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• W1558443783 abstract "Whenever organized psychiatry claims to speak for the rights of others, it is perhaps time to step back and reevaluate the landscape-for altruism has had, at times, a dark heart. Community treatment orders (CTOs), controversial tools now widely adopted in various guises, have sparked a debate within (and without) the profession. Although it makes for odd bedfellows and splits between colleagues, the debate has also highlighted the arguments of those who see treatment as a right and those who see it as a choice. The case for the right to treatment has, perhaps disingenuously, been made to force treatment on individuals whose psychiatric illness arguably deprives them of choice. The discussion has involved the Canadian Charter of Rights and Freedoms, section 7 of which, for example, has traditionally been interpreted as upholding an individual's right to refuse treatment for a mental illness (1,2). The principle of self-determination has run into Gray's human needs perspective that long-term institutionalization is no liberty at all (3). The almost uniform condemnation by psychiatrists of the recent Supreme Court of Canada decision in the case of Starson vs Swayze (4) suggests that there may be a point that we, not the Court, have missed. In our zeal to treat the ill, we may set aside their wishes, however uninformed or psychotically influenced. Each iteration of modern pharmacologie treatment is heralded as state-of-the-art and well thought-out, even as yesterday's remedies are relegated to generic graves. With hindsight several years hence, that certainty in drug choice may seem a little awkward, as each emperor, time after time, begins to lose his clothes. From today's perspective, refusing high dosage haloperidol injections doesn't seem so psychotic. Nevertheless, people with mental illness continue to fall between the cracks of an increasingly complicated health care system, while our duty to our patients and to society requires an assertive role in caring for those too ill to care for themselves. As social services thin, reliance on medication becomes a greater factor in ensuring adequate care. Some of the illnesses we deal with in psychiatry can imprison our patients-the keys to those prisons often taking the form of modern-day psychotropics. When these patients appear incapable of consenting to treatment (a legal determination), we use the legal determination of incapacity as a tool to turn the key in the lock. Psychiatry, we recall, is no stranger to coercive interventions-and a utilitarian model attenuates the discomfort of forced detention or treatment. In this issue, Dr Richard O'Reilly examines the various arguments made in the debate over CTOs (5). A thoughtful advocate for CTOs and author of a Canadian Psychiatric Association position paper on the subject (6), he takes time to examine the protagonists' philosophical differences, outlining their positions, carefully analyzing the arguments, and applying this to current practice. His view of CTOs takes into account the context, including, importantly, the limited resources available. Many questions still remain unanswered in the CTO debate. In their well-researched paper, Dr Marvin Swartz and Dr Jeffrey Swanson look at the current state of the evidence available for CTOs (7). CTOs, mandatory outpatient treatment, or involuntary outpatient commitment (OPC) are available in various forms in many countries. Comparing outcome studies is complicated by the additional forces striving to improve medication adherence. Both authors have been at the forefront of research into OPC. Together, they conducted the first randomized controlled trial into the effectiveness of OPC and community-based care management (8). Although showing some positive outcomes, their study had limitations and showed results contrary to the New York OPC study (9). Although it remains difficult to interpret and compare studies, owing to wide variations in implementation and practice, the results offer guidance in providing care for our seriously ill patients. …" @default.
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• W1558443783 date "2004-09-01" @default.
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• W1558443783 title "Community Treatment Orders: An Uncertain Step" @default.
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• W1558443783 doi "https://doi.org/10.1177/070674370404900901" @default.
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