Community Treatment Orders in Canada: A Historical Overview

A CTO is a tool intended to assist patients in maintaining compliance with treatment while in the community and thereby breaking the cycle of involuntary hospitalization, decompensation, and re-hospitalization (1). Frequent episodes of severe mental illness (SMI) can interrupt achievement of social, educational, and occupational milestones and may simultaneously prevent an individual from accessing care and treatment to minimize relapses and provide longer-term stability (2). Although the extent of treatment ordered in CTOs can vary by jurisdiction, in general a provider may include attendance at appointments and administration of involuntary oral or long-acting injectable medications for up to 6 months, at which time the CTO may be reviewed by two qualified health professionals (1).

CTOs are one form of mandatory outpatient treatments (MOTs) used in various jurisdictions globally. Outpatient commitment is used in most U.S. states and initiated by a judge. Conditional leave or discharge is a form of MOT in which involuntarily hospitalized patients may take a leave of absence from a hospital by complying with specified conditions in the community (3). CTOs are usually initiated by a physician and can be reviewed by the appropriate jurisdictional board. They may be started while an individual is an inpatient or is living in the community (2).

In this article, the origin of CTOs in Canada following the era of deinstitutionalization is explored. The goal is not to argue either for or against but to help provide the reader with context, highlight both perspectives, and encourage thought. Ethical considerations in the COVID-19 pandemic are used to highlight areas of controversy and encourage further discussion and research interest regarding community care for people with SMI.

The asylum system of the 1800s and 1900s burgeoned in the wake of the World Wars. In Ontario alone, an additional 9,000 psychiatric beds were added to hospital systems between 1932 and 1948, largely as a result of soldiers returning from the battlefields (4). However, funding did not keep pace with this rapid expansion, and conditions in mental institutions deteriorated, driving public sentiment that these facilities were antiquated and inhumane (4). Simultaneously, new psychotropic medications helped psychiatrists to manage many of the unpredictable behaviors of patients with schizophrenia and severe mood disorders, bringing hope that patients with chronic illness could be successfully reintegrated into the community (4).

During the 1960s, the equal rights movement called for increased government accountability and viewed people with mental illness as part of the struggle for equal rights. Many viewed psychiatry as a tool of oppression, argued that mental institutions were utilized to contain dissidents, and called for their closure across the Western world (4). In Canada, “the motivations for this evolution were a complex blend of new therapeutics, professional change and fiscal planning, and changes wrought by deinstitutionalisation were far-reaching in their impact on the Canadian economy and on human rights discourses” (5). The summation of these factors was a wave of deinstitutionalization that swept across the country. In the 1960s and 1970s, governments drastically decreased inpatient bed capacities and championed the construction of community mental health centers (4). The Saskatchewan Mental Hospital at Weyburn was the first in Canada to close in 1963, while in British Columbia, Riverview Mental Hospital continued to exist in some capacity until 2012, when it finally closed its doors (5). Unfortunately, the promises of robust community-based care and supported reintegration did not materialize, and for many with SMI the transition to community left them marginalized, socially isolated, and with few resources.

The era of deinstitutionalization signaled the end of the asylum and the dawn of a complex, decentralized matrix of services and accommodations, while the number of people seeking assistance for mental illness continued to rise. Simultaneously, universal, publicly funded health care was introduced for Canadians in the 1960s (5). The complexities of instating such large systemic changes added a layer of entanglement to the development of a unified, well-organized mental health care system, which has often been limited by budgetary restrictions and organizational incoherence (5). This reorganization introduced new features of transinstitutionalization, or the movement of people through institutions, including penitentiaries, nursing homes, hospitals, or new psychiatric facilities (5, 6), which has left some questioning the merit of revisiting the concept of asylum for persons with SMI (7).

In the past 30 years, community-based mental health agencies and all levels of government have attempted to provide a range of crisis management, treatment programs, emergency shelters, and affordable housing options. However, “as many as 520,700 people living with mental illness are inadequately housed in Canada and among them as many as 119,800 are homeless” (8, 9). A study conducted in Vancouver, Toronto, and Ottawa and published in 2010 found that 52% of the homeless or vulnerably housed participants reported a previous diagnosis of a mental disorder, 23% reported unmet mental health care needs, and 19% did not know where to get the care they needed (9).

