suggested that in the first years of a new act, up to 5000 people would be placed under an order (pretty much reflecting the numbers today), and that the use of orders in England and Wales was likely to build over a period of some 10-15 years to between 7800 and 13 000 people in total.

It remains to be seen whether the latter estimate will be accurate. Much will depend on whether clinicians change their practice in the light of the OCTET evidence. There is certainly an urgent need for the Department of Health and the Royal College of Psychiatrists to encourage clinicians to limit CTO applications only to genuinely ‘revolving door’ patients with impaired decision-making (as in Scotland), a history of non-engagement followed by relapse with significant risk to self or others, and a known positive response to medication given.

Of course, in the light of both past reviews pointing to a lack of evidence that CTOs are associated with any positive outcomes, ⁵ and the recent OCTET findings, there is a strong argument for repealing the CTO powers completely. Whether or not there is the political will to do so is another matter.