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Henry Barron: [00:00:01] Welcome back to Psyched, the Educational Psychiatry Podcast for Learners by Learners. I'm Henry Barron, one of the medical students on the podcast, and I'm going to provide a quick introduction to the episode, and then Alex Rabern is going to take it away with today's interview. This episode is the third of four in our series on schizophrenia. If you haven't listened to Episode nine, it may be helpful to go back and listen to it because this episode builds on it and reinforces those ideas. For this episode, we sit down with Dr. Arash Nakhost, a psychiatrist and scientist at the Lee Caching Knowledge Institute here in Toronto who's an expert on health systems and serves delivery to people with complex mental health and social needs in the community. Alex got a chance to talk to Dr. Arash Nakhost about Community treatment orders, also known as CTOs and Assertive Community Treatment Teams, also known as ACT Teams. Before we get started, I'm just going to quickly go over the learning objectives for this episode of which there's five. So number one is to provide a brief description of the history of ACT teams and CTOs, as well as the challenges in establishing evidence for their use. Number two is to be able to compare and contrast ACT teams with intensive care management teams in terms of their composition methods and respective strengths and weaknesses. Number three is to be able to describe an array of services that teams can help provide its clients, as well as some of the challenges and drawbacks of teams. Number four is to outline the major reasons someone might be put on a community treatment order and describe how a CTO is applied and enforced. And number five is outlined the major challenges in using CTOs as a treatment tool. So that's all the learning objectives for today's show. Now, without further ado, here's Alex with the show.
Alex Raben: [00:01:40] Today, we're going to be continuing Muhammad's case. And so we'll start with that premise. Before we get there, I want to introduce our expert guests today, Dr. Arash and. He is a staff psychiatrist at St Michael's Hospital.
Dr. Arash Nakhost: [00:01:54] I'm one of the psychiatrist on the Focus team, which is a flexible set of community treatment team at St Michael's Hospital.
Alex Raben: [00:02:01] Thank you for being here. So let's start with the case and then we'll have a discussion. Talk about the learning and teaching points we want to go over. If you remember from last time, Muhammad was someone who presented quite young with schizophrenia, and since the last time you've seen him, he followed through with some of the treatment recommendations. He did take his antipsychotic the four milligrams of risperidone for about a year under the supervision of his family. However, about two years ago, Muhammad became homeless. He left the home suddenly and he stopped following up with his outpatient psychiatrist, stopped taking his medications. He's now been admitted for the second time in the past year. This is his third time total, and the inpatient team feels he is suffering from psychosis. He was found by police throwing rocks at a window and has cellulitis in both his feet as he was not wearing shoes outside. And the in-patient psychiatry team has now contacted you. You're working as part of the ACT team and they want you to come by and see if he would be a good candidate for foreign team and for a CTO. And they want your opinion on that. So that's the setup. Perhaps before we dive into the case, though, we should get a better understanding of what teams are and what CTOs are. So that's our goal today is to get a better understanding of that through the use of Mohammed's case. So Dr. No-cost, let's start with the basics. What is an attack team exactly?
Dr. Arash Nakhost: [00:03:48] So ACT teams or assertive community treatment teams are psychiatric teams that provide care to patients with severe mental illness who are living in the community and they need assistance. They are based on initial work that was done by Stein and his colleagues in the 1970s in Madison, Wisconsin. Initially, what they were trying to do was trying to figure out how to provide care for some of these clients who were being discharged from inpatient units of these hospitals but were not able to stay out for very long. So they would tend to decompensated, come back and need to be readmitted. Now, you also need to kind of put this in some kind of a context in a historical sense, is that they were closing up these massive psychiatric hospitals where people had stayed for for a very long period of time. And now the intention was that people were going to be provided with services in the community. However, they weren't really that many services available. And although many people tend to do well after these big hospital are closed, some patients were not able to cope and they would end up back in a hospital and kind of a revolving door scenarios. So that's where Stein and his colleagues came up with this idea. And their initial plan was the first time, if I'm not mistaken, was called training in community Living is where they were provided with some small amount of money and try to run these teams, which were idea was you would provide rehabilitation and care at the same time to these clients and see how they would do.
Alex Raben: [00:05:24] Is this a Canadian term or are there other is it referred to other things in other countries?
Dr. Arash Nakhost: [00:05:29] So initially was called this teaching in community living or TCL team, but eventually the term translated were changed to assertive community treatment teams. They are in existence in many countries in the world. The initial data was quite promising. It showed that they could reduce the number of hospitalisation, maybe length of stay or hospitalisation. They had some initial findings showing that they could do some genuinely successful rehab work with some of these clients, and this led into disseminating all across the US their activities in in Canada, for example, in Ontario we have, I believe, close to 70 teams. They started in Toronto in the 1990s. In other provinces there are teams and are also ACT teams in many countries in the world. And there are also some variations on ACT that's been adopted over time. But the initial success of ACT was actually quite important because what they were able to show is you could actually provide care and support for these patients in the community and they actually developed some fidelity skills, basically looking at what are the elements that you need to havefor an ACT team to be successful.
Alex Raben: [00:06:40] You mentioned fidelity in regards to the team, and I've certainly heard that before, but I don't think I've ever really understood exactly what that means. What can you take us through that a little bit?
Dr. Arash Nakhost: [00:06:52] From what I understand is some initial data coming from ACT teams were quite promising. Then other people try to meet ACT teams and then some of the subsequent data that was coming out wasn't really showing as robust of an outcome. So the question was, are they sticking to the basis of a model or were they deviating too far? And then that led to a number of different fidelity models. Basically, they're looking at parts of an act like how closely are they following the model? And it comes down to things like what is the admission criteria? Do they have a crisis services? So can they provide 24 hour coverage? Are they doing active outreach? How many case managers do you have on a team? What is their case load? What is the rate that you take patients on? An important element of an ACT team is that you have a small case load, but it's also shared. So everybody on a team knows every patient. And then if you think about somebody being an acting, the idea is you can see them up to twice a day if need be. But in average you would see them at least 2 to 3 times a week. And for some people that is basically what differentiates an ACT level of service from intensive case management, kind of a level of service.
Alex Raben: [00:07:59] You mentioned a revolving door patient scenario being key to why this service was initiated, what actually makes a patient this kind of revolving door patient.
Dr. Arash Nakhost: [00:08:10] As we know through the literature, many patients with a psychotic illness don't actually have insight into their illness. So what we know is anywhere between 30 or 50% of people who have a primary psychotic illness don't tend to think their symptoms are a sign of an illness. So then it becomes paradoxical that why should somebody take medication for something a problem they don't have? That is what to some extent can lead to the fact that these clients can become revolving door patients. And we know that many patients with this psychotic illness have fairly short readmission rates. So if I'm not mistaken, based on the data from CHI in. Canada. We know that for somebody with a primary psychotic illness after their first admission, the readmission rate within the first year is about 39 to 40%. And in addition to the psychotic illness, you have substance use issues. Then that rate substantially go up, gets closer to 50%. So then it's understandable that why someone like Muhammad can have these these problems, that he doesn't feel that he has a problem. So he's not going to be comply with his treatment. And when he comes out, he's going to get ill. So an ACT team can be helpful in maybe helping him with his compliance by observing him, maybe for taking his medication, by providing him services. It's not just necessarily about being assertive or coercive. Maybe Mohammad wants to go back to school, maybe he wants to get a job. Maybe he's thinking about moving on his own. And that's one of the elements of an ACT services that are important because on an acting, you're going to have a case manager. Typically on an acting, they have a very low case load. So a case manager is going to have anywhere between 8 to 12 patients. Most often ten is the standard number. So this person can spend a lot of time with Muhammad, try to get him actively involved in his recovery. And then as part of that discussion or part of that work that they're going to do together is the idea of medication compliance. So medication is important, but it's just a piece of the puzzle.
Alex Raben: [00:10:07] You have to think of the bigger social picture as well. I'm hearing I heard insight is one of the main things that you were talking about there. Would Muhammad be someone you might typically have on an ACT team?
Dr. Arash Nakhost: [00:10:19] Then in general, most teams provide services for people with psychotic illness and then clients with mood disorder, typically bipolar illness. And because of that, Muhammad would be a very common or typical candidate. There isn't a lot of evidence supporting for other clients with other type of illnesses Being picked up by an ACT team reality is that many of these folks just fall through the cracks. For example, if you have significant brain injury with substance use, then you may not be picked up by anybody. That doesn't assume means that they don't need services. It just means that we don't have enough literature to support good candidates for an ACT team.
Alex Raben: [00:10:54] I see. I see. You've mentioned early on the results were very promising and there's been lots of literature since then. And I actually just read a the newer Cochrane review of ACT teams and the results were not great according to that. But I know that the literature is very nuanced and I'm not nearly as familiar with it. Could you take us through some of like highlight some of the important parts of what's come out in the literature about the benefits of ACT teams?
Dr. Arash Nakhost: [00:11:21] So I think the way I like to look at it and this may be kind of a more simplistic way of analysing the data is that before ACT came to the scene, there wasn't really much happening. We didn't really know how to care for these patients. We had hospital based method of providing care and it worked for some people, but it failed many others. So ACT came with the idea that you actually have to actively go out. You need to assertively go out, see the patient, provide care with them where they are, seem in their homes, and not just think about trying to medicate people. It's like you need to provide an array of services from housing to rehab to vocational work, all of that, and they actually develop standards for how to do this. And that led to an improvement in my mind, of quality of other services that came on board. So many other teams or many other models of care that came to existence after that adopted some of these scales or some of the things that ACT teams are doing. What it means to have a case manager, whether they're supposed to do things along those lines. So in many ways, ACT raised the level of what standard of care was supposed to be.
Dr. Arash Nakhost: [00:12:32] It led to the development of what they call intensive case management team. And what we know is that many intensive case management teams basically adopt many of ACT elements. The case managers generally have a higher caseload. It can go up to 20. They may see the patients less frequently. It's not a shared caseload. So you see your own patients, but they have been actually being able to provide very excellent quality of care and then use you get to the point when you see in the in mid 2000 where studies coming from like Netherlands that come from UK, they're not able to show any improvement over ACT. Now you can say that part of it is because the quality of the standard care has gone up. Now there are issues with the studies, issues from the for example, studies from from the UK and the teams that they were selected and how closely did they adhere to the fidelity scale and all that. And part of it is the overall improvement in the quality of the services. Now one of the things that if you look closely at the data, like some of the data coming from Netherlands or even data that we have in Ontario, it shows that yes, ICM teams are pretty good at providing services and maybe you they provide the same level when you look at, for example, rate of hospitalisation or length of stay.
Dr. Arash Nakhost: [00:13:43] But ACT teams do a phenomenal job, for example, at retaining patients. You know, the drop off rate on an ACT Team is typically very low. You're talking about 2 to 3% when on an ICM team, even based on the studies from Ontario, it can be 25% and that people who kind of fall through the cracks are not showing up for follow up are the ones who you tend to worry about and you think they need to come in. So I think that that's an important element that you can kind of put it in perspective. And I think that's why when you look at the Cochrane Review, initially it used to be an ACT review that was withdrawn and now it's kind of put together as an intensive case management. But for an intensive case management to be successful, they actually need to stick to many of elements that was kind of brought on by ACT teams.
Alex Raben: [00:14:26] Right. So there's many reasons why the studies may not be showing huge changes.
Dr. Arash Nakhost: [00:14:32] You know, you can even question is like, is this is the hospitalisation rate or admission rate is the only element you can look at if you're looking at someone's trajectory and the recovery. Now again, I think in some ways ACT has been incredibly important in improving the quality of care, but that doesn't mean that it cannot be improved upon. Or maybe there are ways that things can, can, can move forward because the initial studies from ACT or now for better part of 50 years old, we haven't really changed anything from 50 years ago. You improve on it and it's understandable that some of these things have have changed and improve. And in my mind, for a certain patient population, you always need to have the intensity of act that ICM can't manage some of these folks and can't help them. But there's also much to be said about intensive case management and what it can.
Alex Raben: [00:15:19] Do, right, And unhinging ourselves a bit from the literature. What in your opinion, do you feel are the benefits? What do you see on a day to day in your clinical experience that really shines with the ACT model in terms of benefits to patients?
Dr. Arash Nakhost: [00:15:35] I think as a whole put them together with ACT and ICM is the ability to have a case manager who can come out and see you in your own home, that they can look at you as a person and looking at the totality of your issues. So maybe you need help with your banking, maybe you're having issues with your housing, maybe you need better housing, maybe you need somebody to help you get a family doctor. And sometimes some of the clients are overwhelmed with the multiple tasks that they need to do. And in some cases, people have significant legal issues. You may, because of your illness, you may have got into trouble with the law, you may have complicated medical issues, you may have diabetes, you may be there are many, many things that you need to to deal with that it can be quite overwhelming to someone with somewhat limited capacity. And I think that's where the model becomes important in a way that you're not forcing the patient to adapt to your to what your 9 to 5 office are, is like you're adapting to what their needs are. So you go out and you see them where they're at.
Alex Raben: [00:16:40] Right? And I imagine a lot of that is hard to capture in a study as well. Right. A lot of those benefits are.
Dr. Arash Nakhost: [00:16:47] Some are. And I think, you know, it's I think that's why you kind of need to look at these longitudinally. And I think, again, part of it is it's not necessarily trying to say, is it act better than it seems that I same. But in fact, I think you need to have a range of services you can provide.
Alex Raben: [00:17:02] In my own experience on inpatient psychiatry have certainly seen patients come back into hospital. I've seen patients who have been very difficult for our team at St Michael's to connect with by virtue of just the way the city works. And it's hard to find people. I'm wondering what are the what are the challenges that you guys face day to day? And maybe we could do it in the context of Muhammad. What would you anticipate would be difficult in providing Muhammad with care?
Dr. Arash Nakhost: [00:17:31] So somebody like Muhammad, you know, one of the things at the top of my head when I'm thinking of it is where is it going to be housed when he's going to come up Post-discharge is family going to take him back? Are they interested for him being at home? You know, if he is homeless and if he's not stable, they may not be interested in having him back home. If he has a history of assault at home, they may not be interested to be involved. And that's one of the tragedies. One of the difficulties of working for some of these clients is that over the length of time, as they become more and more unwell, they actually lose their social support. Many of them, for example, with people with schizophrenia, as it tends to affect men in their late teens, early teens, early twenties, they actually haven't really made close friends. They don't have close friends that stay in the picture. So it's kind of becomes very difficult for them to connect to other people. You know, if you look at some of the issues that kind of comes up with with the ACT teams, you know, they tend to have very long waiting lists. Right now, for example, in Ontario, the average length of people staying on a waiting list when active is a year, because a typical length of stay on an acting in most literature is anywhere between 5 to 8 years.
Dr. Arash Nakhost: [00:18:38] So you build these teams, they're expensive, they are labour intensive, you bring people on, but then you can't discharge them. You can't send them anywhere. They stay there. And sometimes it's challenging to provide follow up for some of these folks, although they may be in a place where they can do better, but maybe they're not well enough to to start going to seeing their GP only or going to have other services. And I think that's part of the problem is that as wonderful an ACT teams are, they can't fix the system if somebody doesn't have adequate housing, doesn't matter what you do, if somebody is having physical health issues and you can't find them, a GP doesn't matter how the case manager is, you're still not providing adequate services. So for Mohammed, another issue that comes to mind is, is he going to be compliant with his meds? Is he going to take his meds, is he going to take oral meds? And then ultimately, if he's not, then would he be someone that he can put in a community treatment order?
Alex Raben: [00:19:34] You've said, perfectly to our next topic, which is the community treatment order. So why don't we talk again from the basics? What what is a community treatment order? What is the purpose of this?
Dr. Arash Nakhost: [00:19:47] So community treatment orders have been in effect since basically the 1960s. My understanding is District of Columbia in the US was the first place that put a community treatment order in place and they're currently used in many jurisdictions in the US. I think last count were 44 states have them, multiple provinces have it in Canada, many countries in the Europe, Europe have it, New Zealand, Australia have had it. So I look at community treatment as a tool in treatment of the patients. The idea of them is that it can be a mix of two different things. Some of them are meant to be at least restrictive method of care for the patients. So in some places they say for you to be able to go on a community treatment order, you need to meet criteria for admission to a hospital. In some places it can be preventative. You can actually be pretty well and they can say, you know what, your past history shows that you're not going to follow through with treatment. We're going to put you on an CTO. Many places as a combination of both. And the basic idea is you are going to be obliged to take your treatment, come to appointments, and if you don't, then you can be brought back for an assessment. A very few places allow force treatment, although it can exist or happen in most places similar to Ontario. The idea is you're not coming for your appointment based on your community treatment plan. You're supposed to see your team every week and you're supposed to get your injection every month. You haven't come to your appointment. This week. The physician can issue a form and ask the police to pick you up, bring you to a hospital for an assessment, and then from there they can decide what they want to do.
Alex Raben: [00:21:24] Right now defining what is treatment. I imagine a lot of it is depo intramuscular anti-psychotic medications because we can give them over a longer period of time and then see people in every couple of weeks. But our other two other treatments fall under this umbrella.
Dr. Arash Nakhost: [00:21:46] So treatment is actually in at least in Ontario, has been defined very broadly. So if you look at the the health act, it's it's it's fairly broad as what is considered treatment as part of a treatment plan. You can have a number of visits to the office. Some clients may be asked to come daily to take their medication, observed oral medication. Now you're right, intramuscular antipsychotic injections are probably the easiest to monitor, but other elements can be added as part of a treatment. Maybe somebody needs to follow up with their diabetes care. Maybe somebody needs to see their case manager. This amount of time a week placement has been raised as a possibility, so basically asking someone to live in a specific location in Ontario is not that common. But in Quebec I know that placement or placements are a very typical part of a treatment order. When you say what you need to stay in this house or this rooming house or this place for the length of your community treatment order. Now the important question is always enforcement. So how are you going to enforce it and what's the benefit to the patient? Why are you asking for something if you're not going to enforce it or if it's not going to have any specific benefit to the to the to the client.
Alex Raben: [00:22:58] And just in terms of anti-psychotic medications, I'm thinking about Clozapine as something that would be pretty complicated to monitor but may come up because it is the most effective medication for treatment resistant schizophrenia. Does that issue come up at all?
Dr. Arash Nakhost: [00:23:14] So we've had from my clinical experience, we've had some success with patients on, well, clozapine or valproic acid or lithium, different mood stabilisers. And we basically make it known to the patient that we expect them to take the medication observed at certain times of a day, and then that we would do blood levels to make sure that they are actually compliant. And again, it really comes down to where somebody is maybe they're initially reluctant because they have no insight or they're not well. But over time, when somebody is feeling better, may they may actually decide that, no, actually, I need this. This is not something that needs to be forced upon me. On a CTO.
Alex Raben: [00:23:55] Getting back to a similar question we did with the ACT teams, what is the the benefits of this treatment option? What does the literature show and what what? From your own experience, do you feel the benefits are?
