The OCTET Follow-up Study was designed to answer two questions. First, was there evidence that increased use of compulsion resulted in disengagement of patients from services? Second, was there any long-term impact of being in the original CTO arm of the study on hospitalisation and care outcomes? Neither of these was found to be the case.

All of the hospitalisation outcome measures were favourable towards the CTO group but none of these differences was statistically significant. Given that all three published RCTs used a follow-up period of either 11 or 12 months and failed to demonstrate any difference, this would suggest that any further RCT should aim at an extended follow-up period of 2 or 3 years. The practical difficulties of conducting such a trial are considerable, but it seems the more logical test than a further RCT with a restricted follow-up.

What our study did show, however, is that CTO compulsion was extensive in both groups, with a median of 308 days of community compulsion for the non-CTO group and 364 days for the CTO group over the 3 years. Once CTOs are imposed they tend to be protracted. The median of 183 days in the original OCTET Trial was clearly a consequence of the trial cut-off at 12 months and we believe our current figures are still an underestimate because of censoring at 36 months. Certainly when reliable long-term data are available, it is clear that many patients, once established on CTOs, may continue on them for very long periods, sometimes for several years.⁴

Recall was not common in our sample. Only 136 recalls were invoked in 198 patients. Of these, over two-thirds resulted in the patient being detained for treatment in hospital. This sparing use may reflect the opinions expressed by clinicians in the OCTET Qualitative Study (see Part 2, Chapter 8) that recalls were difficult to arrange and of limited practicality or use. Only two patients were discharged directly from a recall to voluntary status in the 36 months.

We were unable to distinguish confidently between managers’ hearings and MHA tribunals for CTOs and those for inpatient detention. That the lawfulness and appropriateness of detention were tested 558 times during the follow-up period does suggest that procedures were being followed and that effective scrutiny was provided. Similarly, the continued rate of contact over the 36 months (a slightly increased median of 2.8 per month compared with 2.1 CTO and 2.2 non-CTO during the first 12 months) is evidence that this patient group was receiving a substantial level of care. The rates of failed contacts emphasises just how seriously the clinical teams took their responsibilities to this very vulnerable group. That the rate of contact with the CTO group was so similar to the rate of contact with the non-CTO group would argue against the view that CTOs may work by ensuring that patients feel obliged to keep appointments through a respect for legal powers which in the USA is referred to as the ‘black robe effect’²⁰⁰ (i.e. respect for legal powers).

The OCTET Follow-up Study was conducted at a time of considerable reorganisation in mental health services. Many AOTs were being disbanded, crisis teams being reconfigured, and inpatient and outpatient consultant responsibilities being separated. Knock-on effects of these changes also included the redrawing of catchment area boundaries for teams. This is manifest in the number of consultant psychiatrists who were responsible for patients. The average patient changed consultant at least once a year. This was a consequence of the introduction of so-called ‘functional services’. In these services, inpatient and outpatient consultant responsibility is split, and this contrasts with the model of the traditional ‘integrated’ consultant who is responsible for patients both on the ward and in the community. This is a remarkable and disturbing change in provision for a group who are selected for their enhanced need for persistent supervision. Had our study been conducted a decade earlier, we would have anticipated that the majority of our patients would have had the same consultant for the whole period. This is a disruption in continuity of care that might undermine any potential benefits of CTOs or other community-based services and deserves more attention than it is currently receiving.³⁶

The figures for care co-ordinators were marginally more reassuring, with an average of just over two during the 36 months. There can, of course, be clinical reasons for changing care co-ordinators, such as from a CPN to a social worker, but these are probably rare. Most of the changes must reflect staff turnover and team changes.²⁰¹

Despite this turbulence, we found that only 19 patients (6%) were completely disengaged after 3 years. This shows a surprisingly high level of continuity of care, which contrasts with the discontinuities of professional staff. It testifies to the persistence of these teams and their active outreach. Further evidence of this persistence is provided by the fact that only 74 patients (23%) had experienced more than one discontinuity of contact over the 3 years. We also found no evidence that subgroups of patients generally considered to be more distrustful of care (such as younger patients or ethnic minority patients) experienced more disengagement or disruption of care with increasing compulsion.

There was no difference between the randomised groups in disengagement. The significant association observed between time to disengagement and duration of compulsion in the whole sample could therefore not be attributed to CTO use. In view of the low numbers who disengaged (n = 19, 6%) this needs to be interpreted cautiously.

This high level of clinical follow-up may explain why CTOs have not achieved the outcomes expected of them. Much of the motivation for the introduction of CTOs was based on the assumption that these patients were dropping out of care and consequently not being supported and encouraged to take their medicines to prevent relapse. This does not appear to be the case. English mental health teams appear to be remarkably focused and successful in providing relatively intensive and persisting contact with this patient group. This may hold for most patients with psychosis: in a parallel study of contingency management for patients treated with depot antipsychotics, the inclusion criteria had to be radically loosened because of the difficulty of finding sufficient non-adherent patients.²⁰²

We have presented our data on the association between duration of community compulsion and hospitalisation in some detail. We cannot draw any conclusions about causality from this, however. Greater community compulsion was significantly associated with the duration of psychiatric rehospitalisation and time to first readmission in this non-randomised sample. The results in this sample should be interpreted with caution, however, because of the fact that patients could be placed on a CTO during follow-up only if they had been readmitted involuntary; there is therefore an inherent bias in the nature of these data. Similarly, the time available for inpatient days was inevitably reduced for patients with longer recorded community compulsion, thereby driving an association. Given that all three of the published RCTs find that CTOs do not reduce hospitalisation or improve other, wider, outcomes, these data do not undermine the conclusion that excessive compulsion is being used to no obvious benefit.

The OCTET Follow-up Study has demonstrated that the standard of outpatient care of patients with severe psychoses is higher than perhaps anticipated. English mental health teams are successful in persistent long-term clinical follow-up of this difficult group of patients, despite repeated service reorganisations. There is no support from our findings for the concern, expressed by many patient groups during consultations prior to the introduction of CTOs (see Part 2, Chapter 5), that they might lead to a disengagement from services perceived to be more concerned with social control than treatment.

There was an unexplained divergence in readmission rates between the CTO and non-CTO groups in the 6 months directly following the end of the OCTET Trial (between 12 and 18 months after randomisation). This may simply have been a random variation, as there was no significant overall difference in any of the hospitalisation outcomes over the full 36 months. We speculated that it might reflect teams reducing their input to patients in the non-CTO group once the requirements of the original trial had been removed. To explore this, we compared the rates of contact between the CTO and non-CTO groups for the period between the 12th and 18th months but could not find any support for this explanation. Overall, however, there was a non-significant trend favouring the CTO group in all the readmission outcomes, in contrast with the original OCTET Trial. This would lend further support to our contention that any future RCT should include an extended outcome period of at least 2 years, although we recognise the practical difficulties of accomplishing this.