title: A systematic review of the effect of community treatment orders on service use.
abstract: OBJECTIVE
  The evidence regarding community treatment order effectiveness has been conflicting. This systematic review aims to bring up to date the review performed by Churchill and colleagues in 2005 by assessing and interpreting evidence of CTO effectiveness defined by admission rates, number of inpatient days, community service use, and medication adherence published since 2006.
  
  
  METHODS
  Databases were searched to obtain relevant studies published from January 2006 to March 2013.
  
  
  RESULTS
  18 studies including one randomised controlled trial were included. There remains lack of evidence from randomised and non-randomised studies that CTOs are associated with or affected by admission rates, number of inpatient days or community service use. The most recent and largest RCT is included in this review and found no significant impact on admission rate (RR = 1.0, 95% CI 0.75-1.33) or number of days in hospital (IR = 0.90, 95% CI 0.65-1.26). Results from the two largest longitudinal datasets included in this review do not concur. Studies using the New York dataset found that CTOs were associated with reduced admission rates and inpatient days, while studies using the Victoria dataset generally found that they were associated with increased admission rates and inpatient days.
  
  
  CONCLUSIONS
  There is now robust evidence in the literature that CTOs have no significant effects on hospitalisation and other service use outcomes. Non-randomised studies continue to report conflicting results. Distinguishing between CTO recall and revocation and different patterns of community contact is needed in future research to ensure differentiation between CTO process and outcome.
authors.affiliation: Oxford Health NHS Foundation Trust, Oxford, UK, drdanielmaughan@gmail.com.
authors.forename: Daniel
authors.initials: D
authors.lastname: Maughan
authors.forename: Andrew
authors.initials: A
authors.lastname: Molodynski
authors.forename: Jorun
authors.initials: J
authors.lastname: Rugkåsa
authors.forename: Tom
authors.initials: T
authors.lastname: Burns
mesh_terms: D014150:Antipsychotic Agents / Q000627:therapeutic use; D003134:Commitment of Persons with Psychiatric Disorders; D003156:Community Mental Health Services / Q000706:statistics & numerical data*; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D055118:Medication Adherence; D001523:Mental Disorders / Q000188:drug therapy; D016896:Treatment Outcome; D014739:Victoria
chemical_list: D014150:Antipsychotic Agents