Transcript Treatment Delayed * Liberty Denied

CTOs and ACT:
Necessary? Effective?
Ethical?
R. O’Reilly
A Successful CTO – Background
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27 year old single male
Diagnosis – Paranoid schizophrenia
7 previous hospitalizations
Several charges
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Assault
Concealed weapon
Possession drugs
Threatened GP with knife
Abused cannabis & other drugs
Successful CTO – Admission
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Hearing messages from electric wires
Believed members of a motorcycle gang were
going to kill his brother
Rambled into brother’s school yelling and
threatening to kill people
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Had a short hospitalization
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Discharged: assaulted mother and brother
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Readmitted as an involuntary patient
Successful CTO – Hospital Course
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Believed patients were transmitting the smell of
farts to his nose
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Believed the nurses were giving him erections
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Very agitated
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Gradually settled on high-dose oral risperidone
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Psychotic symptoms resolved, but no insight
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Adamant that he would not take medication or
follow-up with team when discharged
Successful CTO – Treatment Plan
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Transferred to an ACT team
Placed on a CTO
Mother substitute decision maker
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Treatment Plan
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Take medication as directed
 See Dr. O’Reilly monthly
 ACT visit home daily for medication observation
 Live in area served by the ACT team
 Provide urine for random drug screens
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Successful CTO – Follow-up
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Initially lived with mother and brother
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GP agreed to take him back (reluctantly)
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ACT team did daily medication observation
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ACT team helped patient get identification
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Patient complied, but kept minimal contact
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At 2nd renewal, mom refused CTO consent
Successful CTO – Outcome
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Stopped medication when off CTO
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Became symptomatic and threatened family
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Readmitted to hospital as involuntary patient
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Mom again consented to CTO
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Patient insisted risperidone be stopped
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Placed on LAI typical antipsychotic
Successful CTO – Aftermath
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Did have 2 subsequent short voluntary
admissions associated with heavy drinking
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In last 6 years, has had no symptoms
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Agreed to take medication without CTO
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Moved to his own apartment
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Little motivation, but no legal charges
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Briefly held a part-time job
An Unsuccessful CTO - Background
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27 year old single male
Diagnoses –
 Bipolar disorder type 1
 Antisocial and narcissistic personality traits
 Polysubstance abuse
Dull normal intelligence
4 previous hospitalizations
Assaultive when manic
Unsuccessful CTO – Admission
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Non-adherent to medication
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Abusing cannabis and cocaine
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Became manic with delusions that he was God
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Evicted from apartment
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Up all night shouting and aggressive in shelter
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Hospitalized involuntarily
Unsuccessful CTO – Hospital Course
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Treated with sodium valproate and quetiapine
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Many assaults and periods in seclusion
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Slowly resolved over 8 month admission
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Referred to an ACT team
Unsuccessful CTO – Treatment Plan
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Live in a 24-hour supervised group home
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See Dr. O’Reilly every 2 months
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Take medication as prescribed by Dr. O’R
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See ACT workers 3 times weekly
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Refrain from using cocaine
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Give urine for drug screen on request
Unsuccessful CTO – Outcome
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Took treatment and attended appointments
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Continued to use cannabis, no evidence cocaine
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Mood remained stable
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Good therapeutic relations: occasional tensions
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9 months moved to non-supervised group home
Unsuccessful CTO – Outcome
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Quickly non-adherent with medication regimen
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ACT team instituted daily medication observation
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Not available for medication observation
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Started using cocaine
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Multiple breaches of CTO with 4 hospitalizations
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Deterioration of therapeutic relationships
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Gave nurse a cold urine sample – Gave up!
Unsuccessful CTO - Aftermath
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Attempt to manage with ACT alone
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Patient agreed to injections of risperidone
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Re-hospitalized after 6 months with mania
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Took injection – limited adherence to oral
medications when discharged
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Ongoing substance abuse
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Further hospitalizations with violence
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Many legal problems
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Left the catchment area
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Why we need CTOs
Do they work?
Is ACT an alternative to using CTOs?
Review of ACT and CTOs
Which patients are suitable for a CTO?
