Sir: It is good to see the debate concerning Community Treatment Orders (CTOs) opening again in the Bulletin (Moncreiff & Smyth, Psychiatric Bulletin, November 1999, 23, 644-646).

In response, we would like to make the following points. Moncrieff & Smyth portray a dismal picture of response and tolerability to neuroleptic medication. As they note, a proportion of patients do not improve with conventional neuroleptics. Sensibly, this minority group would be excluded from compulsory treatment orders. Strict inclusion criteria would determine this. Relapse prevention is not all gloom either. Although around 55% of patients with schizophrenia may relapse during one year without medication, this compares with 20-25% on antipsychotic drugs (Reference Dixon, Lehman and LevineDixon et al, 1995). Psychosocial interventions may further enhance this reduction in relapse.

The hazards of extrapyramidal side-effects are also cited. These are, most commonly dose-dependent. Lower doses (i.e. less than 600 mg chlorpromazine equivalent) may be equally efficacious (Reference Dixon, Lehman and LevineDixon et al, 1995) and better tolerated than higher ones. The welcome advent of atypical neuroleptics has offered our patients alternative treatments that have a much lower incidence of these unwanted effects. The risk of more permanent neurological damage, for example, tardive dyskinesia is a recognised complication of long-term neuroleptic treatment. However, it has been observed in untreated populations and should not be a reason to bar medication.

Moncrieff & Smyth at least concede that our patients may prefer to live in the community. If we had at our disposal a chance to keep them there in better mental health, surely this would lead to a duty to facilitate this process.