Welcome to the Oxford Psychiatry Podcast series brought to you today by Daniel Maun, I'm an advance trainee at Oxford Deanery.
Today I have Professor Tom Burns with me. He leads the social psychiatry group here at the Oxford University Department of Psychiatry.
And I've actually been privileged to be involved with this over the past two or three years.
He's here to talk to us today about his recently completed randomised control trial into community treatment orders.
So hello, Tom. Hello, Dan. Thank you for joining us. Before we start, maybe we could go back a bit earlier.
And and just for those who might not be familiar with social psychiatry,
could you tell us a bit about what social psychiatry is or maybe what a social psychiatrist interests are?
Yes, Social Security is hard to define, but very easy to recognise,
essentially social psychologist or psychiatrist who are interested in people's relationships.
That doesn't mean we are disinterested in the biochemistry and the physiology and genetics disorder order,
but our primary interest is in how they react to the world around them. And that can be with their families.
It can be with their communities. And in my case, it's particularly I'm interested in how they react with us as professional caregivers.
Right. And in your recent editorial piece in the British Journal of Psychiatry,
you argue that social psychiatry is not at the recognition or potentially the financial support it deserves.
And it was a very interesting piece.
And I just maybe like to ask you a bit more about the opportunities for developing social psychiatry as a as a discipline.
Yes. What we what we wrote about in that editorial was actually slightly more, more, more dramatic than that.
We argue two things. We thought that psychiatry is slowing down because it had begun to ignore the interpersonal dimension of our trade, our craft.
If you want to call it that, because although the last 30 years have seen an enormous emphasis on pharmacology and biology,
the reality is that psychiatry is a relationship based activity.
All of our symptoms, all of our findings have to have social meaning attached to them, to it.
So, for instance, if you show an MRI scan of somebody's brain lighting up when they're depressed,
it's only meaningful if you can say they're depressed.
And that actually requires a judgement about their relationship to themselves and their relationship to the world around them.
Now, our thinking behind that editorial was that for all sorts of historical reasons,
we've the pendulum has swung to a very scientific and often a very episodic
interventionist approach to psychiatry and shields and interesting findings.
But it hasn't really advanced the subject as much as we often think it has.
And I believe was that ignoring the interpersonal and psychiatry has two two major problems with it.
First of all, it misrepresents the subject and therefore it slows down what we can do in research.
We ignore it. Our research questions are going to be limited and perhaps a little bit oversimplistic.
But secondly, I think it actually impacts on recruitment into our profession, because if you're going to work in psychiatry,
you have to be interested in people, people's narratives, their lives, their relationships.
If you're not interested in that, the job would disappoint you. And I think we've seen that,
that people who go into psychiatry thinking it's going to be just the same as neurology very quickly become disaffected and leave.
And similarly, if we don't make clear the people of psychiatry is embedded in this very rewarding interpersonal interaction,
then we may fail to connect the people who would otherwise flourish in it.
So that's what we were concerned to say in the editorial. That was more important to us, I think,
than to say we need more money invested in family interventions or or looking at how resilience is developed by people in their social networks.
Although we think that sort of research is important,
we were more interested in in identifying the degree to which ignoring the interpersonal or social
aspects of psychiatry was skewing our understanding of it and limiting all of our activity,
both research and clinical. Thus fantastically interesting, actually, Tom,
to hear a little bit about not only a social psychiatry perspective on our current position in psychiatry,
but also to have the historical understanding of the development of our profession at large.
Yes, that's very interesting and maybe gives us a good background into beginning
to talk about your your recent research or recent randomised control trial,
which is looking specifically into one recent developed.
In mental health law, this happened recently, community treatment orders, so maybe we can get back to that topic and talk about that.
So what you know, let's start with talking about what community treatment orders are,
because I'm sure there are a lot of people who are listening to this who aren't quite familiar with that term.
The country has always had the provision to compel treatment on patients against their wishes, but that has always been restricted inpatient care.
Traditionally, as psychiatrists moved out of mental hospitals the last 30 or 40 years across the world,
people have begun to recognise that if coercion and compulsion was sometimes necessary in hospital,
it might be necessary to help people comply with treatment outside hospital.
So there are many legislations, over 30 legislations.