What care and treatment under a CTO?
How long should a CTO last?
Why Do We Need CTOs?
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Deinstitutionalization is a massive public
policy experiment
Deinstitutionalization is relocating the
locus of treatment to the community
The authority to treat in hospital settings
must be extended to the community
Do CTOs Work?
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Three randomized controlled trials
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New York
North Carolina
England & Wales
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Some case-controlled studies
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Many before-and-after studies
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A few studies using data-bases
Is ACT an alternative to CTOs?
If we had sufficient services would not need CTOs
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Not when there is outright refusal of Rx
Not when ACT alone has failed because of
non-adherence to Rx
Should we try ACT alone first?
CTO can dispense with repeated cajoling
 CTO has more procedural justice
 CTO renewals can reignite irritation
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North Carolina RCT
Less 3 services per month
North Carolina RCT
More 3 services per month
Typical use of ACT and CTOs
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London, Ontario
Average
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17%
10-30%
Indiana State
Median
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16%
0-65%
Moser 2009
Research on ACT and CTOs
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CTO & ACT compared with ACT alone
Doubled engagement with services
 Halved hospitalization
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Swartz 2010
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> medication adherence & < admissions
after CTO ended:
CTO < 6 months needed ACT
 CTO > 6 months persisted without ACT
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Van Dorn 2010
ACT, CTOs and Coercion
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CTOs increase perception of coercion
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ACT does not increase perceived coercion
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No addition when CTOs & ACT combined
Galon 2011
London ACT/CTO Study
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Did you use ACT alone before adding CTO
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Yes
No
No response
57%
40%
3%
Reasons ACT Insufficient
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Patients refused medication
Patients unavailable for Rx and F/U
CTO recall powers necessary for timely Rx
Patients had violent potential or Hx
Who is Placed on a CTO?
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There is remarkable consistency in the characteristics of patients on
CTOs across jurisdictions embedded in very different cultural and
geographical settings.
The descriptive data indicate that patients are typically males,
around 40 years of age, with a long history of mental illness,
previous admissions, suffering from a schizophrenia-like or serious
affective illness, and likely to be displaying psychotic symptoms,
especially delusions, at the time of the CTO. Criminal offences and
violence are not dominant features amongst CTO patients. This
picture is largely reinforced in the comparative data, which suggest
that CTO patients are more likely to be severely mentally ill with
high hospital admission rate histories, poor medication compliance,
and aftercare needs.
The Churchill Report 2007
Who Should be on a CTO?
~Geller’s Criteria~
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Wants to leave hospital
Previously failed in community
Understands treatment order
Can comply
Not dangerous if complies
Treatment previously effective
Treatment meets the patient’s needs and can be
delivered by system
Treatment can be monitored
Outpatient system must be willing partner
Inpatient system must be willing partner
Geller 1990
Who Does Well on a CTO?
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Patients refusing Rx who can be convinced
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Patients with high probability of default
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Patients who lack insight (incapable)
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Patients who respond to the treatment
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Patients with psychotic disorders
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Patients on long-acting injections
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Those without Cluster B personality disorder
Who is suitable for a CTO?
~North Carolina RCT~
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Patients with psychotic disorders who
were placed on a CTO for > 6 months
showed a 72% decrease in hospitalization
In contrast, patients with affective
disorders on CTO for > 6 months
disorders showed no decrease
Why Psychotic > Mood?
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Most mood disorder patients fully recover
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Most mood disorder patients have insight
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More mood disorder patients have PD?
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Mood disorder patients take oral meds
What Care and Treatment?
