Abstract
In Victoria, there is insufficient integration of community treatment orders into patients' clinical management. As a result, the clinical role of CTOs is often overshadowed by administrative issues relating to their implementation and review.
With increasing pressure on early discharge plans for psychiatric inpatients, community treatment orders are often implemented shortly before discharge without incorporating the order into the patients' Management Plan beyond improving patients' compliance with antipsychotic medication. The Mental Health Act of Victoria [1] defines treatment in relation to a mental disorder as “things done to remedy the mental disorder or lessen its ill effects or the pain and suffering which it causes”.
Patients placed on a CTO must satisfy all of the following criteria [2]:
the person appears to be mentally ill;
the person's mental illness requires immediate treatment and that treatment can be obtained by making the person subject to a CTO;
because of the person's mental illness, the person should be made subject to a CTO for his or her health or safety (whether to prevent a deterioration in the person's physical or mental condition) or for the protection of members of the public;
the person has refused or is unable to consent to the necessary treatment for the mental illness; and
the person cannot receive adequate treatment for the mental illness in a manner less restrictive of the person's freedom of decision and action.
Since the Mental Health Act defines treatment of a mental disorder more broadly than just medication, it is appropriate for CTOs to be integrated with other forms of treatment in the patient's Management Plan, such as promoting a more therapeutic alliance with patients who fulfill the criteria described.
Patients discharged from a psychiatric hospitalization on a CTO are likely to perceive the order as a purely policing tool. The inpatient staff are well placed to promote more therapeutic aspects of the CTO such as providing an ongoing treatment alliance between the patient and the mental health team. A rationale for the CTO in the patient's inpatient individual service plan setting would provide continuity of care regarding the CTO by the community mental health team.
There are few clinical guidelines for discharging patients from community treatment orders [3]. Because CTOs are rarely integrated into patient's active management plan in the community, decisions about reviewing these orders are relegated by community psychiatric staff to the consultant psychiatrist prior to the annual mental health review board hearing. The decision to extend or discharge a patient from a CTO appears to be dictated more by the administrative demands of the mental health review board hearings rather than an active process of reviewing patient's management plan, including the role of a CTO.
The number of CTO extensions has jumped 43% in Victoria over the last 12 months compared to the previous 12 months while the number of inpatient CTOs has dropped marginally over the same time period [4]. It is uncertain whether these figures reflect a higher number of seriously disturbed patients who are being managed in the community or whether this reflects patterns of clinical practice in the community. With this trend of increasing community treatment orders, it is important for psychiatrists to be seen to provide a leading role in safeguarding their patients' personal liberties, such as the need for ongoing involuntary community treatment. The patient on a CTO and members of the mental health team should identify what goals in the management plan are required to be met in order that the patient can be considered for discharge from the order. A model for integrating CTOs into best clinical practice has been described elsewhere [5].
Further research into the efficacy of CTOs is required, such as identifying which patients are most likely to benefit from being on such orders [6]. The authors are researching the process of decision making regarding CTOs by clinicians and mental health review board members.
The clinical role of Community Treatment Orders should be more actively promoted by psychiatrists so as to better integrate these Orders into patients' Management Plan.