Background
Suicide represents a global public health problem, with over 700 000 people dying by suicide each year.1 According to the most recent data in England and Wales, in 2019, there were 5691 suicides registered, representing 11.0 deaths per 100 000 population.2 Mental illness is strongly associated with an increased suicide riskReference Hawton and van Heeringen3 and all member states of the World Health Organization (WHO) have committed to improving mental health and reaching a global target of reducing suicide rates by a third by 2030.4 Identifying high-risk groups is a key preventative goal, and people under the care of mental health services, including in-patients, have been identified as a priority in England's National Suicide Prevention Strategy.5 For those with severe mental illness with impaired decision-making capacity, the use of compulsory admission and detainment for treatment under the Mental Health Act 1983 (MHA; amended 2007) is considered where there is a potential risk of harm to the patient or others. Two common detaining sections of the MHA are Section 3 (admission for treatment) and Section 37 (hospital order for those convicted of a criminal offence).
The introduction of community treatment orders (CTOs) in England and Wales in 2008 provided the option for people detained under the MHA to be treated in the community rather than in hospital. Their purpose was to reduce levels of readmission and provide supervised treatment in a less restrictive environment, while maintaining close clinical contact. Two mandatory conditions attached to a CTO involve the availability of the patient for assessment at the time of CTO renewal, and agreement to be seen by a second psychiatrist if the individual is too unwell to consent to receiving drug treatment themselves. Discretionary conditions can also be applied with the patient's agreement, typically prescribed treatment adherence and service engagement. Although treatment is not coercively imposed on patients in the community, those who show deterioration in mental health may be recalled back to hospital for assessment and medication. Qualitative studies have indicated that patients benefit from closer involvement in their care planning under a CTO,Reference Rugkåsa and Canvin6,Reference Corring, O'Reilly and Sommerdyk7 and family caregivers have viewed CTOs as a ‘safety net’, welcoming the option of recall at times of relapse.Reference Canvin, Rugkåsa, Sinclair and Burns8,Reference Stroud, Banks and Doughty9 However, the coercive nature of supervised community treatment has caused much debate, with critics viewing CTOs as punitive, restricting civil libertiesReference Munetz and Galon10 and compromising trust in the patient–psychiatrist relationship.Reference McMillan, Lawn and Delany-Crowe11 A recent systematic review and meta-analysis found inconsistent evidence that compulsory community treatment improved patient outcomes.Reference Barnett, Matthews, Lloyd-Evans, Mackay, Pilling and Johnson12 It also confirmed findings from the only randomised controlled trial of CTOs in England, the Oxford Community Treatment Order Evaluation Trial (OCTET), that CTOs did not reduce rates of readmission.Reference Burns, Rugkåsa, Molodynski, Dawson, Yeeles and Vazquez-Montes13,Reference Burns, Yeeles, Koshiaris, Vazquez-Montes, Molodynski and Puntis14 Other studies in England have reported patients on a CTO had more hospital readmissions and spent longer in in-patient care compared with those not on a CTO.Reference Barkhuizen, Cullen, Shetty, Pritchard, Stewart and McGuire15,Reference Weich, Duncan, Twigg, McBride, Parsons and Moon16 Despite the sparse evidence on whether CTOs reduce bed use and improve treatment response, they are used extensively in many countries and are often initiated to potentially reduce the risk of self-harm and suicide after discharge.
CTOs and suicide
The National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH)17 found 126 (1%) deaths by suicide among patients with recent mental health service contact were subjected to a CTO during 2009–2017, two-thirds of whom were on a CTO when they died. Of note, a third of patients subject to a CTO who died within 3 months of discharge were preceded by treatment non-adherence and missed service contact – two key elements of CTO provision. The evidence base for the effectiveness of CTOs in reducing suicide is limited: one UK observational controlled study found no association between CTOs and suicide risk among patients with schizophrenia,Reference Lopez-Morinigo, Ayesa-Arriola, Torres-Romano, Fernandes, Shetty and Broadbent18 whereas a USA study found that mandated community treatment reduced suicide risk.Reference Phelan, Sinkewicz, Castille, Huz and Link19 Further knowledge is needed to enhance our understanding of the clinical profile of patients who are placed on a CTO who subsequently die by suicide. We utilised a national case series to examine suicide risk in patients who had been treated under a CTO. Our objectives were to calculate suicide rates among patients under a CTO, and to compare rates and features of patients subject to a CTO with those who were not under CTO but who were eligible to be so; i.e. they had been detained for treatment under Section 3 or 37 of the MHA at their last admission. For this comparison, we examined suicides among patients who had ever been under CTO after hospital discharge, to take into account the possibility that the period at risk for patients dying when under a CTO may have been shorter than the equivalent period for those who were eligible for a CTO. We hypothesised that suicide risk would be highest among patients subject to a CTO (on the grounds that management without legal restriction had been viewed by clinicians as inadequate), followed by CTO-eligible patients and then all other patients discharged from in-patient psychiatric care.
