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Community treatment orders and associations with readmission rates and duration of psychiatric hospital admission: a controlled electronic case register study
  1. Wikus Barkhuizen1,
  2. Alexis E Cullen1,
  3. Hitesh Shetty2,
  4. Megan Pritchard2,3,
  5. Robert Stewart2,3,
  6. Philip McGuire1,2,
  7. Rashmi Patel1,2
  1. 1 Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
  2. 2 NIHR Maudsley Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, UK
  3. 3 Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
  1. Correspondence to Dr Rashmi Patel; bmj{at}


Objectives Limited evidence is available regarding the effect of community treatment orders (CTOs) on mortality and readmission to psychiatric hospital. We compared clinical outcomes between patients placed on CTOs to a control group of patients discharged to voluntary community mental healthcare.

Design and setting An observational study using deidentified electronic health record data from inpatients receiving mental healthcare in South London using the Clinical Record Interactive Search (CRIS) system. Data from patients discharged between November 2008 and May 2014 from compulsory inpatient treatment under the Mental Health Act were analysed.

Participants 830 participants discharged on a CTO (mean age 40 years; 63% male) and 3659 control participants discharged without a CTO (mean age 42 years; 53% male).

Outcome measures The number of days spent in the community until readmission, the number of days spent in inpatient care in the 2 years prior to and the 2 years following the index admission and mortality.

Results The mean duration of a CTO was 3.2 years. Patients receiving care from forensic psychiatry services were five times more likely and patients receiving a long-acting injectable antipsychotic were twice as likely to be placed on a CTO. There was a significant association between CTO receipt and readmission in adjusted models (HR: 1.60, 95% CI 1.42 to 1.80, p<0.001). Compared with controls, patients on a CTO spent 17.3 additional days (95% CI 4.0 to 30.6, p=0.011) in a psychiatric hospital in the 2 years following index admission and had a lower mortality rate (HR: 0.66, 95% CI 0.50 to 0.88, p=0.004).

Conclusions Many patients spent longer on CTOs than initially anticipated by policymakers. Those on CTOs are readmitted sooner, spend more time in hospital and have a lower mortality rate. These findings merit consideration in future amendments to the UK Mental Health Act.

  • mental health
  • psychiatry
  • epidemiology
  • health policy
  • medical law
  • health informatics

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  • Contributors The study was conceived by AEC and RP. Data extraction was performed by WB with support from HS and MP. Statistical analyses and reporting of findings were carried out by WB, supervised by AEC and RP. WB, AEC, HS, MP, RS, PM and RP contributed to study design, manuscript preparation and approved the final version.

  • Funding HS, MP, RS and PM receive funding from the National Institute for Health Research (NIHR) Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, which also supports the development and maintenance of the BRC Case Register. RP has received support from a Medical Research Council (MRC) Health Data Research UK Fellowship (MR/S003118/1) and a Starter Grant for Clinical Lecturers (SGL015/1020) supported by the Academy of Medical Sciences, The Wellcome Trust, MRC, British Heart Foundation, Arthritis Research UK, the Royal College of Physicians and Diabetes UK. AEC has received support from a Sir Henry Wellcome Postdoctoral Fellowship (107395/Z/15/Z).

  • Disclaimer The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. The funders had no role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript and decision to submit the manuscript for publication.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The CRIS data resource received ethical approval as an anonymised dataset for secondary analyses from Oxfordshire REC C (Ref: 08/H0606/71+5).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request. The data accessed by CRIS remain within an NHS firewall and governance is provided by a patient-led oversight committee. Subject to these conditions, data access is encouraged and those interested should contact RS (, CRIS academic lead.

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