Swanson et al's (Reference Swanson, Swartz and Borum2000) paper comes at an opportune moment in the on-going debate about Community Treatment Orders (Reference Harbour, Bailey and BingleyHarbour et al, 2000; Reference Protheroe and CarrollProtheroe & Carroll, 2000; Reference Turner, Salter and HowlettTurner et al, 2000). Although not described in detail in their recent article, involuntary out-patient commitment (IOC) (Reference Swartz, Swanson and WagnerSwartz et al, 1999) has much in common with after-care under supervision or supervised discharge in England and Wales. In particular, medication cannot be enforced, patients can be escorted by law officers to the clinic, and sanctions for non-compliance seem non-existent in the absence of grounds for re-detention. In spite of this, and given the acknowledged limitations of the randomised controlled trial reported, there seem to be benefits in reductions in violence and in re-hospitalisation. The message is, however, more complex than simply subjecting patients to IOC; those that benefit are subject to IOC for longer periods (over 6 months) and have frequent contacts with psychiatric services (≥3 per month). Violence seems to be reduced in part by adherence to medication and decreased substance misuse. For readmission IOC was most effective in non-affective psychoses.

Our own experience following the introduction of supervised discharge in 1996 (Davies et al, Reference Davies, Bruce and Fallow1999, Reference Davies, Fallow and Bruce2000) is of an increase in community survival after being subject to supervised discharge and longer survival to readmission. After 18-36 months of follow-up, 15 of 22 patients had not been readmitted to hospital, whereas only one patient survived for an equivalent period before supervised discharge.

The finding that effective IOC must be supported by frequent service contact may, in retrospect, provide evidence for the ambiguous assertion in the Mental Health (Patients in the Community) Act 1995, that supervised discharge “will help secure that he receives the after-care services so provided”. Mr Boateng, then Health Minister, stated at the initiation of the Review of the Mental Health Act 1983 that “non-compliance with agreed treatment programmes is not an option”. The advent of Community Treatment Orders in the UK seems inevitable; what evidence exists suggests that they will be effective for some patients with psychosis but only in conjunction with frequent contacts with effective community services.