Method
Study data-set
We used data from the NCISH. A detailed description of NCISH methodology is described elsewhere.Reference Appleby, Shaw, Amos, McDonnell, Harris and McCann20 In brief, there are three stages to data collection. First, NCISH is notified from the Office for National Statistics (http://wwww.ons.gov.uk) of all unnatural deaths in England with a coronial verdict of suicide or of undetermined intent (‘open’ verdict). Second, details of the deceased are sent to mental health services in the individual's residential district to identify those who had been in service contact in the 12 months before death (‘patient suicides’). Third, sociodemographic and clinical data on patient suicides are collected via a questionnaire completed by the responsible clinician. The questionnaire collects detailed information on patients who died by suicide in the community, including whether the patient was on a CTO at the time of their last discharge or death, and the length of time spent under a CTO (<6 months, between 6 months and 1 year, and ≥1 year). In addition, the nature of patients’ previous admissions (voluntary, detained for assessment or treatment, under the power of recall of a CTO) were recorded.
Deaths that were assigned an open verdict were included in the study, as is conventional in suicide research in the UK,Reference Gunnell, Bennewith, Simkin, Cooper, Klineberg and Rodway21 and are hereon referred to as ‘suicides’ in this paper. We selected all patients who died by suicide during years 2009 and 2018, inclusive.
Denominator data
For overall suicide rates among discharged patients, we applied the number of discharges as the denominator, obtained from the Mental Health Services Data Set (MHSDS) via NHS Digital.22 This national data-set holds patient-level data on all individuals in contact with in-patient, out-patient and community mental health services. To calculate suicide rates among patients who were ever subject to a CTO, we applied the number of open CTOs for the years 2009/10 to 2018/19 as the denominator. We also calculated an overall suicide rate among patients who were on a CTO at the time of death, using the denominator figures on 31 March to give a typical rate on any one day (MHSDS data were available from 2010 onward). Suicide rates among CTO-eligible patients (i.e. those detained for treatment under Section 3 or Section 37 of the MHA, but who were discharged to voluntary community care) were calculated per 100 000 admissions under Section 3 or Section 37 (excluding discharges from a CTO), with MHSDS data available for the years 2011–2018. Denominator data to calculate these rates included conversions to a Section 3 or Section 37 for those who had been voluntarily admitted. The numbers of admissions, discharges and CTOs issued were available by financial year initially; we then converted them to being by calendar year, for consistency with the numerators.
Statistical analysis
We first calculated suicide rates (and their 95% confidence intervals) across the entire observation period for all patients discharged from psychiatric care, as a baseline against which suicide rates in the subgroups of interest could be compared. Suicide rates among patients ever subject to a CTO were calculated by the total number of CTOs issued; suicide rates among patients on a CTO at the time of death were calculated by the total number of patients on a CTO on the 31 March of each year. Suicide rates among CTO-eligible patients were compared with those for persons ever treated under a CTO, stratified according to whether they had died within or after 12 months of discharge. Calendar year was fitted as a continuous variable in a Poisson regression model, to test for linear temporal trends in the suicide rate.Reference Gardner, Mulvey and Shaw23 Poisson models were tested for evidence of significant overdispersion, using the likelihood ratio test of a = 0 that is generated by the negative binomial model. Where tests indicated inadequate goodness of fit, the parameters from the negative binomial model were reported instead of those from the Poisson model.Reference Gardner, Mulvey and Shaw23 Because of small numerator values, we collapsed years into categories of 2011–2014 and 2015–2018 and compared rates between patients subject to a CTO and CTO-eligible patients via incidence rate ratios (IRRs) and their exact 95% confidence intervals. Comparison of patient characteristics between those on a CTO and all other patients (i.e. those not treated under a CTO) were conducted with chi-squared tests, with statistical significance indicated at the two-sided 5% level.
