A Community Treatment Order (CTO), is a provision under the Ontario Mental Health Act that allows a physician to mandate supervised treatment on a patient when they are discharged from hospital. The overall goal of CTOs is to prevent mental health deterioration due to medication non-compliance. This is especially applicable in patients with a history of deteriorating when off medication, and show improvement when they are back on medications.
In Ontario, an active CTO allows a patient to be recalled back to hospital for assessment (through issuing a Form 47). A CTO expires every 6 months, but can be renewed. Each year, there is also a Consent and Capacity Board (CCB) hearing to justify whether a CTO needs to remain in place (to ensure that personal liberties are not infringed). CTOs are used throughout the world, and the specific criteria to be eligible for a CTOs varies between different jurisdictions.
A Form 49 (Notice of Intention to Issue or Renew Community Treatment Order), is the initial notice given to the patient to let them know a physician intends to start or renew a CTO.
A Form 45 (Community Treatment Order), is the Form that issues the CTO formally, and details the conditions of the treatment order in the community.
Only a physician may issue or renew a CTO.
1
of the following criteria?2
or more separate occasions in the last 3
years, or30
days or more in the last 3
years. The admission period does not include the Form 1 assessment period (i.e. - the first 72 hours of admission), or72
hours of conducting the assessment in Step 5. A Form 47 (Order for Examination), can be issued by a physician when a patient is non-adherent to an agreed-upon treatment plan as laid out in the Community Treatment Order (Form 45). The patient is brought to a healthcare facility by law enforcement. This does not need to be a hospital emergency room - it can be a clinic, or any other area where a physician works. The patient is then seen for examination and the treatment is then given to the patient. The physician who receives the Form 47 when the patient is brought into hospital can give the treatment, it does not have to be the same physician who issued the Form 47.
There are several common errors that physicians may make when assessing a patient brought in on a Form 47. Most commonly a patient brought into hospital on a Form 47 are seen in the emergency department.
MD Myth/Error | Explanation |
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“A patient on a CTO is always incapable.” | Almost true. Most patients on a CTO are deemed incapable to consent. However, there are patients who are capable who also consent to a CTO as a “safety net.” |
“I deem them to be not certifiable at this time.” | A patient on a CTO is by definition, certifiable under Box B criteria of the Mental Health Act. Your one-time assessment of the patient at this time does not overturn the certifiability. |
“I deem this patient to be capable at this time, and cannot give the CTO treatment” | If the patient was previously found incapable, you cannot overturn a finding of incapacity based on your one-time assessment of the patient when they are brought in on the Form 47. If a patient was incapable when the CTO was issued (as typically is the case), they continue to be assumed incapable to consent to the treatment outlined in the CTO right now as well. |
“I have not been able to reach the SDM, therefore I cannot give the CTO treatment.“ | You still need to give the treatment, because there is already a treatment plan in existence as documented in the CTO. You do not need to contact the SDM as they have already given permission. |
“I cannot give this person the treatment, because they are refusing it.” | The patient cannot refuse treatment because a treatment plan has already been outlined in the CTO. You are legally able to enforce treatment. |
A patient does not need to be incapable to be on a CTO, although the majority of patients are. Therefore, although 99% of the time, patients on a CTO are already deemed incapable, you must keep in mind there are also capable patients on CTOs. An example would be a patient with bipolar I, and episodes of mania where they decompensate rapidly. Patients like these may request the use of a CTO as as “safety net” to enforce treatment on them during a manic episode.
Incapable patient | Capable patient |
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Can be brought in under a Form 47 and be obliged to accept treatment from previously dictated 6-month treatment plan (Form 45) | Can be brought in on a Form 47, and be assessed for capacity and treatment, but ultimately, the patient can cancel the CTO if they want, provided they are still capable. If consent for CTO is withdrawn at any point, (even when they are well, or if the patient says: “by the way cancel that CTO” in a random phone call) you have a 72-hour period to re-assess the patient. You can actually re-issue a Form 47 to compel a patient to come to hospital for that assessment. |