Table 1 The CTO regime in England and Wales

Criteria

CTOs in England and Wales are initiated by a psychiatrist and a social worker. The legal criteria includes that the patient suffers from a mental disorder for which they require treatment to protect their health and safety or that of others, that the treatment (which must be available) can continue in the community, and that the patient is liable to be recalled to hospital. A CTO can only be made when the patient is already detained for hospital treatment.

Conditions

All CTOs have two mandatory conditions. These require the patient to make themselves available for assessments (i) when an independent medic is assessing the appropriateness of treatment and (ii) when renewal of the CTO is considered. In addition, discretionary conditions may be specified in the CTO form based on the knowledge of an individual patient. The most common are requirements to take medication and stay in contact with services. Having to live on a specified address, comply with monitoring of blood levels and abstain from drugs and alcohol are also used in many CTOs.

Recall and revocation

Should the patient breach a mandatory condition or deteriorate, he or she may be recalled to hospital for up to 72 h, after which the order can be revoked and the patient remains in hospital for involuntary treatment, they continue on a CTO in the community, or they are discharged from compulsion altogether.

Renewal

The CTO lasts initially for six months. They can be renewed for a further six months and then for 12-month periods.

Discharge

The orders can be ended at any time by the responsible psychiatrist. They can also be ended in a judicial hearing. The patient has the right to appeal to managers of the treating hospital and to one hearing by the Mental Health Review Tribunal (MHRN) in each CTO period. Routine hearings are held to ensure that the legal criteria for the CTO are still met even if the patient does not appeal.