July 10, 2013. Compulsory admissions to psychiatric hospitals are on the rise, but there is a concurrent movement to find alternatives to hospitalization. However, two contrasting outpatient treatment strategies that aim to reduce hospital readmissions for psychosis are not effective, report a pair of U.K. studies published May 11 in The Lancet.
The first study, led by the University of Oxford’s Tom Burns and termed the Oxford Community Treatment Order Evaluation Trial (OCTET), examined the effect of mandatory outpatient care plans on hospital readmissions during the following year. Of 333 patients discharged after a diagnosis of psychosis, half received community treatment orders (CTOs), which require strict clinical monitoring and medication adherence for at least six months (Dawson et al., 2011). The remainder were discharged on a short-term “leave of absence” plan, an established practice in the U.K. Under this plan, patients can leave the hospital for hours or even days and are not subject to the same restrictions as a CTO, though adherence to the terms of the plan is mandatory, and patients remain eligible for immediate recall to the hospital.
The rate of readmission—roughly 36 percent—remained the same for both groups, suggesting that even though patients in the CTO group had over a threefold increase in the time spent under supervision while in the community, the use of CTOs did not reduce readmission rates. Noting that their results are consistent with prior small studies, the authors conclude that CTOs, which substantially restrict personal freedoms, are not beneficial to patients.
In the second trial, the Crisis Plan Impact: Subjective and Objective Coercion and Engagement (CRIMSON) study, lead author Graham Thornicroft of King’s College London, U.K., examined the effectiveness of a different approach to reducing hospital readmissions: the Joint Crisis Plan (JCP) (Thornicroft et al., 2010). This method, far less controversial than the CTO, allows the patient to specify treatment preferences ahead of any future psychiatric emergency when he or she is unfit to make such decisions. The JCP is designed to empower patients and encourage them to seek help sooner, thereby reducing the number of involuntary hospital admissions. The CRIMSON trial included 569 patients with relapsing psychosis and at least one psychiatric admission in the preceding two years. Half received a JCP, while the others received the treatment as usual under the U.K.’s Care Programme Approach. In contrast to earlier reports, the researchers found that the JCP did not reduce the number of voluntary or compulsory hospital readmissions.
In an accompanying editorial, Sonia Johnson of University College London, U.K., writes, “These two excellent papers provide no clear means of turning back the slowly rising tide of compulsory admissions. Regarding future strategies, the door remains open for further attempts to reduce compulsory admissions by engaging service users more effectively in decisions about their care.”—Allison A. Curley.
Burns T, Rugkåsa J, Molodynski A, Dawson J, Yeeles K, Vazquez-Montes M, Voysey M, Sinclair J, Priebe S. Community treatment orders for patients with psychosis (OCTET): a randomised controlled trial. Lancet . 2013 May 11 ; 381(9878):1627-33. Abstract
Johnson S. Can we reverse the rising tide of compulsory admissions? Lancet . 2013 May 11 ; 381(9878):1603-4. Abstract
Thornicroft G, Farrelly S, Szmukler G, Birchwood M, Waheed W, Flach C, Barrett B, Byford S, Henderson C, Sutherby K, Lester H, Rose D, Dunn G, Leese M, Marshall M. Clinical outcomes of Joint Crisis Plans to reduce compulsory treatment for people with psychosis: a randomised controlled trial. Lancet . 2013 May 11 ; 381(9878):1634-41. Abstract