We've had the introduction of some form of community treatment order,
and in the UK it was introduced by changing the 1983 Mental Health Act, an amendment in 2007 which became active in 2008.
And what that said was that patients who were currently detained in hospital against their will for treatment and using Section three could,
if their clinical team felt they were great risk of rapid relapse and could not comply with treatment,
could put them on what was called a community treatment order and a community treatment order,
which lasts for six months in the first instance, but can be renewed and indeed can be renewed indefinitely.
And gave could allow you to insist on two things for the patient.
One is that they should maintain contact with the team, and two, that they should agree to take their medication.
And the power that lay behind the community treatment order was that if the patient failed to do either of these two things,
they could be brought back to hospital for review of their condition without any further legalistic processes.
No need to call social workers and do the U.S. forms out if in those 72 hours that they were called, they continued to refuse to take that treatment?
You can make a decision either to accept that and let them go.
Or if you thought they really needed compulsory treatment, you could reinstate their Section three.
So it allowed you to oblige a patient to keep contact with you and to take a treatment.
What it does not allow and in no in no jurisdiction in the world does it allow is for forcible treatment outside the hospital.
Therefore, if a patient says, no, I won't take the medication,
it usually depo medication long acting antipsychotics because this is almost exclusively restricted to psychotic patients.
You can't grab hold of them in their own home and inject them, but you can have them go back to hospital.
That may involve the police sometimes and then in hospital only if they go back on to Section three can force be used.
So that was the legislation that got passed. It had been argued about for over 20 years.
It's always controversial and rightly so, because I think that for most people,
compulsion in somebody who's so unwell, they need 24 hour nursing, has a certain natural justice to it.
But there's a real understandable concern that if somebody is well enough to survive outside hospital, why should they be compelled to do something?
And why can't they just make a mess of their lives, just as you and I make a mess of our lives?
Now, the argument against that has been twofold. One is that we know we have overwhelming evidence that if patients, particularly schizophrenia,
stay on their maintenance medication, their lives are vastly better.
Stay in a hospital. They have less stigmatising compulsive admissions, etc. So there's good reason to want to keep them on their medication.
So that that was really and there was also perhaps we have psychiatrists would not take it seriously, but the government took it seriously.
And I was the psychiatric adviser for the government's committee on this, and it was quite interesting to watch their thinking.
There were two other reasons they wanted to here. The most important was to keep patient on the on the medication, keep them,
while the other was to restore some flagging faith in the public and mental health services.
Because every high profile scandal of a patient who's known was known to be a risk no knew,
but not taking their treatment makes us look really quite questionable in the public's eyes.
And the other reason they wanted it, because it gave them sensible monitoring of what was going on,
because the old system was allowing all sorts of tricks to to compel people which weren't legally registered.
That's a really good comprehensive answer, actually, and it helps us understand what.
The different while the different arguments for seats from different from different corners of our country,
both in the psychiatric community and the government.
So when do they come into effect? Well, they came into effect in November 2008.
Interestingly, they came into effect earlier in Scotland when they were told by England and Wales they came into effect in November 2008.
And we had obtained funding from our random control trial prior to them becoming active legislatively.
And there's a reason for that, that I've been down to Australia and New Zealand.
And it became clear to me that once Kyozo introduced, psychiatrists become extremely wedded to them very quickly.
And to conduct a random drug trial, you have to have an acknowledged doubt about the effectiveness of the treatment.
You have to have some degree of clinical equipoise. Otherwise people won't submit patients to the trial.
And it seemed clear to me that if you leave it a year or two, we might lose that window of opportunity.
So we decided to have our trial as soon as the law was passed as a possible.
I'm just a sort of subquestion on onto your answer there.
Have they indeed been taken up as expected by clinicians and been accepted in that way that they did in Victoria, in Australia?
Well, there have undoubtedly been taken up by clinicians.
And you've done some work with Andrew Linsky, which shows that clinicians attitudes to Kyoto are now much more positive than they were five years ago,
not quite as positive as New Zealand's characters have been used in for 10 years.
So attitudes change very quickly,
and the uptake of them has been about the level that we would expect from within looking at international literature.
The government came up with a very bizarre figure of 400 a year, but that was nothing to do with the clinically predicted level.
And I think actually the uptake is about what we would expect not as high as Victoria.
