Discussion

This study provides an insight into the patient population subject to CCTOs after the rate of uptake of such community measures had reached a steady state. This national sample should be generalisable to other jurisdictions with similar compulsory measures, such as requirements to accept treatment, to attend appointments and to notify professionals before any change of address. This study illustrates that the profile of an individual subject to community compulsion is often a man with a psychotic illness, living alone with a history of non-adherence to medication and services, and in receipt of long-acting injectable antipsychotic medication. This is in keeping with findings by the Institute of Psychiatry, which, following a review of 14 studies across multiple jurisdictions, concluded in its 2007 report that the characteristics of patients subject to CCTO were ‘remarkably consistent’.^{Reference Churchill, Owen, Singh and Hotopf5} Interestingly, the profile of individuals subject to hospital-based compulsory treatment in August 2007 was strikingly similar to that of individuals subject to CCTOs.

TABLE 1 Social circumstances of community compulsory treatment order sample

Social circumstances	n	%
Living alone	248	49.7
Living alone with support service input	65	13.0
Supported accommodation	65	13.0
Living with family	107	21.4
Other, including residential care	14	2.8

TABLE 2 Antipsychotic treatments prescribed in community compulsory treatment order sample

Antipsychotic treatment	n	%
Clozapine	72	14.4
Depot/long-acting injection	287	57.5
One antipsychotic	279	55.9
Two antipsychotics	161	32.3
Three antipsychotics	6	1.2
Not known (data missing)	43	8.6

TABLE 3 Other medications prescribed in community compulsory treatment order sample

Medication	n	%
Antidepressant	85	17.0
Mood stabiliser	99	19.8
Anxiolytic	210	42.1
Hypnotic	33	6.6

TABLE 4 Risk status in hospital-based and community compulsory treatment order samples

Risk	Hospital n (%)	Community n (%)
Danger to others	1 (0.1)	1 (0.2)
Danger to self	372 (27.1)	172 (34.5)
Danger to self and others	998 (72.7)	325 (65.1)
None recorded	2 (0.1)	6.6
Sample total	1373	499

TABLE 5 Diagnosis in hospital-based and community compulsory treatment order samples

Diagnosis	Hospital n (%)	Community n (%)
Mental illness	1106 (80.6)	451 (90.4)
Mental illness and personality disorder	72 (5.2)	7 (1.4)
Personality disorder	5 (0.4)	0
None recorded	4 (0.3)	0
Personality disorder and intellectual disability	10 (0.7)	3 (0.6)
Intellectual disability	56 (4.0)	10 (2.0)
Mental illness, personality disorder and intellectual disability	15 (1.1)	3 (0.6)
Mental illness and intellectual disability	105 (7.6)	25 (5.0)

Almost half of the sample were assessed as lacking capacity to consent or were actively refusing medical treatment. Every patient was deemed to lack insight into their mental disorder or need for treatment. Of the CCTO sample, 65% were deemed to pose a risk to others (in addition to self), which may indicate that clinicians are more likely to use community treatment orders in situations where risk to others is a concern but hospitalisation is not required, and adherence to medical treatment is considered necessary to minimise that risk.^{Reference Taylor6} This is suggested by a recent study of community treatment orders in Birmingham and Solihull, in which reported rates of previous violence in their sample reached 92.3%.^{Reference Evans, Makala, Humphreys and Mohan7} Evans and colleagues comment that few studies have reported on this area,^{Reference Evans, Makala, Humphreys and Mohan7} but a study by Swanson and colleagues reported 51% of their sample had a history of violence shortly before use of a community treatment order.^{Reference Swanson, Swartz, Wagner, Burns, Borum and Hiday8} Studies from New Zealand, however, have reported much lower rates of any history of aggression in their sample (38.2%).^{Reference Dawson and Romans9} A review of 11 reports of non-randomised comparative studies of community treatment order outcomes concluded that community treatment orders had no real effect on social functioning, violence, disturbed behaviour or arrest.^{Reference Churchill, Owen, Singh and Hotopf5}

Community treatment orders remain controversial, despite their widespread uptake, as indicated by a Cochrane review that concluded that 85 people would need to be subject to community compulsory treatment to avoid 1 psychiatric admission, and that 238 community treatment orders would be required to avoid 1 arrest.^{Reference Pinfold and Bindman3} Additionally, a systematic review by Churchill and colleagues concluded that community orders lacked consistent evidence of benefit.^{Reference Churchill, Owen, Singh and Hotopf5} Qualitative data were excluded from the Cochrane review, however, and some authors have concluded that community compulsory treatment does have benefits; for example, O’Reilly and colleagues, who found that patients thought community compulsion provided structure in their lives, families found community compulsion to be necessary when patient insight was limited, and clinicians ‘were more consistently positive’ than either patients or families.^{Reference O'Reilly, Keegan, Corring, Shrikhande and Natarajan10} This may reflect negative past experience of hospital on the part of the patient or reflect views at a time when patients have gained insight into their treatment needs.

Herein lies the paradox in the use of community treatment orders - international research evidence to date is contradictory but suggests that community compulsory treatment is no more effective than standard care, and yet clinicians continue to favour use of community treatment orders in arguably the more challenging clinical populations. Clearly there remains a need for further research into the effect of community treatment orders on a range of different outcomes to evidence and guide their use in everyday practice. In particular, it would be relevant to examine the impact of community treatment orders on hospital bed days and admission rates, suicide rates and patients’ level of functioning, and for further qualitative research into attitudes towards community treatment orders. At the time of writing, a separate study is being pursued to research these issues.