Over the study's observation period, the overall response rate for questionnaires was 95%, but was lower during calendar years 2016 (94%), 2017 (90%) and 2018 (71%) because of the time associated with legal processes and data collection. We therefore estimated the number of suicides in 2016–2018, based on the expected final return of questionnaires for the previous 7 years (2009–2015), to enable comparable numerator data when assessing rates across the study period. Descriptive statistics of patient characteristics were carried out on actual cases. All statistical analysis was performed with Stata software version 15.1 for Windows.24 Ethical approval was obtained from the North West – Greater Manchester South Research Ethics Committee (reference: ERP/96/136). NCISH also has Section 251 approval under the NHS Act 2006 (reference: PIAG 4-08(d)/2003).
Results
Over the study period 2009–2018, there were 12 771 suicides by people who had been in contact with mental health services in the 12 months before they died. Of these, 11 921 (93%) were patients treated in the community, and 143 were treated under a CTO at their last discharge (referred to as ‘ever subject to a CTO’ herein); 3.9% of all community patient suicides with a previous admission, or 1.2% of all community patient suicides. This represents a mean of 14 suicide deaths per year in those ever subject to a CTO. At date of death, 93 patients were still on a CTO and 47 had had their CTO revoked; in the remaining three cases, CTO status at date of death by suicide was unknown. There were 483 CTO-eligible patients during the observation period, i.e. those who had been detained for treatment but were not under a CTO at discharge. This group represented 7.4% of all community patient suicides with a previous admission, or 4.1% of all community patient suicides. Suicide rates among CTO-eligible patients were calculated for those who died during 2011–2018 (n = 377) as denominator data were available for that period only.
Characteristics of patient suicides ever treated under a CTO
The median age of patients ever subject to a CTO (N = 137) was 44 years (interquartile range 16 years) and 85 out of 137 (62%) were male. Over a quarter (39 out of 137, 28%) were from a minority ethnic group, proportionally more than other patients (832 out of 10 599, 8%; P < 0.001). The suicide method profile of the CTO group differed from that of other patient suicides, with a higher proportion jumping from a height or in front of a moving vehicle (46 out of 136, 34% v. 1492 out of 10 851, 14%; P < 0.001) and a lower proportion of self-hangings/strangulations (42 out of 136, 31% v. 4974 out of 10 851, 46%; P = 0.001). The most common primary psychiatric diagnosis was schizophrenia and other delusional disorders (108 out of 137, 79% v. 1536 out of 10 688, 14% of other patients; P < 0.001). Patients subject to a CTO more often had coexisting drug dependence or misuse (37 out of 137, 27% v. 1075 out of 10 633, 10%; P < 0.001).
Suicide rates
Between 2010 and 2018, the overall suicide rate among patients who were under a CTO at date of death was 191.3 per 100 000 CTO patients on the 31 March (Table 1). There was no overall linear temporal trend in rates across the study period (linear trend; 1 d.f. = 1.08; P = 0.30; see Supplementary Fig. 1 available at https://doi.org/10.1192/bjo.2021.1021). Suicide rates among patients under a CTO were lower compared with all patients discharged from in-patient care at 482.3 per 100 000 discharges (IRR 0.40; 95% CI 0.32–0.49; P < 0.001) (Table 1). There was a fall in the number (linear trend; 1 d.f. = 8.5; P = 0.004) and rate (linear trend; 1 d.f. = 4.22; P = 0.04) of suicide among discharged patients across the observation period (Supplementary Fig. 1).
Table 1 Suicide rates among all discharged patients and among patients on a CTO when they died
CTO, community treatment order; IRR, incidence rate ratio.
a. Rate per 100 000 discharges from in-patient care.
b. Rate per 100 000 patients subject to a CTO on the 31 March of each year.
c. Data shown for 2010–2013 as denominator incomplete in 2009, therefore the total does not total 93 as reported in the main text.
