Doubts About the Clinical Effectiveness of Community Treatment Orders

Community treatment orders (CTOs) have largely superseded earlier leave schemes and spread to most (though not all) Canadian provinces since their introduction to Canada, in Saskatchewan, in 1995. Their use may be increasing, possibly due to continuing deinstitutionalization of psychiatric services. The Canadian Psychiatric Association (CPA) has also endorsed their use in a Position Paper, provided, it says, ‘‘specific legal rights and safeguards are in place’’ and a ‘‘comprehensive package of psychiatric and community support services’’ is available. p 1,6 The weight of the evidence for the clinical effectiveness of CTOs has been growing weaker, not stronger, however, in recent years. There is no robust evidence that the mandatory element in a CTO—the requirement to accept outpatient treatment under an order—produces greater clinical benefits for patients than simply offering them the same package of services on a voluntary basis.