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|Year : 2019
: 61 | Issue : 10 | Page
|Is it the right time to implement Community Treatment Order in India?
Guru S Gowda1, Arun Enara1, Bevinahalli Nanjegowda Raveesh2, Mahesh Gowda3
1 Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
2 Department of Psychiatry, Mysore Medical College and Research Institute, Mysore, Karnataka, India
3 Department of Psychiatry, Spandana Health Care, Bengaluru, Karnataka, India
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|Date of Web Publication||8-Apr-2019|
| Abstract|| |
India enacted the Mental Healthcare Act, 2017 (MHCA 2017) on April 7, 2017 to align and harmonize with United Nations Convention on Persons with Disabilities and the principles of prioritizing human rights protection. While MHCA 2017 is oriented toward the rights of the patients, the rights of the family members and professionals delivering treatment, care, and support to persons with severe mental disorder (SMD) often suffer. MHCA 2017 mandates discharge planning in consultation with the patients for admitted patients and makes the service providers responsible for ensuring continuity of care in the community. The concerns surrounding the chances of relapse and recurrence when a person with a SMD stops medications continue to remain largely unaddressed. The rights-based MHCA 2017 makes it difficult for the prevailing practices of surreptitious treatment by the family/caregiver and proxy consultations on behalf of the patients. This will, in turn, lead to increased chances of relapse, risk of violence, homelessness, stigma, and suicide in persons with SMDs in the community, largely due to noncompliance to treatment. This will also result in increased caregiver burden and burnouts and may also cause disruptions in the family and the community. To strike a balance over the current MHCA 2017, there is a need to amend or bring-forth a new law rooted in the principles of community treatment order.
Keywords: Community treatment order, India, Mental Healthcare Act 2017, severe mental disorders
|How to cite this article:|
Gowda GS, Enara A, Raveesh BN, Gowda M. Is it the right time to implement Community Treatment Order in India?. Indian J Psychiatry 2019;61, Suppl S4:816-20
| Introduction|| |
Community treatment order (CTO) is a way of helping persons with severe mental disorder (SMD) through legal order by a magistrate or mental health tribunal. CTOs often set terms under which a person must follow treatment provisions while living in the community for his/her mental well-being. It is often viewed as a mild form of a coercive treatment option in psychiatry. It is reserved for persons with SMDs who have non-adherence to medications. CTO allows and authorizes outpatient care in the community when the patient cannot take treatment-related decisions. CTOs can also be viewed as a potential way of deinstitutionalization of psychiatric care and providing care in the community setting. This has also become a clinical and policy decision of the hospitals, to reduce readmissions rate and the need for emergency psychiatry care. Overall, CTO aims to provide community-based care to a person with SMD and to reduce the morbidity of SMD due to poor compliance, under the ambit of the right to health and welfare of the patient, family, and the community. CTOs reduce the public–private health-care cost related to emergency care and readmissions. In the international context, CTOs have faced strong oppositions from rights-based activists. CTOs were first introduced in the USA, and their use varied significantly between states. It was subsequently introduced in Australia and New Zealand. Several European countries have introduced CTO legislation, including Scotland in 2005 and England and Wales in 2008., The CTOs are an accepted legal practice in many western countries. It was known by various names such as outpatient commitment, involuntary outpatient treatment, involuntary outpatient commitment, compulsory community treatment, compulsory ambulatory treatment, and assisted ambulatory treatment. There is also an array of ethical and legal issues surrounding the practice of CTOs in western countries.