Table 2 shows the numbers and rates of suicide among patients ever subject to a CTO and among CTO-eligible patients (i.e. those detained for treatment but were not under a CTO at discharge). Although the number of CTOs issued increased across the observation period, the number and rate of suicide fluctuated, and there was no evidence of linear temporal trend (1 d.f. = 0.07; P = 0.79). There was, however, a significant increase in the rate of suicide in CTO-eligible patients between 2011 and 2018 (linear trend; 1 d.f. = 11.38; P = 0.001).
Table 2 Suicide rates among patients ever placed on a CTO and among CTO-eligible patients
CTO, community treatment order; IRR, incidence rate ratio.
a. Rate per 100 000 CTOs issued.
b. Rate per 100 000 discharges.
Annual suicide rates were significantly lower among patients on a CTO at the time of death (Table 1) compared with those ever subject to a CTO (350.1 per 100 000 CTOs issued; IRR 0.55; 95% CI 0.44–0.68; P < 0.001) and CTO-eligible patients (382.9 per 100 000 discharges; IRR 0.50; 95% CI 0.40–0.62; P < 0.001)) (Table 2). The suicide rate for CTO-eligible patients was slightly higher than for those ever treated under a CTO, but this difference did not reach statistical significance (IRR 1.09; 95% CI 0.99–1.21; P = 0.09). However, the rate among CTO-eligible patients who died within 12 months of discharge was lower than for patients ever subject to a CTO who died within 12 months of discharge (161.5 v. 205.1; P = 0.045; Table 3). The opposite was found when comparing suicide rates after 12 months of discharge (Table 4), when rates in patients ever subject to a CTO were lower than among patients who were CTO-eligible (153.2 v. 223.4; P = 0.003).
Table 3 Suicide rates among patients ever placed on a CTO and among CTO-eligible patients who died within 12 months of discharge
CTO, community treatment order; IRR, incidence rate ratio.
a. Rate per 100 000 CTOs issued.
b. Rate per 100 000 discharges.
Table 4 Suicide rates among patients ever placed on a CTO and among CTO-eligible patients who died more than 12 months after discharge
CTO, community treatment order; IRR, incidence rate ratio.
a. Rate per 100 000 CTOs issued.
b. Rate per 100 000 discharges.
Discussion
Our results suggest that suicide under CTO is a rare event, accounting for around 1% of all psychiatric patient suicides that occur in the community in England, for an average of 14 deaths per year nationally. We found a lower suicide rate among patients who were under a CTO when they died, compared with the rate among all discharged patients. Suicide rates were significantly lower for patients under a CTO at death compared with both the rate in patients ever subject to a CTO and in CTO-eligible patients. Overall, the suicide rate among patients ever treated under a CTO was not significantly different from the rate among patients who were CTO-eligible. We also found a difference in rates in relation to time under a CTO, with higher suicide rates within 12 months of discharge among all patients subject to a CTO compared with those who were CTO-eligible. However, after 12 months of discharge, this difference reversed, with the suicide rate among patients subject to a CTO becoming significantly lower than the rate among CTO-eligible patients.
It is well-established that suicide risk is greatly elevated after discharge from in-patient psychiatric care.Reference Chung, Ryan, Hadzi-Pavlovic, Singh, Stanton and Large25,Reference Haglund, Lysell, Larsson, Lichtenstein and Runeson26 However, both patients under a CTO and those eligible for a CTO appear to be at lower suicide risk compared with all discharged patients. There are two reasons to consider that our findings may suggest a benefit from CTOs specifically. First, the CTO-eligible patients are likely to have been at lower risk than the CTO group, hence the decision not to treat under a CTO, and the comparison of suicide rates should take into account this possible difference in risk. Second, the lower suicide rate in those under a current CTO suggests that an active CTO confers most protection. Our finding of a higher suicide rate among patients subject to a CTO within 12 months of discharge, and a lower rate more than a year after discharge, may be an indication that clinical stability takes longer to establish for patients subject to a CTO and that the main benefit is seen long term. Although there may be a causal effect that is attributable to improved care, alternative explanations are also possible, such as a longer period of pre-discharge stability in patients preparing for CTO, or selection of patients whose illnesses are more responsive to treatment.
