1. Community Treatment Orders use in Assertive Outreach Dr Mohammed Al-Uzri Consultant Psychiatrist & Honorary Professor (University of Leicester)

2. Acknowledgment Dr Chinyere Iheonu, Dr Zena Bayatti, Dr Fabida Noushad, Dr Mohammed Abbas

3. Contents AOT CTO The Study Discussion

4. Assertive Outreach Team Patients who have a severe and enduring mental illness, and who are difficult to engage. Often issues with poor compliance with medication. Patients often require admissions under the Mental Health Act

5. Mental Health Act In 2007, amendments to the MHA, included Community Treatment Order (CTO) replacing Supervised Discharge. This came into force in November 2008. Patient must be detained under section 3, hospital order, hospital direction or transfer direction to be eligible for CTO.

6. Community Treatment Order (CTO) mandatory conditions of a CTO patient makes themselves available for examination to consider the extension of the CTO, patient will make themselves available for examination by a SOAD for the purposes of providing a Part 4A certificate

7. Community Treatment Order (CTO) Responsible Clinician can include additional conditions, such as compliance with treatment Patient giving access to the treating team If any of these conditions are not met by the patient, they can be recalled to hospital.

8. Community Treatment Order (CTO) Once recalled, patient can stay for 72 hours after which can Revoked Discharged Stay informal

9. What do we know about CTO? Community treatment orders for patients with psychosis (OCTET): a randomised controlled trial Supervised community treatment: 2-year follow-up study in Suffolk. Use of community treatment orders in an inner- London assertive outreach service.

10. The Study Aim: whether a CTO makes a difference to the number of admissions, the number of bed days, the number of total community visits by the (AOT) the number of missed community visits by the patients. approved by the local R & D department

11. Methodology retrospective study All AOT patients who had been on a CTO between October 2009 and June 2013 Identified from the Trust’s Mental Health Act Administration Office database Hospital records were reviewed to obtain demographic data and psychiatric diagnosis for the patients

12. Methodology Data Collection Tool ; Demographic data Psychiatric diagnosis Date CTO commenced Length of time on CTO (in months) Total number of admissions Total length of admissions (in days) Total number of planned community visits Number of community visits missed by patients

13. Methodology “study period”; length of time on CTO was calculated in months from the start and end dates of the CTO identified from the Mental Health Act Administration Office database. “control period”; equivalent period was calculated for each patient and was taken from the period before the CTO commenced.

14. Methodology The primary outcome measure; total number of admissions (excluding index admission) identified from the Trust database (MARACIS). The secondary outcome measures; the total length of inpatient stay (in days), total number of planned community visits by AOT staff and number of planned visits missed by the patients. A paired-samples t-test was conducted to compare the outcome measures in the two periods ( pre CTO and on-CTO).

15. Results 394 patients under the care of the AOT (144 F and 251 M) 66 patients were identified as being on a CTO 63 patients were included in this study ( 3 patients excluded due to insufficient data) Of the 63 patients, 42 Male and 21 Female

16. Results Primary diagnosis; 46 patients (73.0%) had Paranoid Schizophrenia, 13 (20.6%) had Bipolar Affective Disorder and 4 (6.3%) had Schizoaffective Disorder. The mean length of the CTO was 19.9 months, with a range of 2.0-42.5 months. The age of the patients ranged from 27 to 71, with a mean age of 42 yrs.

17. Admission data and community visits before and after the use of CTOs Pre CTOOn CTO Mean Difference C.I of mean difference tdfP MeanSDMeanSD Number of admissions 2.001.611.111.430.890.53 – 1.25 4.95 63 < 0.0001 Bed days243.97248.9585.31162.17158.65102.21-215.09 1.15 63 < 0.0001 Visits in Total164.60225.34143.56141.6321.03-15.43 – 57.50 1.15 610.253 Missed Visits15.6320.6213.6925.011.93-2.41 – 6.28 0.89 610.377

18. Discussion statistically significant reduction in the number of admissions and bed days when a CTO is in place ( total of 8145 bed days saved) the decision to use CTO is not based on an experimental design, but on a detailed clinical knowledge of patients allowing better decision about suitability legal framework (CTO) may benefit certain patients who respond better to clearer boundaries ensuring better concordance with medication and subsequently lower chance of relapse

19. Limitation Sample size Observational/naturalistic study Generalizability

20. Conclusion CTO can make significant impact for the appropriate patients and team CTOs is a cost-effective intervention ?

21. Thank you Questions?