Victoria is the world leader on Kyoto, and it's a sobering fact that every 1000 individual in Victoria is on almost kto at every of patient,
not even every thousands adult, every thousand person.
I don't think we're anywhere near that. I hope we won't get that. Yes. Yes, that's interesting.
So let's move on to talking about your particular trial.
So maybe you could just outline what what the the the time course was and the methods and and how you went about the trial octet is a very standard,
rigorous, randomised controlled trial. Patients were randomly allocated between either going on to CTO or not going on to sit here.
And they were followed up for a year. And before we start the trial, we submitted our protocols, The Lancet,
and we had a clear decision that the primary outcome would be the proportion of patients readmitted to hospital over those 12 months of follow up.
So that's a good outcome measure because it reflects relapse and we were hoping to reduce relapse.
And that's the explicit purpose of KIOS in nearly every jurisdiction.
And so it was one to one randomised controlled trial, bit of stratification for age,
gender and duration of illness, but basically had to be randomly allocated to either care or not for care.
Now, because of legal and ethical reasons, we had to construe that randomisation as between CTO and Section 17 leave.
But in practise, Section 17 was what was being done anyway.
And actually many of the people who were being considered for CTO already on Section 17, and that's confused a few people.
Essentially, this is a trial of CTO that is not clear.
And now we say our primary outcome was proportionally admitted.
And that's because the only two previous trials also have that was their outcome measure.
And also it was executed for and we wanted the patients to arms as much as possible
to be treated similarly so we could test and isolate the effect of the KTO itself.
So we encouraged him to try and offer the same level of clinical support to both arms.
And we encourage them to aim for contact about once a week and at least once a fortnight over randomisation took place.
It was across 32 trusts south of England, and it wasn't every consultant in any given trust.
It was consultants who were prepared to convince their teams to take part because that
was a major hurdle and could accept that there is a legitimate area of uncertainty here.
So, no, every consultative part, these are essentially, I would think,
a slightly better educated consultant were aware of the state of the evidence and know that we don't know, randomly allocated.
And after that, we had no information whatsoever.
So it was a very nail-biting time, frankly, because we didn't know, first of all, whether people would do what they said they would do.
We didn't know whether some of them were keep on Section 17, leave for months, which they're not supposed to do.
But you don't know.
We didn't know whether the randomisation worked perfectly and we didn't know whether the treatments offered were going to be very different.
And all of those could have made interpreting the results very complex.
When we got the results. It seems simpler. First of all, the randomisation did work to groups exactly the same.
Secondly, people did not abuse Section 17, leave a median of eight days.
So as opposed to six months on a CTO. And thirdly, the treatment offered to be fairly comparable, about two and a half to three contacts a month.
So they were both all about the same.
So we knew that when we actually looked at our outcome measures, which was readmission rates and time to readmission.
We could rule fairly confident conclusions are any differences were due to the Q because everything else was about say, shall I tell you the results?
Well, just for those people who don't know what Section 17 leave is, OK, given that it's sort of the comparative arm,
even though maybe the median duration was only eight days and Section 17 leave it such to 17,
leave is a condition that the clinicians can give people leave if they are under detention and the Mental Health Act for a given period of time.
And it's usually used when patients are getting to the end of their inpatient stay to allow them a bit of time in the community to see how it goes.
And that usually ends pretty briefly, pretty quickly. And they go to being not under detention under the Mental Health Act, Section 17 leave it.
Is that it's a comparative arm. Yes. Can you tell us about the results?
That would be great. Well, the results were a bit of a shock, frankly.
Her real worry was that either that, you know, that we haven't seen the results.
A bit of shock with the other anxiety we had was that we get a massive result
from the difference between statistical significance and clinical significance.
Might be quite a tricky question, but actually, in the end, there is no tricky question.
Our results are that there's not a flicker of difference between the two groups.
Over the course of a year, 36 percent of patients were readmitted in both groups, not only with the same proportion readmitted.
When we looked at trying to make sure we did a survival curve, there's no distinction whatsoever between that.
So the rate of readmission hasn't changed.
So the number of readmitted, the proportion and the time to readmissions, exactly the same two groups despite six months of extra caution.
Now, although it isn't statistically significant, the duration of hospitalisation is a bit lower in patients.
