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The OCTET trial, community treatment orders and evidence-based practice

Published online by Cambridge University Press:  02 January 2018

Feras A. Mustafa
Feras A. Mustafa*
Affiliation:
Northamptonshire Assertive Outreach Team, Northampton, UK, email: [email protected]
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Abstract

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The Psychiatric Bulletin , Volume 38 , Issue 4 , August 2014 , pp. 197
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Copyright © Royal College of Psychiatrists, 2014

Based on the findings of the OCTET study, Reference Burns and Molodynski1 Burns & Molodynski reject observations of consultants who reported directly observable benefits from community treatment orders (CTOs). They argue that it is not possible to ‘see with one's own eyes’ a probabilistic outcome that takes months to manifest itself.

This is a false analogy. In a subgroup of patients, CTOs result in a striking improvement in treatment adherence: if the CTO is lifted, patients discontinue treatment; re-implement the CTO (following relapse and re-hospitalisation) and treatment adherence is achieved again. In such cases, clinicians are able to ‘see’ the effect of CTOs on treatment adherence and reasonably expect improved clinical outcomes in the longer term. With such a dramatic response (treatment adherence) to the intervention (CTO), it would be scientifically unnecessary, Reference Glasziou, Chalmers, Rawlins and McCulloch2 and ethically unacceptable, to refer patients to a randomised controlled trial (RCT).

A number of previous reports have highlighted the potentially detrimental flaws in the methodology of the OCTET, Reference Mustafa3,Reference Segal4 which could explain the apparent paradox between the naturalistic observational studies that have shown significant benefit from CTOs, Reference Rawala and Gupta5 and the negative findings of the OCTET.

Take the scenario of a young man with chronic schizophrenia, who attends the psychiatric out-patient department escorted by his carer. He has a long history of non-adherence to treatment, as well as multiple formal admissions. The patient is known to discontinue treatment immediately after discharge from hospital, invariably leading to rapid relapse and hospitalisation. Since discharge from hospital on CTO 3 months earlier, his mental stability has been maintained and he has been accepting his fortnightly antipsychotic depot injections. His positive psychotic symptoms are minimal. He has become more sociable and has applied for a part-time college course. The psychiatrist tells the patient and his carer that he is going to lift the CTO. To his dismay, the carer asks the psychiatrist ‘Have you not seen with your own eyes that the CTO works?’ The psychiatrist replies, ‘Yes I have, but an RCT says this could not have been possible’. Would this be evidence-based practice?

References

1 Burns, T, Molodynski, A. Community treatment orders: background and implications of the OCTET trial. Psychiatr Bull 2014; 38: 3–5.Google Scholar
2 Glasziou, P, Chalmers, I, Rawlins, M, McCulloch, P. When are randomised trials unnecessary? Picking signal from noise. BMJ 2007; 334: 349–51.Google Scholar
3 Mustafa, FA. On the OCTET and supervised community treatment orders. Med Sci Law 2014; 54: 116–7.Google Scholar
4 Segal, SP. Community treatment orders do not reduce hospital readmission in people with psychosis. Evid Based Ment Health 2013; 16: 116.Google Scholar
5 Rawala, M, Gupta, S. Use of community treatment orders in an inner-London assertive outreach service. Psychiatr Bull 2014; 38: 13–8.Google Scholar
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