Lower all-cause mortality rates have been previously reported in patients subject to a CTO compared with control patients, with closer community follow-up and opportunity for early identification of physical health problems cited as possible explanations.Reference Barkhuizen, Cullen, Shetty, Pritchard, Stewart and McGuire15,Reference Kisely, Preston, Xiao, Lawrence, Louise and Crowe27 Such findings provide support for the effectiveness of CTOs in providing intensive case management in the community. Other studies have also suggested that patients under CTO have better engagement with community teams and sustained contact with services compared with non-CTO groups,Reference Puntis, Rugkåsa and Burns28,Reference Lei, Barnicot, Maynard, Etherington, Zalewska and Quirk29 and published evidence has shown that optimising continuity of care for vulnerable patients is effective in reducing suicide risk.Reference Kapur, Ibrahim, While, Baird, Rodway and Hunt30
Our findings concur with those reported from previous studies, which showed that patients under a CTO have more severe mental illness and are younger compared with those discharged without a CTO.Reference Barkhuizen, Cullen, Shetty, Pritchard, Stewart and McGuire15,Reference Lei, Barnicot, Maynard, Etherington, Zalewska and Quirk29 Over a quarter of the patients subject to a CTO who died by suicide in our study belonged to an ethnic minority group. An overrepresentation of certain ethnic minority groups under compulsory treatment has previously been reported,Reference Barnett, Mackay, Matthews, Gate, Greenwood and Ariyo31 yet controlled observational studies have not found ethnicity to be associated with CTO receipt, after adjusting for associated demographic or clinical factors.Reference Barkhuizen, Cullen, Shetty, Pritchard, Stewart and McGuire15,Reference Lei, Barnicot, Maynard, Etherington, Zalewska and Quirk29 Considering the known relationship between ethnicity and psychotic disorders,Reference Halvorsrud, Nazroo, Otis, Hajdukova and Bhui32 it may be that the higher proportion of minority ethnic patients under a CTO reflects the greater prevalence of schizophrenia among the patients subject to a CTO within the NCISH case series. In line with other studies,Reference Lei, Barnicot, Maynard, Etherington, Zalewska and Quirk29,Reference Churchill, Owen, Singh and Hotopf33 we also found that comorbid substance misuse was more prevalent among patients subject to a CTO, highlighting the more complex clinical profile of these patients.
Strengths and limitations
This national study was based on robust case ascertainment and, to our knowledge, was the first to examine suicide rates among patients under a CTO. The findings should, however, be interpreted in light of certain limitations. First, the observational nature of the study precluded elucidation of causal associations. Second, we did not have specific information on risk assessments and the decision-making process for patients on a CTO. However, as risk is fundamental to the use of MHA powers, it seems likely that patients subject to its provisions are perceived as being higher risk than those who are not, whether as a result of clinical presentation or non-clinical risk factors. We also cannot establish whether specific interventions to reduce suicide risk were implemented with the patients subject to a CTO, thereby explaining the lower suicide rates. How clinician- or patient-related factors influence a CTO outcome is worthy of further study. Third, the retrospective data collection from clinicians was based on their knowledge of the patient, clinical judgement and case records, as opposed to standardised assessments. However, the reliability and validity of NCISH questionnaire data have been shown to be good, and the NCISH consistently achieves high response rates.Reference Appleby, Shaw, Amos, McDonnell, Harris and McCann20,Reference Appleby, Shaw, Kapur, Windfuhr, Ashton and Swinson34 Fourth, in patients subject to a CTO, the number of suicides that occurred across the study's observation period indicated an unstable pattern (most likely because of the small number of suicides that occurred each year), and our projected figures for the most recent years may be over- or underestimates. Fifth, denominator data were obtained from the MHSDS and therefore were not specifically collected for the purpose of conducting this study. We were therefore unable to stratify the results by age, gender or ethnicity, or estimate suicide rates by duration of care under CTO. Furthermore, some of the aggregate denominators that we applied to calculate rates may have contained multiple episodes; for instance, if more than one CTO had been issued or there were multiple discharges during a year, this may have slightly reduced the accuracy of these calculated rates. Nonetheless, the MHSDS represents the most complete source of national denominator data on mental health activity that is available for academic research in England. Finally, the findings were based on patients in England only and may not be generalisable to the devolved nations of the UK, or to other countries where CTOs are applied. They may also not be applicable to individual healthcare providers where the use of CTOs varies widely.Reference Lei, Barnicot, Maynard, Etherington, Zalewska and Quirk29 Part of this variation may lie in differences in case-loads and procedures between healthcare settings, but may also reflect differing experiences of clinicians with regard to CTOs,Reference Manning, Molodynski, Rugkåsa, Dawson and Burns35 which warrants further investigation.
