Do we need community treatment orders in Ireland?

Re-admissions to inpatient psychiatric care are now so frequent as to be designated the 'revolving door' phenomenon and constitute 72% of admissions to Irish inpatient psychiatric units and hospitals. It is commonly believed that treatment non-adherence with aftercare following inpatient discharge contributes to readmission. Attempts to improve adherence and reduce or shorten readmission through compulsory community treatment orders have been made in several countries including Scotland in 2005 and, from November 2008, England and Wales. Provision for conditional discharge in Ireland has already been furnished by the Criminal Law (Insanity) Act 2006 but has been compromised by the inability to impose enforcement of conditions. The paper aims to determine whether compulsory community treatment orders are effective in improving adherence and reducing re-admission and whether, in consequence, their introduction in Ireland should be considered.

The legislative measures adopted to improve treatment adherence and thereby reduce re-admissions are presented. The evidence of their effectiveness is examined.

Evaluation of the effectiveness of community treatment orders is limited and hindered by confounding factors. What evidence there is does not provide convincing evidence of their utility.

It is concluded that there is insufficient evidence to advocate their early introduction in Ireland in civil mental health legislation. Instead a wait and see policy is suggested with critical assessment of the outcome of such developments in Scotland and England and Wales. In addition further research on the characteristics of revolving door patients in Ireland and the circumstances determining their readmission is advocated. There is an anomaly in the Criminal Law (Insanity) Act 2006 which allows of conditional discharge but does not provide for its enforcement.