News Release 

Study finds that Community Treatment Orders do not reduce hospital readmission rates or stays

This research finds that CTOs are associated with an increased risk of readmission as well as increased time spent in psychiatric hospitals

King's College London

In the first large, observational study with a control group in England and Wales, research funded by the NIHR Maudsley Biomedical Research Centre has found that Community Treatment Orders (CTOs) are associated with an increased risk of readmission as well as increased time spent in psychiatric hospitals, contrary to results from previous uncontrolled studies. Researchers suggest that these findings should be considered in future reforms to the UK Mental Health Act.

CTOs were introduced in England and Wales under the 2007 amendment to the Mental Health Act (1983). They are a legal order for compulsory monitoring and treatment of people discharged from psychiatric hospitals with serious mental disorders within a community care setting. They also allow quicker readmission to hospital, if necessary, following suspected relapse. Their use has exceeded initial expectation and 5,000 are now used in England each year on average.

Researchers compared 830 patients who were discharged on a CTO with 3,659 patients discharged to voluntary community mental healthcare. Results showed that in the two years following discharge from psychiatric hospital, patients on CTOs spent, on average, 17.3 additional days in hospital and had a 60% greater rate of readmission compared to patients receiving voluntary care. The study also found that the average CTO lasted three years, more than four times longer than initial government projections of nine months.

These findings are contrary to previous uncontrolled observational studies carried out in the UK and Wales, some of which reported a reduction in readmission rates in patients on CTOs. However, the addition of a control group of patients discharged without a CTO in this study allowed researchers to compare outcomes more robustly than in previous studies.

These results could be due to the tendency for patients with CTOs to have historic relapses and severe symptoms, or due to the ease of readmission through the CTO pathway.

Lead author Dr Rashmi Patel, MRC UKRI Health Data Research UK Fellow at the Institute of Psychiatry, Psychology & Neuroscience at King's College London, said: "Community Treatment Orders were designed to prevent relapse and readmission to hospital for people with serious mental illnesses. In fact, our study suggests that they have the opposite effect, with people on CTOs being more likely to be readmitted and spending longer in hospital. In light of these findings, we need to think carefully about what role (if any) CTOs should play in providing care to people with serious mental illnesses".

Co-author Dr Alexis Cullen, Research Fellow at the Institute of Psychiatry, Psychology & Neuroscience at King's College London added "While we cannot establish a causal effect of CTOs on readmission rates, our findings concur with smaller randomised controlled trials from the UK in showing that readmission rates are not reduced. Importantly, our inclusion of patients treated in forensic psychiatric settings (who have been excluded from previous studies) means that our sample is more reflective of the patients who typically receive these treatments."

Researchers used the Clinical Record Interactive Search (CRIS) system which has access to over 400,000 anonymised electronic health records from the South London and Maudsley NHS Foundation Trust. Records available from patients who were discharged between 2008 and 2014 under the Mental Health Act were analysed.

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The findings have been published today (5 March 2020) in BMJ Open.

Notes to editors

To find out more and for a copy of the embargoed paper, or to arrange interviews, please contact the Communications team at NIHR Maudsley BRC:

· Alex Booth, Communications and Engagement Manager, NIHR Maudsley Biomedical Research Centre, Tel 020 7848 0495 alex.booth@kcl.ac.uk

· Serena Rianjongdee, Communications and Engagement Officer, NIHR Maudsley Biomedical Research Centre, Tel 020 7848 2137 serena.rianjongdee@kcl.ac.uk

Notes to editors

The Clinical Records Interactive Search (CRIS) system was funded and developed by the NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, and by a joint infrastructure grant from Guy's and St Thomas' Charity and the Maudsley Charity.

The National Institute for Health Research (NIHR) is the nation's largest funder of health and care research. The NIHR:

  • Funds, supports and delivers high quality research that benefits the NHS, public health and social care
  • Engages and involves patients, carers and the public in order to improve the reach, quality and impact of research
  • Attracts, trains and supports the best researchers to tackle the complex health and care challenges of the future
  • Invests in world-class infrastructure and a skilled delivery workforce to translate discoveries into improved treatments and services
  • Partners with other public funders, charities and industry to maximise the value of research to patients and the economy

The NIHR was established in 2006 to improve the health and wealth of the nation through research, and is funded by the Department of Health and Social Care. In addition to its national role, the NIHR supports applied health research for the direct and primary benefit of people in low- and middle-income countries, using UK aid from the UK government.

This work uses data provided by patients and collected by the NHS as part of their care and support and would not have been possible without access to this data. The NIHR recognises and values the role of patient data, securely accessed and stored, both in underpinning and leading to improvements in research and care. http://www.nihr.ac.uk/patientdata

About King's College London and the Institute of Psychiatry, Psychology & Neuroscience

King's College London is one of the top 10 UK universities in the world (QS World University Rankings, 2018/19) and among the oldest in England. King's has more than 31,000 students (including more than 12,800 postgraduates) from some 150 countries worldwide, and some 8,500 staff.

The Institute of Psychiatry, Psychology & Neuroscience (IoPPN) at King's College London is the premier centre for mental health and related neurosciences research in Europe. It produces more highly cited publications in psychiatry and mental health than any other university in the world (Scopus, 2016), with 31 of the most highly cited scientists in this field. World-leading research from the IoPPN has made, and continues to make, an impact on how we understand, prevent and treat mental illness and other conditions that affect the brain. http://www.kcl.ac.uk/ioppn

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