An Updated Meta-Analysis of Randomized Controlled Evidence for the Effectiveness of Community Treatment Orders

Abstract

Objectives: It is unclear whether community treatment orders (CTOs) for people with severe mental illnesses can reduce health service use, or improve clinical and social outcomes. Randomized controlled trials of CTOs are rare because of ethical and logistical concerns. This meta-analysis updates available evidence. Method: A systematic literature search was performed of the Cochrane Schizophrenia Group Register, Science Citation Index, PubMed, MEDLINE, and Embase to November 2013. Inclusion criteria were studies comparing CTOs with standard care including those where control subjects received voluntary care, for most of the trial. Results: Three studies provided 749 subjects for the meta-analysis. Two compared compulsory treatment with entirely voluntary care, while the third had control subjects receiving voluntary treatment for the bulk of the time. Compared with control subjects, CTOs did not reduce readmissions (risk ratio 0.98, 95% CI 0.82 to 1.16) or bed days (mean difference [MD] −16.36; 95% CI −40.8 to 8.05) in the subsequent 12 months ( n = 749). Moreover, there were no significant differences in psychiatric symptoms (standardized MD −0.03; 95% CI −0.25 to 0.19; n = 331) or the Global Assessment of Functioning (MD −1.36; 95% CI −4.07 to 1.35; n = 335). Only including the 2 studies that compared compulsory treatment with entirely voluntary care made no difference to the results. Conclusions: CTOs may not lead to significant differences in readmission, social functioning, or symptomatology, compared with standard care. Their use should be kept under review.