In conclusion, the most important test of CTOs is whether they improve patient safety and lower suicide risk. This is difficult to accomplish via randomised controlled trials for practical and ethical issues, and therefore we are left with conducting prospective observational follow-up studies to further our understanding of the potentially beneficial effect of CTOs. Overall, the findings generated from the current study contribute to the debate as to whether CTOs are effective in enhancing patient safety. The UK Government's 2018 Independent Review of the Mental Health Act 198336 considered the implications if CTOs were replaced or reformed. This review concluded that CTOs should remain for the time being, but be reduced in number, whereas their application criteria should be tightened. We have shown evidence of the beneficial effect of CTOs in potentially reducing suicide risk, but further monitoring is needed to determine whether the rates continue to remain lower than among patients who are treated voluntarily. CTOs remain a controversial treatment option and clinicians making judgements about the use of CTOs have to consider not only risk, but factors such as patient autonomy, long-term adherence and potential stigma.
Supplementary material
Supplementary material is available online at https://doi.org/10.1192/bjo.2021.1021
Data availability
All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of data analysis; access to the data is currently ongoing. Data from this study cannot be shared because of information governance restrictions in place to protect confidentiality. Access to data can be requested via application to the Healthcare Quality Improvement Partnership (www.hqip.org.uk/national-programmes/accessing-ncapop-data/).
Acknowledgements
The study was carried out as part of the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) and we thank the other members of the research team: Alison Baird, Lana Bojanic, James Burns, Huma Daud, Julie Hall, Rebecca Lowe, Nicola Richards, Cathryn Rodway, Phil Stones and Su-Gwan Tham. We thank the administrative staff in NHS Trusts who helped with the NCISH processes, and the clinicians and nurses who completed the questionnaires.
Author contributions
All authors were responsible and accountable to all part of works related to the study. I.M.H., P.T., J.G., S.I., J.S., N.K. and L.A. contributed to data acquisition. L.A. conceived the study. I.M.H., R.T.W. and S.I. were responsible for data analysis. L.A., I.M.H., R.T.W., J.G., J.S., P.T. and N.K. were responsible for interpretation of the data. I.M.H. drafted the article under the supervision of R.T.W., N.K. and L.A. All authors critically revised and approved the final manuscript for submission. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Funding
The study was supported by the Healthcare Quality Improvement Partnership (HQIP) and was carried out as part of the NCISH. All researchers are independent from the funders. The funders of the study had no role in study design, data collection and analysis, interpretation of data, preparation of the manuscript or decision to publish. R.T.W. and N.K. are supported by the National Institute for Health Research (NIHR) Greater Manchester Patient Safety Translational Research Centre (grant reference number PSTRC-2016-003). N.K. is also funded by the Greater Manchester Mental Health NHS Foundation Trust.
Declaration of interest
All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf. L.A. chairs the National Suicide Prevention Strategy Advisory (NSPSA) Group at the Department of Health and Social Care in England (of which N.K. is also a member) and is a non-executive Director for the Care Quality Commission. He was also National Director for Mental Health in England when the CTO was introduced. N.K. chaired the guideline development group for the 2012 National Institute for Health and Clinical Excellence (NICE) guidelines on the longer-term management of self-harm, currently chairs the guideline development group for the NICE depression in adults guidelines and is a topic advisor on the new NICE guideline on self-harm, currently in development. Views expressed in the paper are those of the authors and not those of NICE or the Department of Health and Social Care. All other authors declare no other relationships or activities that could appear to have influenced the submitted work.
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