Effectiveness of community treatment orders: The international evidence
Open accessAbstract
OBJECTIVE: Community treatment orders (CTOs) exist in more than 75 jurisdictions worldwide. This review outlines findings from the international literature on CTO effectiveness. METHOD: The article draws on 2 comprehensive systematic reviews of the literature published before 2013, then uses the same search terms to identify studies published between 2013 and 2015. The focus is on what the literature as a whole tells us about CTO effectiveness, with particular emphasis on the strength and weaknesses of different methodologies. RESULTS: The results from more than 50 nonrandomized studies show mixed results. Some show benefits from CTOs while others show none on the most frequently reported outcomes of readmission, time in hospital, and community service use. Results from the 3 existing randomized controlled trials (RCTs) show no effect of CTOs on a wider range of outcome measures except that patients on CTOs are less likely than controls to be a victim of crime. Patients on CTOs are, however, likely to have their liberty restricted for significantly longer periods of time. Meta-analyses pooling patient data from RCTs and high quality nonrandomized studies also find no evidence of patient benefit, and systematic reviews come to the same conclusion. CONCLUSION: There is no evidence of patient benefit from current CTO outcome studies. This casts doubt over the usefulness and ethics of CTOs. To remove uncertainty, future research must be designed as RCTs.
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There is limited evidence about whether involuntary treatment is effective.
“Some interview participants in this study expressed concern that there is limited evidence about whether involuntary treatment is effective, and this concern is also echoed in the literature.”
From “Backed into a Corner”: Lived experiences of receiving and providing involuntary psychiatric treatment under British Columbia’s Mental Health Act (2026) · cites this paper as [11]
The Discussion says existing evidence does not support the desired benefits of community treatment orders (CTOs), and that uncertainty remains about whether some patients benefit. This supports the concern for compulsory treatment in the community, but the paper does not assess involuntary treatment more broadly, such as inpatient treatment. (LLM, conf=0.84)
Experimental — accuracy not yet measuredWhile non-randomised studies reported conflicting results, randomised controlled trials uniformly showed no significant differences between community treatment order cases and controls.
“While non-randomised studies reported conflicting results, RCTs uniformly showed no significant differences between CTO cases and controls.”
From The benefits and harms of community treatment orders for people diagnosed with psychiatric illnesses: A rapid umbrella review of systematic reviews and meta-analyses (2024) · cites this paper as Rugkåsa (2016)
The Abstract reports mixed results from nonrandomized studies, and the Results report no significant CTO–control difference on most outcomes in the three RCTs. But the Results (Table 2 and accompanying text; page not provided) identify exceptions: CTO patients were less likely to report being victims of crime in one trial, and spent significantly longer under compulsion in another. Thus, 'uniformly' no significant differences overstates the source. (LLM, conf=0.92)
Experimental — accuracy not yet measuredAll three sibling papers concluded that there was no robust evidence about either the positive or negative effects of community treatment orders on key outcomes, including hospital readmission, length of hospital stay, or patients' quality of life.
“All three papers concluded that there was no robust evidence about either the positive or negative effects of CTOs on key outcomes, including hospital readmission, length of hospital stay, or patients’ quality of life.”
From The benefits and harms of community treatment orders for people diagnosed with psychiatric illnesses: A rapid umbrella review of systematic reviews and meta-analyses (2024) · cites this paper as Rugkåsa (2016)
The Results section reports no evidence that CTOs improve readmission rates or length of stay, and cites a review finding no evidence of an effect on quality of life. But this paper alone cannot establish what all three papers concluded, and its Abstract reports a potential adverse effect: patients on CTOs are likely to have their liberty restricted for significantly longer. (LLM, conf=0.84)
Experimental — accuracy not yet measuredPrior systematic reviews found no evidence of patient benefits from community treatment orders.
“Similarly, prior systematic reviews found no evidence of patient benefits from community treatment orders [11].”
From “Backed into a Corner”: Lived experiences of receiving and providing involuntary psychiatric treatment under British Columbia’s Mental Health Act (2026) · cites this paper as [11]
A study drawing on two comprehensive systematic reviews concluded that there is no evidence of patient benefit from involuntary treatment practices, casting doubt over both the usefulness and ethics of these orders.
“while a study drawing on two comprehensive systematic reviews concluded that there is no evidence of patient benefit from such practices, casting doubt over both the usefulness and ethics of these orders [11].”
From “Backed into a Corner”: Lived experiences of receiving and providing involuntary psychiatric treatment under British Columbia’s Mental Health Act (2026) · cites this paper as [11]
Uncontrolled before and after studies generally reported more positive outcomes than controlled before and after or randomised controlled trial designs.
“UBA studies generally reported more positive outcomes than CBA or RCT designs.”
From The benefits and harms of community treatment orders for people diagnosed with psychiatric illnesses: A rapid umbrella review of systematic reviews and meta-analyses (2024) · cites this paper as Rugkåsa (2016)
Decisions can vary significantly across judges and institutions despite similar clinical contexts.
“decisions can vary significantly across judges and institutions despite similar clinical contexts”
From A hybrid fuzzy logic–Random Forest model to predict psychiatric treatment order outcomes: an interpretable tool for legal decision support (2025) · cites this paper as Rugkåsa, 2016
The Results section discusses clinicians’ views of community treatment orders and differences in how studies measure outcomes, but does not address variation in decisions across judges or institutions under similar clinical circumstances. Searches for judges and for variation in decision-making found no passage supporting the claim; page numbers were unavailable in our copy. (LLM, conf=0.74)
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References 80 · Cited by 98
Research works printed but not linked: 1
- [3]3. Dawson J. Community treatment orders: international comparisons. Dunedin (NZ): Otago University; 2005. [Google Scholar]
- Authors
- Rugkåsa, J.
- Affiliations
- Akershus University Hospital (NO)
- Corresponding author
- Rugkåsa, Jorun
- ORCID
- Rugkåsa, Jorun
- Venue
- The Canadian Journal of Psychiatry
- Publisher
- SAGE Publications
- Published
- 2016-01
- Volume
- 61
- Issue
- 1
- Pages
- 15-24
- ISSN
- 0706-7437 (ISSN-L)
- 1497-0015
- PMC
- PMC4756604
- OpenAlex
- W2341817293
- Cited by
- 98
- References
- 80
- Citations by year
- 2026: 4 · 2025: 7 · 2024: 11 · 2023: 3 · 2022: 8 · 2021: 9 · 2020: 13 · 2019: 12 · 2018: 16 · 2017: 11 · 2016: 4
- FWCI
- 19.03
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- The Canadian Journal of Psychiatry (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Healthcare Decision-Making and Restraints
- Social Sciences › Psychology › Clinical Psychology › Psychiatric care and mental health services
- Health Sciences › Medicine › Psychiatry and Mental health › Schizophrenia research and treatment
- Keywords
- community treatment orders, forensic psychiatry, mental health law, involuntary psychiatric treatment, treatment effectiveness, hospital readmission, hospitalization, victimization, randomized controlled trials, non-randomized studies
- MeSH terms
- Commitment of Persons with Psychiatric Disorders, Community Mental Health Services, Humans, Global Health
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