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Research Team: Tom Burns, Jorun Rugkåsa (OCTET Manager), Ksenija Yeeles, Andrew Molodynski, Krysia CanvinStephen PuntisTanya Smith, Francis Vergunst , Julia Sinclair, Maria Vazquez-Montes

Study details: OCTET is a randomised controlled trial of Community Treatment Orders, which we started in 2008 and we will report on towards the end of 2012. We are currently extending the trial in  OCTET - Follow-up study 

Community Treatment Orders (CTOs) became part of the Mental Health Act in England and Wales in November 2008. CTOs were designed to assist the so called ‘revolving door’ patients who have long histories of involuntary hospital treatment followed by repeated relapse and readmission soon after discharge. Patients on CTOs need to agree to comply with compulsory treatment in the community and can be recalled to hospital should they fail to do so.

CTOs have been highly controversial. They have generally been met with opposition from patient advocates and with mixed views among clinicians. While some view CTOs as ethically inappropriate because of infringement to people’s rights and freedom, others see them as potentially beneficial to patients and their families, as only a minor amendment to current law, or as a way of harmonising practice and law.

There is currently no high quality research evidence for the outcomes and effectiveness of CTOs. While several international studies have analysed outcomes of CTOs in different jurisdictions, the majority have been observational, non-randomised or explorative studies from which it is problematic to generalise. Only two randomised controlled trials (RCTs, the ‘gold standard’ test to establish causality) have been conducted. Both are from the US and both have methodological weaknesses (for a brief outline of current research, click here)

A rigorously conduced RCT in this jurisdiction is the only methodology which can convincingly address the current lack of evidence. An urgent need for such a trial has been identified by academics, policy makers and mental health practitioners alike, who are concerned that without it, the practice of restricting patients’ freedom under a CTO is not based on evidence of patient benefit. The study is funded by a NIHR programme grant.

Working with mental health teams across England, OCTET will recruit 300 patients as they prepare for discharge from involuntary treatment in hospital (under section 3 or unrestricted section 37of the MHA). The trial will compare the new provision with what is currently available for patients who need on-going supervision in the community by allocating patient at random to experimental (CTO) or control group (other available treatment) and compare outcomes over 12 months.

The aim of the trial is to improve patient outcomes by informing mental health policy and practice by:

 • Providing rigorous and convincing evidence as to CTO effectiveness

• Demonstrating whether adding CTOs to high quality community care reduces readmission rates and affects a range of other patient outcomes

• Identifying patient characteristics and care patterns associated with good outcomes

• Informing an economic analysis to model the national cost of introducing CTOs

• Contributing to training for effective implementation

The key research questions are:

• Does the use of CTOs reduce the rate of readmission to hospital in individuals with a psychotic illness and an established history of frequent relapses?

• Does the use of CTOs improve compliance with anti-psychotic medication?

• Does the use of CTOs improve clinical and social outcomes, reported quality of life and satisfaction with services?

The trial will also seek to establish:

• Baseline patient characteristics associated with outcome

• Treatment patterns associated with outcome

• In depth experiences of patients and families

• Ethical and practical challenges experienced by staff

• Cost effectiveness of CTOs

A qualitative sub study is also underway, and this will involve in-depth interviews with service users, their families and clinicians to explore how people experience this form of outpatient treatment.

Further Information... Both OCTET and OCTET Follow-up study are funded by a Programme Grant from the NIHR [RP-PG-0606-1006)