CTOs can be broadly classified into preventive CTOs and least coercive/restrictive CTOs. Preventive CTOs aim to prevent violence and other foreseeable circumstances. Least coercive/restrictive CTOs focus on least coercive/restrictive care to prevent hospitalization. In this article, we review the international perspectives, the arguments for and against CTO, as well as the relevance of CTOs on the background of Mental Healthcare Act, 2017 (MHCA 2017) in India.
| International Perspectives|| |
Rationale and background
The international perspectives on CTOs rationalize its use to prevent relapse or to provide a less restrictive alternative to hospital for a person with SMD. This was one way to ensure care for patients after the policy of deinstitutionalization. Initially, CTOs as a provision for patients were welcomed by civil activists, considering the least restrictive nature of care. It was also looked upon as an option to protect the public from dangerous persons with SMD. On the downside, the CTOs have often been criticized for being a measure that could be misused to get a larger proportion of people to compulsory care. They have also been criticized for human rights abuse and violations. Further, CTOs have also been blamed for reducing the use of proactive approaches through which one motivates the patients to involve in their own care. The USA predominantly practiced the least restrictive CTOs over the preventive CTOs during the inception of CTO in the country. However, toward the later years, there has been a shift to practice preventive CTOs in the country. The Wisconsin CTO is unusual in the US in having features of least restrictive CTOs while including an explicitly preventative element. In Canada, there are only very few jurisdictions that practice CTOs, and the two predominant ones practice only preventive CTOs. Further, the consent criteria in these jurisdictions vary and often create issues for psychiatrists to implement CTOs. The CTOs in New Zealand have been implemented since 1992 and have very little opposition for its practice in the country. Most states of Australia practice CTOs and work in accordance with the concept of “conditional release,” “least restriction,” and “preventative commitment” all in one procedure. CTOs are looked upon as an effective post-discharge option in both Australia and New Zealand. There is a restriction on the duration, the maximum often being 6 months. In Israel, the CTO laws are modeled around the laws in the USA and often leave room for clinical decisions, with an onus on least restriction and personal liberty. The first CTO to be introduced in Europe was in Scotland and provided a clause to ensure treatment and prevent deterioration. In most jurisdictions, a patient is placed on a CTO after discharge from an involuntary hospitalization. The common duration of the treatment in the initial order is 6 months.
Patients, caregivers, and clinician perspectives
Patients who were subjected to CTO perceived a lack of control over various aspects of their lives. They were concerned about the issues related to unpleasant side effects and frequent appointments at the hospital and felt that it negatively impacted their well-being. They felt constantly under surveillance and stigmatized.
From the perspective of the family, the CTOs are often viewed as an option to ensure continuity of care and to prevent untoward outcomes. The coercion quotient is often ignored by the family members for want of a better outcome. There are also studies that point to family members being worried about the experience of coercion and the consequence of the same on the patient. The family members also did not experience themselves as particularly stigmatized when a CTO was in place. The family members also appeared to feel more involved in the care of their relative as a result of the order. The overall positive impact on family relationships reported by relatives is consistent with the improvements in relationships reported by the patients who also referred to the family's improved sense of safety, lessened stress, and reduced burden of monitoring.
The descriptive studies on CTO point toward the clinicians preferring to work in systems where CTOs are available. It is also reported that the views among psychiatrist on CTOs get more positive over time. Many also believe that CTOs have positive clinical outcomes.
Patient characteristics and clinical outcome
The characteristics of the patient population subjected to CTOs largely remained consistent across jurisdictions and service contexts. The patients were predominantly male, in middle age, diagnosed with schizophrenia, and with a history of nonadherence and multiple admissions. They were also single, self-neglecting, relatively isolated, and had a history of criminal offense or violence in the past.
A systematic review  included 72 papers published till 2006: most reported descriptive or observational studies, but 28 papers investigated CTO outcomes, including the two randomized controlled trials (RCTs) from the USA and the Cochrane review. Eleven papers reported nonrandomized studies and 14 analyzed RCT data. The general quality of the evidence base was found to be “poor,” and studies showed discrepant results. The authors concluded that there was no robust evidence of positive or negative outcomes of CTOs.
One further systematic review  included 18 outcome papers from 2006 to 2013. It concluded that the balance of current evidence is that CTOs do not confer advantages. Like the other reviews, it recommended standardization of outcome measures so that more studies may be included in future reviews and more patients pooled in meta-analyses.
There are also questions raised on the published evidence for CTOs and their effectiveness. However, treatment options such as assertive community treatment and case management have demonstrated good outcomes for patients who are nonadherent. CTOs improve compliance with treatment, which contributes to reduced positive and negative symptoms, shortened hospital stays, and improved functioning. The available research indicates a lack of effectiveness of CTOs on patient outcomes and hospitalizations., Although the effectiveness of CTOs is lacking, there will still be a set of patients who require mandated treatment merely for control and relapse prevention. It is important to look into the cultural context and the social and family fabric in which these studies are conducted. There is a definite need for more studies to gain clarity on CTOs.
| Community Treatment Orders: Arguments for and Against – Public Health and Stakeholders' Perspectives|| |
The arguments for and against CTOs vary among stakeholders such as the patients, caregiver/family, clinician, and rights-based activists. These arguments will also depend on the cultural contexts and value systems from which the stakeholders come. The perspectives and viewpoints of each stakeholder are important. [Table 1] looks at arguments for and against CTOs from the stakeholders' perspective. The arguments for the CTO far outnumber the arguments against it. This supports the need for CTO from the stakeholders' perspective. From the public health perspective, the presence of CTO ensures the least restrictive care for a patient who is refusing care and prevents foreseeable emergencies. This will ensure continuity of care which plays a major role in improving the outcome  and will also decrease the treatment costs on the public health system.
|Table 1: Community treatment orders: Arguments for and against – stakeholders and public health perspective|
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| Relevanceof Community Treatment Order in Indian Mental Healthcare|| |
Mental health system and India
In India, the role of the family is vital in the care of persons with SMD. Some studies report that ≥90% of patients with SMD live with family members. The roles of the family members are multiple and include supervising medications, arranging for follow-up, bringing the patient for inpatient care, staying with the patient during the inpatient care, and providing financial support. The family also makes treatment decisions on behalf of the patient, which is in line with the cultural fabric of the country. The decisions taken by the family are often not seen as violations of the individual's autonomy from the social and cultural perspective. A study from Mysore, India showed that the family is very important in providing care and assists the nurses during inpatient care of psychiatric patients. A recent study from South India showed that the prevalence of involuntary admission in psychiatric patients is 85% in a tertiary psychiatric setup. Caregivers reported risks of harm to self, altered biological function, and risk of harm to others as the most common reasons (82.5%, 81.5%, and 64.5%, respectively) for seeking involuntary admission. Caregivers used threat (52.5%) as the most common method of coercion, followed by persuasion (48.5%), to bring the patients to the hospital for care, and as a result, 16.5% of the patients eventually agreed and consented for a consultation. Overall, it was not easy for caregivers to convince the patients for consultation. A study observed a rate of 52% for nonadherence to treatment in schizophrenia patients in India. To address the problems of nonadherence, the family practiced surreptitious medication/covert medication.
The study on determinants of outcome of SMD and other studies showed good outcome for SMDs in India over the countries in the west. The role of the family structure and the involvement of family members in the treatment and care of the person with SMDs were regarded as protective factors that promote a positive clinical outcome. Overall, the role of family is integral and fundamental in the Indian context, and the social paternalism should be balanced with the individual autonomy of a person with SMD to ensure better outcomes for the person.
A rapidly changing social, political, and cultural fabric of the Indian society has led to an increase in the nuclear family structure in urban India. This offers a much more compelling case for CTOs. When persons with mental illness do not have the support of the family, there is a need for the state to step-in and provide care for the patients such that they do not become a risk to themselves or the society. The absence of such provisions will augment the dilution of social obligations and in turn lead to the suffering of the individual and the society.
Community Treatment Order and MHCA 2017
MHCA 2017 aims to protect, promote, and fulfill the rights of persons with SMD during the delivery of care. Its section 98 talks about discharge planning as a compulsory procedure for all patients discharged from a mental health establishment. This is done in consultation with the patient. The objective of the discharge planning is to ensure continuity of care at the community. The act makes the psychiatrists liable by putting the onus of care of the patient in the community their prerogative. On the other hand, a CTO can also be viewed as Comfortable Treatment Order/Complete Treatment Order for the patient and a Convenient Treatment Option or Collaborative Treatment Option for the psychiatrist to ensure continuity of care in the community, respecting the autonomy of the patient and looking at the caregivers' need and the sociocultural fabric of the country.
MHCA 2017 is highly patient rights oriented and often undermines the rights of family members and professionals in the care and support of persons with mental illness. Curtailing the role of the family, which is the cornerstone of Indian society, is equivalent to undoing all the progress done so far in mental health care.
By taking away the rights of the family, there is a high chance of increasing the legalities involved in the care of the mentally ill. This will prevent the family from taking help in the form of (a) proxy consultations, (b) proxy prescriptions, and/or (c) covert medications during emergencies. In the Indian context, the proportion of people who perceive coercive experiences during treatment are much lower than in the west, and further, the perceived coercion and subjective coercive experience decrease at discharge. Possible factors that play a role in this include treatment improving the capacity related to decision-making and subsequently autonomy. Perception of coercion may also be influenced by cultural factors, societal factors, and medical and social paternalism in the country. Taking this into regard, the role of CTO is paramount in ensuring care and protection of the person with SMD in the Indian context.
Fostering and enhancing the resilience of the family members, is what would be ideal, in the Indian scenario. However, MHCA 2017 curtails the roles and responsibilities of the family and limits their power. This could prove to be a social disaster, leading to severe disruption in the families of those suffering from an SMD and could further worsen the sigma. This could also lead to untreated SMDs and increase rates of homeless mentally ill, crime, and violence., Many doctors might become more defensive in clinical practice and could resort to herculean legal measures, which will bring in delays in the treatment and will affect patient care and outcome. Involuntary admission could be done only when the patient is at risk for self or others, and there is no provision for the doctor to provide help, to the patient or the family, in anticipation of risky situations.
The legal system in India is overloaded, and there is a priority to dispense off the existing cases. Bringing in more legalities in the treatment of persons with SMD might paralyze the Mental Health Review Board's right from its inception, and this may bring in delays in the treatment. This can also worsen the illness and can lead to a risk to the individual and society.
Majority of the patients need to be on maintenance treatment for SMD. Unfortunately, providing complete autonomy and upholding the patient rights may indirectly contribute to multiple relapses because of treatment refusal. This becomes all the more relevant in the context of MHCA 2017 not taking into account the need for maintenance treatment to prevent relapse/recurrence and thereby increasing treatment costs for emergency care. This puts forth a case for an amendment in MHCA 2017 or a new legislation on addressing the issue of compliance and prevention of deterioration in the community through treatment options like CTO. In the Indian context, when there is a scarcity of data in terms of effectiveness or ineffectiveness of CTO, over-relying on the western data without taking into account the social and family fabric of our country will be a regressive step, especially when the role of families in the outcome of mental illness in India is proved time and again.
| Conclusion|| |
The clinical outcome and effectiveness of CTO from the international perspective neither supports nor contradicts its legal use in psychiatric patients. The arguments for CTO far outnumber the arguments against the same, when viewed from a multi-stakeholder and public health perspective. To ensure continuity of care at community through discharge planning, to address nonadherence to treatment in a person with SMDs in the community, and to strike a balance over the rights-based MHCA 2017, there is a need to amend it or bring-forth a new law rooted on the principles of CTO. Such legislation will take into account the inherent strengths of the Indian society and ensure treatment adherence and long-term care for a person with SMD.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Arun Enara
Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru - 560 029, Karnataka
Source of Support: None, Conflict of Interest: None