The Oxford Community Treatment order Evaluation Trial (OCTET)

On 3 November 2008 supervised community treatment orders become available for the first time in England and Wales. These have been in discussion for nearly 20 years and are well established in Australia and New Zealand, and were introduced in Scotland 2 years ago. They have been controversial for a range of reasons – legal, ethical and empirical (Lawton-Smith et al, 2008). We are conducting a randomised controlled trial of their effect.

Why is this study necessary?

Many clinicians have criticized the introduction of community treatment orders without convincing scientific evidence of their effectiveness; in particular no convincing randomised controlled trial. The OCTET aims to remedy this. We have a unique opportunity as there is currently genuine clinical equipoise about their value. Despite a range of opinions nobody can confidently claim to know that community treatment orders are either better or worse than current practice. In such a situation it is both ethical and imperative to test the hypothesis.

Who is eligible?

We aim to randomly allocate patients who their clinicians (you) consider suitable for a community treatment order or management without a community treatment order for a period of 12 months. Eligible patients are those currently detained in hospital on section 3 (or unrestricted, non-forensic, section 37) with a primary diagnosis of psychosis. Learning from the North Carolina study (Swartz et al, 1999) we will restrict patients to those you think need sustained community treatment orders (i.e. months not weeks) and to services that can offer to provide weekly contact.

What does it mean for me in practice?

We have explored the ethical and legal implications of our trial at great length and confirmed that it is both lawful and practical. You would identify patients and ask them if they will see us. Our researchers will explain the study to your team and the patients and obtain written informed consent and conduct interviews at baseline, 6 and 12 months. If randomised to non-community treatment order you would continue to manage the patient as you do now (a mixture of section 3, section 17 and voluntary care). If randomised to a community treatment order then you would proceed with that. Other than trying to maintain weekly contact your clinical practice is entirely unconstrained. We anticipate that a proportion of patients in both arms will be discharged to voluntary care (either by you or the Mental Health Review Tribunal (MHRT)). We have confirmed that the MHRT understands that while the new Code of Practice recommends that section 17 should not be repeated it does not oblige it.

This is a vital trial for UK psychiatry and may inform practice internationally. The window of opportunity to conduct it is narrow (the first 18 months after introduction) so please consider taking part. We have prepared detailed briefing for clinicians, MHRT members and legal representatives, which, along with various fact sheets, are available on our website (www.psychiatry.ox.ac.uk/research/researchunits/socpsych/research/octet/) and would be delighted to discuss and explain more by emailing [email protected].