Use of community treatment orders to prevent psychiatric hospitalization

Objective: The purpose of the present study was to analyse how, for whom, under what circumstances, and with what consequences for a patient's treatment career the community treatment orders ( CTOs) were used to prevent psychiatric hospitalization during the course of a decade in Victoria, Australia. Method: Records were obtained from the Victorian Psychiatric Case Register for 8879 patients who were exposed to CTOs. Descriptive statistics and logistic regression were used to determine the characteristics of patients solely selected for placement on orders directly from the community, in lieu of hospitalization, versus patients selected for placement on orders only from the hospital or for those who experienced both hospital- and community-initiated orders. Ordinary least squares regression was used to evaluate the relationship of sole reliance on community-initiated orders and experienced changes in future hospital utilization. Results: CTOs were infrequently issued directly from the community by comparison with outpatient orders issued at termination of inpatient episodes. Patients whose placements on orders were carried out only through direct community placement differed from those whose placement was primarily initiated from hospital or from both hospital and community. The former group, although largely consisting of people with schizophrenia, was less likely to include such patients than the comparison samples. It also included fewer male subjects and 'never married' individuals as well as more individuals with major affective disorders. Those served solely with community-initiated orders had significantly less use of subsequent inpatient care than individuals in the comparison samples, all other diagnostic and pre-morbid adjustment characteristics taken into account. Conclusion: For patients at risk of beginning a career of long-term psychiatric hospitalization, sole reliance on community-initiated orders appeared to prevent additional hospital involvement. The issuance of orders from hospital and the combined-order strategy were associated with protective oversight throughout extended inpatient careers. Sole reliance on community-initiated outpatient orders provided a 'least restrictive' alternative to hospitalization.