December 2012, Volume 62, Issue 12

Opinion and Debate

‘Community Treatment Order’ — How often is it being used?

Amin A. Muhammad Gadit  ( Discipline of Psychiatry, University of Toronto, Canada. )

The new Mental Health Act in Pakistan did not bring any visible change on the horizon. Some cosmetic committees were established and few inspections were conducted in some of the mental health facilities without any visible findings, recommendations or actions. However, it has found its place in shelves and showcases like any other act or law. Lack of implementation of any policy has become an inherent tradition in Pakistan. There are still a number of people wandering in the community without proper mental health assessment and treatment. There are a number of such people who would not comply with the treatment in the absence of supervision. A number of them may be even incapable of consenting for treatment. A significant number of people are left on shrines and even abandoned. Such people are at a greater risk of mental deterioration, suicide and even homicide. The \\\'Community Treatment Order\\\' is a valuable piece of the legislature that empowers a mental health physician to compel a mentally ill person to seek and comply with the treatment. This is based on a community treatment plan which outlines the medications, medical appointments and other aspects of care that the doctor deems essential in order to allow the person to live in the community. The consent is an essential component either given by the patient or a substitute decision maker. It is also important to inform the \\\'patient\\\'s rights adviser\\\' in order to validate the process. This order can always be challenged by the patient before the panel of review board\\\'s members.
A study1 examined implementation of Community Treatment Order (CTO) in terms of clinical efficacy and ethical issues involved in its use. The findings indicated paucity of research on the efficacy of CTOs. It was also noted that concerns about their negative effects on civil liberties have been stressed in UK and American literature. Conclusion was also made about the necessity of controlled research in order to identify whether CTOs are more effective than comprehensive assertive community outreach programmes in reducing relapse rates and hospitalisation and increasing compliance. Another paper2 reviewed the empirical literature on CTO procedure\\\'s effectiveness. They found that two randomized controlled studies have conflicting findings. They concluded that CTO is effective under certain conditions, although some of the evidence has been contested and policy remains controversial. It was also implied that CTO appears to be most effective if sustained for 6 months or more. CTO prevents hospital admission but this depends upon the clinical characteristics of the individual patient, consequences of non-compliance and the duration of the CTO.3
A study4 concluded the involuntary out-patient treatment significantly lower the risk of violent behaviour in persons with severe mental illness by improving compliance with medications and diminishing substance misuse. "Studies and data from states using assisted outpatient treatment (AOT) prove that AOT is effective in reducing the incidents and duration of hospitalization, homelessness, arrests and incarcerations, victimization, and violent episodes. AOT also increases treatment compliance and promotes long-term voluntary compliance. Violation of the court-ordered conditions can result in the individual being hospitalized for evaluation to see if inpatient treatment or a modification of the court order is needed."5
"The members of APA Task Force are in agreement that such commitment to outpatient treatment can be a preferable alternative both to involuntary hospitalization and to no treatment for a specific population of patients. The patients for whom such commitment might be expected to be most effective include those with psychotic illnesses which respond well to antipsychotic medication, but who have a demonstrated pattern of noncompliance with medication after inpatient discharge. Another target population would be those patients who need externally imposed structure in order to function as outpatients, but who are not capable of requesting the establishment of such structure on their own."6
The local scenario in Pakistan in terms of mental health still appears gloomy. This picture is visible when we talk about mental health legislation and its implementation in true sense. We do not have data on the usage and efficacy of CTOs. Irony of the fact is that even it is not clearly known whether CTOs are ever used at all and if yes, then, what type of documents and forms are used and the role of review boards and patient challenges if any. This becomes even more difficult to comprehend in the background of massive human rights violations.
It is important to revisit the situation and work on this important aspect of mental health. We need elaborate understanding and education about mental health legislation and its dynamics. Can we get any input into this matter?


1. McIvor, R. The Community treatment Order: Clinical and ethical issues. Aust New Zealand J Psychiatr 1998; 32: 223-8.
2. Swartz MS, Swanson JW. Involuntary Outpatient Commitment, Community Treatment Orders and Assisted Outpatient treatment: What\\\'s in the data? Can J Psychiatry 2004; 49: 585-91.
3. O\\\'Reilly RL. Does involuntary outpatient work? Psychiatr Bull 2001; 25: 371-4.
4. Swanson JW, Swartz MS, Borum R, Hiday VA, Wagner HR, Burns BJ. Involuntary out-patient commitment and reduction of violent behaviour in persons with severe mental illness. Br J Psychiatry 2000; 176: 324-31.
5. Mental Health Policy Org. Research on Assisted Out-Patient Treatment. (Online) (Cited 2012 September 30). Available from URL:
6. American Psychiatric Association (APA).Involuntary Commitment to Out-patient Treatment. (Online) (Cited 2012 September 30). Available from URL:

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: