Compulsory treatment orders double in Scotland for patients in community

This is six times more than the numbers originally predicted when mental health legislation was passed in 2003, with the then-Scottish Executive expecting that "about 200" patients might be subject to a community-based CTO "at any one time".

There were more than twice as many individuals on a community CTO in 2020-21 as in 2007-08 (1,243 vs 571) while the number of individuals on a hospital CTO only increased by 16% (1,532 vs 1,316) (Source: MWC Scotland)

The MWC report notes that the increase coincided with a 13 per cent (600 bed) reduction between 2014 and 2019 in the number of inpatient beds for psychiatry, addiction and learning disability in Scotland, adding: "While there are likely many factors that play part in this rise, we suggest that reduced inpatient beds may have led to more community CTOs.

"Whilst this might be a cause for a cautious optimism in the reduction of detention in hospital, the fact that many people on community CTOs tend to continue on these suggest that compulsion as a practice is increasing, albeit in the community."

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The report, published today, is the first in-depth investigation into the trends around compulsory mental health treatment in Scotland.

It comes amid an ongoing review of Scottish mental health law, and mixed evidence over whether community-based CTOs are effective at speeding recovery without hospital treatment.

The number of newly-issued community CTOs has been relatively stable, averaging 329 per year.

New community CTOs have remained stable, with around 329 each year, with the overall increase in the number of people on community CTOs driven by orders being extended (Source: MWC Scotland)

However, the report found that the main driver behind the increase in community-based CTOs is the number of people whose orders are being continually extended.

It states: "This may seem counter-intuitive to the principle of least restriction [but] in viewing the episode over time, it may be that people are likely to experience less overall compulsion if they have had further treatment in hospital or on a suspended hospital-based CTO than on a community based CTO."

Orders for compulsory treatment are granted, and renewed, by Mental Health Tribunals.

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They should only apply where a person's mental disorder impairs decision-making, where effective treatment is available, and where a lack of treatment would endanger themselves or others.

The orders initially apply for up to six months, but can be extended for a further six and, thereafter, for 12 month periods.

A 600-bed decline in inpatient beds for psychiatry, addiction and learning disability has coincided with a rise in the number of people on community CTOs (Source: MWC Scotland)

The report found 995 patients who had been subject to a CTO for more than three years, including 73 patients for 13 to 14 years.

The MWC said it was also "worrying" that the Black community is significantly over-represented, making up 12.8% of the community CTO population in Scotland despite accounting for just 1% of the population.

Patients whose CTOs had been extended were also more likely to be male, younger, and from the most deprived communities.

The report found that few CTOs were revoked early, and recommends that more is done to evaluate whether "a person is achieving real benefit from community-based compulsion".

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Dr Arun Chopra, medical director at the Mental Welfare Commission, said: “For a number of years we have been raising concerns about the increasing use of compulsory treatment for mental ill health in Scotland.

"With increasing number of people being treated against their will, it is critically important that the law should be updated and kept relevant.”

A Scottish Government spokeswoman said: “Effective and up-to-date mental health legislation plays a vital role in ensuring that the rights of everyone are respected, protected and fulfilled.

“The independent review of Scottish mental health legislation is considering how our mental health and incapacity legislation complies with developments in international human rights and looking at where improvements could be made.

"We welcome the publication of this report from the Mental Welfare Commission as it provides an important evidence base for the Review and will assist with the development of final recommendations due later this year.”