Compulsory community treatment: beyond randomised controlled trials
Authors: Feras Ali Mustafa
Journal: The Lancet Psychiatry (2018)

Few topics in psychiatry are more controversial than compulsory community treatment (CCT) and the research into its effectiveness, which have been subjects of ongoing debate among clinicians and academics.1Rugkåsa J Burns T Community treatment orders: are they useful?.BJPsych Advances. 2017; 23: 222-230Crossref Scopus (15) Google Scholar, 2Mustafa FA Why clinicians still use community treatment orders.Acta Psychiatr Scand. 2015; 132: 309-310Crossref PubMed Scopus (7) Google Scholar, 3Mustafa FA Notes on the use of randomised controlled trials to evaluate complex interventions: community treatment orders as an illustrative case.J Eval Clin Pract. 2017; 23: 185-192Crossref PubMed Scopus (13) Google Scholar, 4Segal SP Assessment of outpatient commitment in randomised trials.Lancet Psychiatry. 2017; 4: e26-e28Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar Critics of CCT raise concerns about the potential infringement of patients' civil rights and damage to the therapeutic alliance, and the lack of substantial empirical evidence for its effectiveness.1Rugkåsa J Burns T Community treatment orders: are they useful?.BJPsych Advances. 2017; 23: 222-230Crossref Scopus (15) Google Scholar Others, however, argue that CCT is a less restrictive alternative to compulsory admission to hospital, highlighting its perceived usefulness in clinical practice2Mustafa FA Why clinicians still use community treatment orders.Acta Psychiatr Scand. 2015; 132: 309-310Crossref PubMed Scopus (7) Google Scholar and emphasising the limitations of randomised3Mustafa FA Notes on the use of randomised controlled trials to evaluate complex interventions: community treatment orders as an illustrative case.J Eval Clin Pract. 2017; 23: 185-192Crossref PubMed Scopus (13) Google Scholar, 4Segal SP Assessment of outpatient commitment in randomised trials.Lancet Psychiatry. 2017; 4: e26-e28Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar and non-randomised5Mustafa FA Naturalistic studies evaluating “real world” OPC patients are welcome.BJPsych Bull. 2015; 39: 101Crossref PubMed Scopus (1) Google Scholar controlled studies in evaluating CCT and, in particular, the inability of randomised trials to recruit representative patients. The largest and most recent randomised trial, the OCTET trial,6Burns T Rugkåsa J Molodynski A et al.Community treatment orders for patients with psychosis (OCTET): a randomised controlled trial.Lancet. 2013; 381: 1627-1633Summary Full Text Full Text PDF PubMed Scopus (257) Google Scholar a priori excluded patients who were viewed by their clinicians as clear candidates for CCT;7Dawson J Burns T Rugkåsa J Lawfulness of a randomised trial of the new community treatment order regime for England and Wales.Med Law Rev. 2011; 19: 1-26Crossref PubMed Scopus (12) Google Scholar furthermore, as many as one in five patients who were referred to the trial refused to be randomised, raising doubts about the representativeness of the study sample. 2 years after completion of the trial,8Burns T Yeeles K Koshiaris C et al.Effect of increased compulsion on readmission to hospital or disengagement from community services for patients with psychosis: follow-up of a cohort from the OCTET trial.Lancet Psychiatry. 2015; 2: 881-890Summary Full Text Full Text PDF PubMed Scopus (31) Google Scholar patients in the sample remained highly engaged with their community services whether or not they were subject to CCT, signalling that the study might have missed the target clinical population and, thus, questioning the generalisibilty of its negative findings. Conversely, CCT has been shown in clinical practice and observational studies to substantially reduce hospital admissions of patients with more chronic and severe conditions and an established history of non-adherence to treatment and disengagement with services.2Mustafa FA Why clinicians still use community treatment orders.Acta Psychiatr Scand. 2015; 132: 309-310Crossref PubMed Scopus (7) Google Scholar, 9Rawala M Gupta S Use of community treatment orders in an inner-London assertive outreach service.Psychiatr Bull. 2014; 38: 13-18Crossref Scopus (29) Google Scholar In The Lancet Psychiatry, Phoebe Barnett and colleagues10Barnett P Matthews H Lloyd-Evans B Mackay E Pilling S Johnson S Compulsory community treatment to reduce readmission to hospital and increase engagement with community care in people with mental illness: a systematic review and meta-analysis.Lancet Psychiatry. 2018; (published online Oct 31.)http://dx.doi.org/10.1016/S2215-0366(18)30382-1Summary Full Text Full Text PDF PubMed Scopus (39) Google Scholar report the findings of the first quantitative synthesis of all evidence published in English on the effectiveness of CCT, which included 41 studies comprising 189 749 patients. The authors did a systematic review and meta-analysis of randomised controlled trials, non-randomised controlled studies, and (unlike previous meta-analyses1Rugkåsa J Burns T Community treatment orders: are they useful?.BJPsych Advances. 