Dr. Arash Nakhost: [00:24:08] So the literature is, I find, difficult to fully decipher just because there's so much variability on, you know, even what did they mean when they say a CTO, you know, what are the terms of enforcement? So there have been two RCTs done on patients or community treatment order versus standard care, one done in New York and the other one in North Carolina. And there was also a study done on in UK on comparing community treatment orders versus extended leave. And these studies haven't really managed to answer the question partially because there are significant shortcomings in all of these studies. So, you know, if you for example, look at this study from New York, it didn't show a difference between CTO and the control group, but the team is quite honest about the fact that the police in New York refused to enforce the CTO. So if you have an order that nobody enforces, then really, what's the point? Similarly, for example, if you look at the study done in in UK, they didn't show a difference between the two things that we're looking at. But because of the restrictions that they had with their ethics, they only could ask patients to participate in the study who had capacity to to consent to treatment. So in many places, if you have capacity to consent, you can't actually be forcefully put on a CTO.
Dr. Arash Nakhost: [00:25:28] So then then you're looking at a very narrow slice of the patients and there are multitude of other issues. Now, the study from North Carolina was not on the initial group, but on a subgroup analysis. They were able to show that for people who were in a CTO for six months and more, they were benefits reduce hospitalisation, length of stay, less victimisation things along those lines. If you look at the Canadian studies, we don't have a randomised controlled trial in Canada, but four studies have been done. These are small studies, pre post type of study like case controls or just pre post looking at the same patient population and all four have been supportive that they help with reducing the length of stay and the hospitalisation. So my feeling is that CTOs are a treatment tool, they're not a treatment unto themselves. It really comes down to what other services are available, what jurisdiction you're working on, what else is out there, and then ultimately how they're utilised. They're not. Going to answer for everyone. Some clients are not going to do well on them. I don't think we know enough to to say who's going to fail and who's going to work for it. But in general, they tend to be utilised for people with psychotic illness. They tend to be used for some clients with bipolar illness.
Dr. Arash Nakhost: [00:26:41] And the overall indication is that it works. And I think it works better for someone who is on an intramuscular injection and someone who probably has some some challenges in some other issues. You know, maybe they're not having issues with substance use maybe or other things now as a whole. I think it's a piece of a puzzle. So you can put somebody in a CTO, but if you don't have other pieces, then it's going to be limited outcome. But if you have other pieces to put in and then you give someone time because think about all the challenges that someone like Muhammad may be facing right now, you know, what's the likelihood of putting him on a you know, in some states in the US and a 90 days treatment order is going to do for him, you know, how far are you going to go? He may still be trying to figure out the very basics of his life and he gets out of a hospital. So that's why I think the although the literature is limited, I think six months would be a minimum. You probably need to be closer to maybe a year or two on a community treatment order before you see a difference. And then you need to have other services on board.
Alex Raben: [00:27:42] Right now. By other services, do you mean ACT teams? Because I could imagine that getting someone to comply you're going to need people monitoring is what is the overlap between ACT teams and CTOs.
Dr. Arash Nakhost: [00:27:55] So in many places, like for example, in Ontario, often they want you to show that the patient has improved when you're putting somebody on a CTO, and the idea is that you can provide adequate community services. So actually an ideal, although we've done studies, one of the works that I've done on CTOs and was published in 2012 and the clients we looked at, the hospitals that we looked at did not have an ACT teams or ICM team. Now you can say so maybe some of the most challenging patients at some point would be lost to follow up because you can't find them and they just disappear. But I think as a whole, if you look at these clients as high need individuals, then ideally when you put somebody in a community treatment order, then in some ways now you are you kind of binding yourself to them, that you're going to provide the best services that you can. And then having an intensive case management or ICM or ACT teams are essential because then actually help you to put these other places in place. So you you're not just trying. The issue is not just about trying to medicate someone is you're actually trying to help them with housing and education and vocational work. In all other pieces of the puzzle.
Alex Raben: [00:29:00] Write the important results and correct me if I'm wrong, but that's built into the legislation in Ontario anyways that they need, that they.
