The epistemic challenges of CTOs

19 April 2016

Controversy around the use of community treatment orders (CTOs) arises in part from their ambiguous evidence base. Recent research has provided valuable new insights into the effects of CTOs, while also highlighting the critical importance of first understanding what CTOs are and what they are meant to achieve. A genuine public discourse on the significance of CTOs will have multiple perspectives. This necessitates a more pluralistic approach to constructing the necessary knowledge of CTOs to enable communities to make sound decisions about their use. Despite the controversies surrounding their efficacy, the utilisation of community treatment orders (CTOs) is increasing worldwide.1,2 Debates about ethical and human rights issues relating to CTOs span all jurisdictions, whether CTOs are a recent development (as in the 2007 Mental Health Act provisions in England and Wales) or more established (as in the provisions first introduced in the Australian state of New South Wales in 1990). These debates concern the principle of using coercion in clinical practice, the impact of CTOs on the autonomy and privacy interests of individuals, and the provision of appropriate mental healthcare that is not reliant on unnecessary compulsion to compensate for under-resourced community services.3–6 Such issues are common to all jurisdictions, despite the variations in legislative provisions for CTO systems, which include differences in the criteria for applying CTOs and the powers given to healthcare providers. These concerns are highlighted by the significant variation in the rates of use of CTOs around the world,7 which has prompted concerns about their use being determined by various factors besides clinical need.8,9 The controversy arises, in part, from the inconsistent results of research into CTOs, which has failed to demonstrate positive clinical outcomes and which reveals that patients, carers and clinicians have mixed views about CTOs.4,10,11 Although existing research into CTOs may be accurately representing variation and inconsistencies in their application, the heterogeneity and inadequacies of the evidence base10,12 make it difficult to draw conclusions from the published literature. Nevertheless, it is important to take proper account of the data that do exist.