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Medication
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Clinical monitoring
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Stable residence
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Laboratory tests
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Counselling/therapy
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Refrain from substances
The Importance of Medication
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50% of patients with schizophrenia lack insight
Amador et al 1993
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74% of patients with schizophrenia nonadherent within 2 years of discharge
Weiden & Olfson 1995
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When LAIs stopped in 1st episode patients, 78%
relapsed within 1 year and 96% within 2 years
Gitlin et al 2001
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Mortality increased X 12 after stopping meds
Tiihonen et al 2006
Long-acting Injections
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Modest evidence for superior effectiveness
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Naturalistic studies stronger than RCTs
Zhornitsky & Stip 2012
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Better treatment adherence independent of
being on a CTO
Swartz et al 2001
NSW < admissions on CTO with depot vs. oral
Vaughan et al 2000
Specifying Residence on a CTO
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“Treatment can be monitored”
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Observe medication
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Daily monitoring of symptoms
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Nighttime supervision
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Limits drug use
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Three square meals
Geller 1990
Specifying Residence on a CTO
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PG&T will give consent
 The individual will reside in a group home or
residential setting which, by program design,
supports the development of life skills and
promotes treatment adherence
CCB has upheld the practice
 Case of Ms. MBG July 2003
Laboratory Tests
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Monitoring mood stabilizers
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Tests for specific medical indications
Segal 2006
Kisely 2013
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Screening for drugs of abuse
What Care and Treatment?
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Medication
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Clinical monitoring
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Stable residence
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Laboratory tests
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Counselling/therapy
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Refrain from substances
How Long Should a CTO Last?
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North Carolina study reported positive outcomes
when CTO was continued > 6 months
Actually found that the longer the CTO, the
better the outcomes
Swartz et al 1999
New York study also suggests 6 month minimum
Van Dorn 2010
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Iowa study average duration was 4.5 years
Rohland et al 2000
A Successful CTO – Background
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58 year old separated male
Diagnosis – Paranoid schizophrenia at 45
Destroyed property when living with family
3 previous hospitalizations
Past delusions about poison injected up nose
He surgically removed a polyp from his nose
Severe hemorrhage
Refused to take thyroid hormone post-surgery
Successful CTO – Admission
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Delusions that sister was poisoning family
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Saved his vomitus for analysis
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Went to the police to press charges
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Hoarding and eating rotten food
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Increasingly irascible
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Admitted as an involuntary patient
Successful CTO – Hospital Course
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Adamant that he had no mental illness
Refused medication
Attributed all physical discomfort to meds
Deemed treatment incapable
Daughter SDM
Started on injectable antipsychotic
Plan to discharge to a group home
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Gradually became less paranoid
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Referred to ACT team
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Ex-wife agreed to his return to family home
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Successful CTO – Treatment Plan
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Treatment Plan
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Take medication as directed
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See Dr. O’Reilly monthly
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Daily visits for medication observation
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Provide blood or urine for laboratory tests on
request
Successful CTO – Follow-up
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Initially unrealistic with bizarre behaviour
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Continued to attribute discomfort to meds
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Applied to the CCB every 6 months
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Reluctant to have a cystoscopy
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Gradually became less bizarre and ornery
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Good relationship with wife and children
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Good relationship with ACT team
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Mother died: I was able to help with will
An Unsuccessful CTO - Background
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31 year old single male
Diagnosis –
 Paranoid schizophrenia with polysubstance
abuse
15 previous hospitalizations
An Unsuccessful CTO - Admission
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Non-adherence to medication
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Psychotic & jumped from 5th floor window
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Fractured ribs and humerus;
lacerated liver and spleen;
pneumothorax
Unsuccessful CTO – Hospital Course
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Mother agreed to be SDM
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ACT agreed to serve patient outside area
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Plan to manage patient on a combination of LAI
and oral antipsychotic
Unsuccessful CTO – Treatment Plan
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See Dr. O’Reilly at least every 3 months
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Take medication as prescribed by Dr. O’R
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See ACT workers weekly
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Give urine for drug screen on request
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ACT must agree to change of residence
Unsuccessful CTO – Outcome
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ACT had problems from the beginning
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Often unavailable for home visits
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Drug tests positive for cocaine and opiates
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I refused to prescribe Concerta
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Refused to see me – two Form 47s
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Evicted from his apartment
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Left catchment area to live with father
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Had fight with father - superficial stab wound:
father ruptured spleen
Unsuccessful CTO – Aftermath
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Lived with various relatives
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Stole from relatives to support drug habit
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Charged with assault, but no conviction
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Had to call Security during an office visit
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ACT team still believes that ensuing treatment is
worth the cost