Case study - Managing mental health in the community

Patients with chronic mental illness can avoid repeated hospital admissions, by Dr C Ruth Butlin.

George agreed to a community treatment order (Photograph: SPL)

George was brought to a place of safety by the police under a 'section 136' for medical assessment. He was dishevelled and distressed, talked incoherently about messages he had received through car number plates and was responding to malicious auditory hallucinations.

The police surgeon and a section 12-approved psychiatrist considered him to be 'suffering from disorder or disability of mindof a nature or degree which made it appropriate for him to have medical treatment in hospital'. George disagreed and could not be persuaded to accept voluntary admission.

The surgeon and psychiatrist completed the two medical recommendations having agreed it was necessary for George's health and safety, and for the protection of others, that he be treated in hospital and that the treatment could not be provided unless he was detained under the Mental Health Act 1983.

History of schizophrenia
In view of George's history of schizophrenia and numerous psychiatry admissions, the doctors decided to apply section 3, which allows detention for up to six months for treatment.

In hospital, George initially ignored information about his rights under the Mental Health Act. Once the antipsychotic medication had taken effect, he was calmer and lucid enough to exercise his right to appeal for a review of his detention.

He declined the option of assistance from a mental health advocate or a lawyer.

At his hearing, the hospital managers considered medical, nursing and social reports and listened to George's own comments. They decided he did fulfil the legal criteria for continued detention under the Act.

Residing out of hospital
In due course, George's responsible clinician, having noticed improvements in George's mental state, allowed him 'section 17 leave' for increasing periods of time. Once George was stable on his medication and well enough to look after himself, the psychiatrist, in consultation with an approved mental health professional, made a community treatment order (CTO).

Realising he would have more freedom living under a CTO than staying in hospital, George agreed to the conditions imposed. The local assertive outreach team arranged to keep in touch with him.

Residing in a group home, receiving regular depot medication, George remains tolerably well.

He still hears voices and uses odd neologisms in conversation, but is not distressed and does not disturb others.

When the CTO was renewed after six months, his case was reviewed and it was felt there were adequate grounds to sustain the order.

Community treatment orders
CTOs can be made by a responsible clinician in agreement with an approved mental health professional, for any patient currently detained under section 3, if they are satisfied the patient meets the criteria.

It is necessary to have the power to recall the patient to hospital.

If recalled, the patient can be detained in hospital up to 72 hours to receive necessary treatment (which cannot be forcibly given in the community).

CTOs carry certain conditions, the most important being that the patient must make himself available for assessment by the responsible clinician or a 'second opinion approved doctor'.

CTOs enable many patients with serious chronic mental illness to remain relatively well, receiving treatment in the community, instead of being subjected to repeated compulsory admissions with relapses whenever they discontinue treatment.

Mental health staff find that patients, having understood the provisions of a CTO, often willingly comply with treatment in the community. GPs will increasingly see their patients benefiting from these orders.

  • The patient described is entirely fictitious
  • Dr Butlin is a part-time GP in Alfriston, East Sussex, and an associate hospital manager for Sussex Partnership NHS Foundation Trust

1. Care Services Improvement Partnership, Workbook to Support the Implementation of the Mental Health Act 1983, as amended by the Mental Health Act 2007.

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