2017; 23: 222-230Crossref Scopus (15) Google Scholar) pre-post observational studies that evaluated the effect of CCT on readmissions, inpatient bed-days, use of community services, and treatment adherence. The meta-analysis combining randomised and non-randomised controlled studies found no effect on hospital readmissions (standardised mean difference −0·14, 95% CI −0·41 to 0·14) or inpatient bed-days (0·13, −0·08 to 0·34), a moderate increase in use of community services (0·38, 0·19 to 0·58), and a non-significant increase in treatment adherence (0·91, −0·70 to 2·51). The only difference that was shown by separately analysing randomised and non-randomised studies was that the effect on community service use became non-significant when only randomised studies were considered (two studies, 0·13, −0·03 to 0·29); these results are in line with previous meta-analyses.1Rugkåsa J Burns T Community treatment orders: are they useful?.BJPsych Advances. 2017; 23: 222-230Crossref Scopus (15) Google Scholar Nonetheless, by contrast, the meta-analysis of pre-post studies found significant improvements in all outcomes, with reductions in readmissions (0·80, 0·53 to 1·08) and inpatient bed-days (0·66, 0·46 to 0·85), and increases in community service use (0·83, 0·46 to 1·21) and treatment adherence (2·12, 1·69 to 2·55). In interpreting their findings, Barnett and colleagues highlight the vulnerability of pre-post studies to regression to the mean and temporal effects, and they conclude that the evidence does not support the use of CCT. However, a plausible alternative interpretation could be drawn from an analogous case by John M Kane and colleagues.11Kane JM Kishimoto T Correll CU Assessing the comparative effectiveness of long-acting injectable vs. oral antipsychotic medications in the prevention of relapse: a case study in comparative effectiveness research in psychiatry.J Clin Epidemiol. 2013; 66: S37-S41Summary Full Text Full Text PDF PubMed Scopus (108) Google Scholar They examined the discrepancy between negative randomised controlled trials comparing long-acting injectable antipsychotics and oral antipsychotics in preventing relapse in schizophrenia, and pre-post studies that consistently showed the superiority of long-acting injectable antipsychotics. Kane and colleagues noted that randomised controlled trials recruited patients who tended to adhere to their treatment, whether injectable or oral, leading to false-negative results; whereas, real world patients in pre-post studies who were non-adherent to oral treatment were more likely to benefit from long-acting injectable antipsychotics, resulting in fewer relapses. Remarkably, Kane and colleagues concluded that randomised controlled trials were not the gold standard for examining the effectiveness of long-acting injectable antipsychotics,11Kane JM Kishimoto T Correll CU Assessing the comparative effectiveness of long-acting injectable vs. oral antipsychotic medications in the prevention of relapse: a case study in comparative effectiveness research in psychiatry.J Clin Epidemiol. 2013; 66: S37-S41Summary Full Text Full Text PDF PubMed Scopus (108) Google Scholar and the same could be argued for CCT. The UK Government has commissioned an independent review of the Mental Health Act, which will probably result in reforming or replacing CCT (referred to in England as community treatment orders) amid concerns12Care Quality CommissionMonitoring the use of the Mental Health Act in 2009/10.http://www.cqc.org.uk/sites/default/files/documents/cqc_monitoring_the_use_of_the_mental_health_act_in_200910_main_report_tagged.pdfDate: 2010Date accessed: October 16, 2018Google Scholar that it is being used inappropriately, such as for patients without a reported history of non-adherence or disengagement, and disproportionately in patients who are Black and in ethnic minorities (ie, at higher rates than expected from the proportion of those minorities in the population). In this context, clinicians and policy makers should ensure that CCT is used only for patients with severe mental illnesses and an established history of non-adherence to treatment and disengagement from services, and that its use should be continued only if the implementation is associated with demonstrable clinical improvement. I declare no competing interests. Compulsory community treatment to reduce readmission to hospital and increase engagement with community care in people with mental illness: a systematic review and meta-analysisWe found no consistent evidence that CCT reduces readmission or length of inpatient stay, although it might have some benefit in enforcing use of outpatient treatment or increasing service provision, or both. Future research should focus on why some people do not engage with treatment offered and on enhancing quality of the community care available. Shortcomings of this study include high levels of variability between studies and variation in study quality. Full-Text PDF Open Access