Community treatment orders: clinical and
social outcomes, and a subgroup analysis
from the OCTET RCT
Rugk asa J, Molodynski A, Yeeles K, Vazquez Montes M, Visser C,
Burns T, for the OCTET Group. Community treatment orders: clinical
and social outcomes, and a subgroup analysis from the OCTET RCT.
Objective: Despite widespread use internationally, there is no convincing
evidence that community treatment orders (CTO) (legal regimes making
out-patient treatment compulsory), reduce readmission rates or have
wider patient benefit. The primary and secondary outcomes of the
Oxford Community Treatment Order Evaluation Trial (OCTET)
(hospitalisation) showed no benefit. This article will, first, test the effect
of community compulsion on wider clinical and social outcomes and on
patients’ experiences of services and the use of treatment pressure and
second, explore differential effects in different groups of patients.
Method: OCTET is a RCT of CTO effectiveness. Three hundred and
thirty-six patients were randomised and data for the 333 eligible
patients were collected from interviews and medical records at baseline,
6 and 12 months.
Results: There was no significant difference at 12 months between the
two arms in any of the reported outcomes, except a small difference in
patients’ view of the effectiveness of treatment pressure, which is
unlikely to be clinically meaningful. Two statistically significant
interactions were found in the subgroup analysis: symptoms interacted
with age and with education, but no pattern was demonstrated.
Conclusion: CTOs do not have benefit on any of the tested outcomes, or
for any subgroup of patients. Their continued use should be carefully
reconsidered.
J. Rugk asa
1,2
, A. Molodynski
2,3
,
K. Yeeles
2
, M. Vazquez Montes
4
,
C. Visser
2
, T. Burns
2
, for the
OCTET Group*
1
Health Services Research Unit, Akershus University
Hospital, Lørenskog, Norway,
2
Department of Psychiatry,
University of Oxford, Oxford, UK,
3
Oxford Health NHS
Foundation Trust, Oxford, UK, and
4
National Institute for
Health Research Oxford Biomedical Research centre and
Nuffield Department of Primary Health Care Sciences,
University of Oxford, Oxford, UK
Key words: coercion; community psychiatry; psychotic
disorders; randomised controlled trial
Jorun Rugk asa, Health Services Research Unit, Akershus
University Hospital, 1478 Lørenskog, Norway.
E-mail: jorun.rugkasa@ahus.no
*OCTET Group members are listed in Acknowledgements.
Accepted for publication November 6, 2014
Significant outcomes
•
Compelling patients to adhere to treatment does not have patient benefits on the wide range of clini-
cal and social outcomes reported, or for any prespecified subgroups.
•
Our results are consistent with the accumulating body of research into the effectiveness of community
compulsion: non-randomised studies show discrepant results while randomised studies consistently
fail to find support for patient benefit.
•
The use of community compulsion continues to increase internationally despite the lack of evidence
for effectiveness. Our findings indicate an urgent review of the use of CTOs is needed.
Limitations
•
As the trial was powered for the primary outcome measure of hospital readmission, it is possible that
differences in other outcomes or between subgroups might have been detected in a larger sample.
•
The outcome ‘type of medication’ was not prespecified and the explorative analysis of this outcome
should be interpreted with caution.
•
There were a number of protocol violations as described, but per protocol analyses did not alter the
primary findings.
1
Acta Psychiatr Scand 2014: 1–9 © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
All rights reserved
DOI: 10.1111/acps.12373
ACTA PSYCHIATRICA SCANDINAVICA