Naturalistic outcomes of community treatment orders: antipsychotic long-acting injections versus oral medication

Abstract

Background: Community treatment orders (CTOs) are initiated to compel the patient in the community to take part in a management plan, of which medication is often a part. CTOs were introduced in 2008, in England and Wales. We evaluated naturalistic outcomes of CTOs, according to the antipsychotic formulation prescribed at CTO initiation. Methods: A cohort study with prospective consecutive sampling and 1-year follow-up was conducted in a large mental health trust in South London. Measures included: demographics, psychotropics and CTO outcomes. Comparison groups were long-acting injection (LAI) versus oral formulations only, for the primary outcomes of time to CTO cessation in days and time to first hospital admission in days, whilst the CTO remained active. Results: For the 188 included patients, the CTO ceased within 1 year, either due to revocation (22.3%), discharge (28.1%) or lapse (19.7%). The CTO was renewed at 6 months for 92 (48.9%) patients, and then 56 (29.8%) were renewed again at 12 months. The antipsychotic formulation at CTO initiation was more likely to be LAI (60.6%) than oral (39.4%). Time to CTO cessation was longer for LAI than oral (median 251 versus 182 days, p = 0.030). A total of 54 patients experienced at least one admission; there was no difference between groups by drug formulation (oral 28.4% versus LAI 28.9%, p = 0.933). The mean time to first admission was 147.1 days and did not differ by formulation. Conclusions: CTO duration was longer for those prescribed an antipsychotic LAI at CTO initiation, although the time to first admission and number of admissions did not differ between groups. CTOs not only compel treatment, but bind services to the patient, resulting in more intensive follow up. Whether enhanced treatment, via oral or LAI and enabled by the CTO, translates into improved clinical outcomes is yet to be determined.