And that reflects all the international findings that usually people on KIOS stay in hospital a bit shorter.
Of course, that's a measure of clinical clinician behaviour, not a patient wellbeing, but presumably that the same illnesses, the same relapse.
But clearly people feel more confident in discharge early on if you're in the queue.
But in terms of the patient outcomes,
the number who relapsed have the time to relapse and indeed the clinical and social measures he used beepers and gaf not a flicker of difference.
Now, the trial isn't perfect. No concrete is ever perfect.
Let me tell you what the limitations of our time are, although I don't think they detract from such so overwhelmingly clear result.
The first is we don't know what the potential denominator was.
We don't know how many patients were being considered in different trusts who could have gone in.
We can't say anything about that.
Secondly, a lot of people didn't follow the the the proposed randomisation practises about 20 to 25 per cent, didn't get what they should have got.
About 20 percent of people randomised to CTO didn't get onto see, perhaps because their condition improved when that was being considered.
But more more upset. Disturbingly, about 20 percent of people allocated to Section 17, they were put on a queue despite the agreement.
And there was a small number of patients, 13 overall, who never got out of hospital at all.
And they always find that if you're looking at such a new group, luckily that was equally distributed.
So we did what's called a per protocol analysis.
You take out those who aren't treated in the way that they should be and that still doesn't find a difference.
But it is an important limitation to the study, frankly.
So that's quite surprising result perhaps, that they were so the two groups were so,
so similar, given the addition of the CTO or the community treatment order.
You've told us a little bit. Well, you told us that you were shocked actually at the results initially.
How have your thoughts developed about community treatment orders in light of these results?
What do you what do you think about the intervention now, having been the government advisor in that in that creation?
Well, I've been an advocate of community. In the early 1990s.
I was on the college's first committee on it. And so I'm very guilty party here, as I've always been very keen on them.
They seem to make sense to me for the reasons we discussed earlier.
And of course, if you do a trial like this for three or four years, you become identified with them.
And I think that of unconsciously we drifted to being from being scientists, being an.
Spoke to some extent. So what a shock. There's no question about that.
It was a real shock and they had to take a deep breath and sit back and hope that I've given some thought that the
first thing to to remind ourselves is it shouldn't have been shelved the beento previous randomised controlled trials.
And they found exactly the same. OK, I thought it might be different here, but it wasn't.
So it's actually not completely out of the blue. I've given a lot and I think it brings us back to what we discussed at the beginning.
My conclusion from it really are that it's reaffirmed my faith in the central aspect of what we do in mental health practise.
Our job is developing skills in understanding and working with very disturbed and troubled individuals.
And the quality of our work is based on that ability to engage with persuade, encourage,
support very ill people to comply with treatment which have some real downsides for them.
We think in the long term it will help them.
So essentially, I think I've had my belief that the carrot is better than the stick reaffirmed.
I think in mental health we really ought to be putting more and more of our energy into building sustainable and durable therapeutic relationships.
Do you think that the about the community treatment order could be improved by a review of the legislation?
In truth, I don't think changing the legislation will make a difference.
We didn't see any suggestion of any subgroup or any particular practise that made active work.
So I just just genuinely think they don't work.
Now, comments on our study have come from forensic psychiatrist who say that their
patient may respond better to KIOS because they're used to being told what to do.
They're used to restrictions. They're used to the legal consequences of not doing what they're asked.
And simply some old age psychiatrists have commented that the the older generation
a bit more law abiding and take take for the majesty of the law more seriously.
And I think we have to take that seriously. Wiedner, we didn't test either of those groups in our study.
And I guess the a contention and ethical contention to community treatment orders is that given the overwhelming
evidence that they don't necessarily make any improvements in admission rates or time to admission,
there has to be held against the the fact that they're being patients being held under detention for longer periods of time.
Yeah, I think our study bear in mind, I studied only four people up for 12 months and the average time,
the median time on a street year was six months. And that means that half the patients had their queue renewed.
My guess is that if we followed these patients up in three years time, which we're doing, by the way, we'll find that those six years,
the average time of which duration, the average duration of coercion, losing their freedom will be perhaps even years.
So so we've underestimated the loss of individual liberty and freedom.