MOT was conceptualized in the 1980s to address community issues thought to have resulted from deinstitutionalization, such as homelessness, incarceration, and recurrent hospitalizations (4, 10). The CTO was advanced to “manage mentally ill patients who failed to adapt to community life following widespread closure of asylums” (10). CTOs were intended to facilitate the provision of treatment allowing a less restrictive alternative to hospitalization (10). However, alongside concerns for people with SMI, worries grew over the risk of harm to the public associated with treatment noncompliance among those with a history of violence when acutely unwell (10). Over time, MOT has shifted from a way to increase individual freedom to an intervention to prevent relapse in the community. This shift in rationale has resulted in ethical controversy over MOT, with these models criticized as unnecessarily extending the net of social control (10).

In Canada, controversy over CTOs continues, with critics saying that “they are dangerously prone to misuse” or have even “become a convenient tool of control” (11). There is concern that they increase stigmatization by legally defining an individual as mentally ill, that compulsory treatment may be perceived as coercion and lead to devaluation or discrimination, and that they may delay or prevent people experiencing a relapse from seeking help (2, 12). Proponents of CTOs argue that they promote the well-being of those individuals by reducing potential harm for persons with SMI who would otherwise decompensate in the community and by reassuring distressed families that their loved ones will receive care even if their insight or judgment is impaired (1, 2, 4, 8, 13). Unfortunately, the current evidence for the positive effects of CTOs is inconsistent across studies and jurisdictions, highlighting the need for further research in this area in Canada and internationally.

Some argue that CTOs would be unnecessary if sufficient community services, such as assertive community treatment (ACT), were more broadly accessible (14–18). The ACT model utilizes multidisciplinary teams with a low staff-patient ratio (1:10) to provide intensive, flexible, and community-based support to people with SMI, who often have co-occurring substance use and poor social functioning (14–18). Although ACT has been criticized for being paternalistic and coercive (14), numerous studies have demonstrated that ACT improves outcomes and patient satisfaction with mental health services (14, 17, 19). Despite apparent philosophical contradictions between CTOs and ACT, they are often used in combination to facilitate regular engagement with treatment and mental health supports for patients with poor insight or poor compliance or at high risk of harm to themselves or others if untreated (14–18). Although some patients have expressed ambivalence regarding CTOs or have viewed them as coercive, studies in Norway and Canada have found that many ACT patients subject to CTOs were in fact more satisfied with ACT than were those voluntarily enrolled in ACT, reported a higher degree of recovery, and would recommend the service to a friend (14–18).

During the current pandemic, many jurisdictions have made temporary exceptions to Mental Health Act (MHA) legislation to allow for virtual follow-up with patients and to obtain verbal consent for CTOs. Review panel hearings have also switched to a virtual format. However, virtual platforms may not be equitably accessible for outpatients based on their level of comfort with and access to technology, reliable internet services, or a private setting from which to communicate with their treatment provider. In fact, some patients may decline to appear at review panel hearings for these reasons. Telephone follow-ups may be more accessible, but they do not allow for a visual assessment of a patient’s mental status to assist in treatment decisions, and the current legislation is not explicit about the sufficiency of telephone assessments for administration of CTOs or other forms under the MHA.

For patients who are noncompliant with the conditions of their CTO and who are brought into the emergency department, there is additional risk of exposure to COVID-19. This may also increase workloads and wait times in emergency rooms when health care resources are already strained. Conversely, judicious use of CTOs may decrease the risk of hospitalization during the pandemic if they do indeed increase time to relapse and decrease frequency and length of hospital readmissions in select populations. These issues highlight the ethical considerations and controversy around CTOs and the need for further research in this area and heighten the importance of balancing procedural justice, individual rights, and maintenance of clinical stability in unstable times (20).