That's very that's very helpful to talk through the the pros and cons and the
different opinions that continue despite the outcomes of your your trial,
at least the the the primary outcome data from your trial.
Let me tell you, one of the most dismaying things about presenting this evidence is the number of psychiatrists who said to me,
very interesting results. But, you know, I've seen with my own eyes close work.
Now you can't see with your own eyes that are probabilistic outcome,
i.e. the difference being 40 percent admission and 60 percent admission over one two years.
You cannot see that with your own eyes. And psychiatry has a really quite a bad record in continuing with treatment because we hope they work.
And I've been disappointed at the reluctance to accept disappointing that these results may be to some of us.
They were, to me, a reluctance to accept that the facts are fairly clear cut.
They do not appear to achieve what they were meant to achieve. Thank you.
So a real argument for evidence based practise in psychiatry given given these results,
which incidentally, are published in The Lancet in March of this year.
So thank you, Tom. It's been a really interesting talk, not only about community treatment orders,
but maybe some more in-depth sort of analysis of our profession and and and how we should operate as clinicians.
I just want to finish with maybe a slightly lighter note. I'm very aware that you have published a book.
Unnecessary châteaux recently, and I wonder whether you could just tell us about this briefly.
Delighted to tell you about the book, Rush out and buy it. This is a book describing psychiatry for non psychiatrists, if you want.
And that's what got me to write this book,
was that I became impatient and I really got tired of many of the books which were written about psychiatry in which straw men were put up.
So suddenly, Rich and Bentall would say, all psychiatrists believe that all disorders are genetic.
Now, you and I know no psychiatrist believe that nobody believes anorexia nervosa is genetic.
Right. Nor do we believe that you can't have a diagnosis that's meaningful unless you can find a physical marker for it.
It was absolute nonsense. It was surrounded by misrepresentation of our profession.
So I really wanted to write a book that described our profession, warts and all, and so that people,
when they read these critiques of our profession, could actually put it in perspective and perhaps understand why,
because we operate in this very rapidly shifting area of social consensus,
we are perhaps more vulnerable than other branches of medicine to make mistakes and we will make mistakes.
But there are often honourable mistakes and we should not be too ashamed of it.
But we need to explain to people what we do.
And there hasn't been a book that simply set out to explain psychiatry rather than to defend one arm from the other,
as it were, for a decade or know for a generation at random.
To get a proper understanding of psychiatry, I think you have to understand its history. It has a short, easily definable history.
200 years ago it started and it has two aspects of history.
One is the medical model. One is well, well known,
which is the development of asylums and the classification of psychosis which has given rise to what we often think of as the medical model.
But the other equally important started around the same time was the whole issue of depth
psychology and how we understood troubled individuals and what that got them there,
the experiences meant to them and to those around them. Both those strands have continued to play a part in psychiatry up into our present time.
So what I did in the book really was outline that history,
outlined how it continues to invent all the controversies that we struggle with in psychiatry at the moment.
And I hope that it will give people who read it. I respect the difficulty of our job without tending to gloss over the things that we have got wrong.
And we certainly have got something quite seriously wrong.
So an honest account of psychiatry, both historically and this and how we see it operating today.
There is a lot of psychiatry around it, particularly with the of coming out of DSM five.
And it's it's I mean, I find it personally very interesting how developments in psychiatric practise bring forth this wave of psychiatry.
And it'll be very helpful to have your book there as a as a proponent of psychiatry and it's in its current form.
And so having said that, I am not defending DSM five at all.
I think it is a disaster for our profession, as was DSM three and four.
And I think it was precisely a failure to respect and grasp the process of making diagnoses,
because the process of making diagnosis in psychiatry always requires a degree of entering into a patient's subjective life and death.
And three onwards ignored that. Now the reality is that most of us still do it, thank God.
But this this attempt to suggest that it's simply like taking a picture is misleading and nothing long term, potentially destructive.
And I think we will reject it and move back to a more commonsensical position.
Eventually we could go on and talk about this. Very interesting.
But, Tom, thank you very much for actually very enlightening discussion.
And we look forward to hearing the new about the other outcomes from OCTETS and its extension as well.
So thank you, Tom. And I hope you tune into other podcasts found on the Oxford University Psychiatry podcast series page.
Thank you.