Dr. Arash Nakhost: [00:29:07] Need to have high intensity care. But, you know, I've followed patients on ICM as an outpatient psychiatrist. There are many other pieces of puzzle that are in place. So for example, maybe they are generally agreeable when they're well or they live at their mom and dad and, you know, mom agrees to bring them to the appointment and at the tail end of their hospitalisation, they're starting to kind of get better. And many other pieces were already in place, so they didn't necessarily require the ACT team acting. I don't think it's a necessary element, but for some clients especially hard to serve clients, it's helpful.
Alex Raben: [00:29:41] So I guess an important question here is would Muhammad meet criteria for CTO? Although we have international listeners and listeners in other provinces, I think it's important to anchor this in something. So we might I think we should go with the Ontario legislation and we don't have to go into super detail about the criteria. But would he meet criteria? Would it be a good idea for him?
Dr. Arash Nakhost: [00:30:05] So it's it's actually right now in Ontario, the legislation is pretty straightforward. So what do you need to have in the past three years? You need to have either to hospitalisation or having spent more than 30 days in a psychiatric hospital. Now, it doesn't necessarily need to be involuntary. It can be any type of hospitalisation and as long as you meet that criteria, you can come in. The other issue is if you have previously been on a CTO, that can also count. So if Mohamed, if I'm not mistaken, has had three.
Alex Raben: [00:30:39] Two in the last year, three total.
Dr. Arash Nakhost: [00:30:40] So then that that is, that is enough for him to meet the criteria for a community treatment order in Ontario and the legislation. And I think this is an important element when you look at different, different legislation, is that the legislation in Ontario is consent based. So either the patient themselves or the substitute decision maker need to consent to treatment. That's not all the same all across provinces. So in some provinces you don't necessarily need the patient's consent to go ahead. You just need the the issuing physicians to agree. And remember, even in all across Canada, it's not it doesn't say needs to be a psychiatrist in some places, for example, in Saskatchewan, if I'm not mistaken. You need two psychiatrist to issue a CTO. In Ontario, the legislation is a physician, although I think if they're looking at the legislation means that even if a GP is going to issue it, they need to do quite a bit of mental health work. But this has actually allowed maybe physicians in a small communities to to issue a CTO if they think it's necessary and again, in some other places.
Dr. Arash Nakhost: [00:31:45] Again, if I'm not mistaken, like in Alberta, if a general practitioner and a psychiatrist to issue it. And I think the issue of consent is also very important as far as, you know, who can you put on a CTO and what the processes are. My experience working in Quebec was that it's probably one of the most wide reaching kind of community treatment orders you can put in place. They can go up to three years and it really comes down to past history. So even if maybe at the day of a hearing, somebody saying all the right thing, if they had six hospitalisation over the past three years and have got into all sorts of troubles and shown that when they're unwell, a danger to themselves or the public at large, then they may still go on to CTO, where in Ontario it's capacity based comes down to day of a hearing. If the patient decides to challenge your request for CTO and if at that moment they're saying what they need to say and they you cannot issue a CTO right?
Alex Raben: [00:32:41] So that's definitely a challenge in issuing the CTOs in Ontario. Are there other challenges to issuing CTOs in Ontario? One comes to my mind that there just a lot of administrative work. I recall from my time in the inpatient unit that it took quite a while to get things going. But yeah.
Dr. Arash Nakhost: [00:32:58] It's so it's kind of I think it's amusing that they call it a community treatment order, but when you look at the mechanics of it in Ontario, at least it's not really done in a way that favours this being done in a community. You need to issue a number of forms. They need to be issued in a certain order. You need to have done your initial assessment before you finish, before you issue your first form four and 49, within 72 hours of assessing the patient. They need to get rights advice. They know the rights advice needs to reach the patient. So I actually find the current legislation in Ontario to be quite challenging sometimes for some certain clients and also the fact that they need to be issued every six months. It makes it sometimes you feel like you're just gone over issuing one when the time is to reissue, because in some cases it can. Realistically, I've had cases when the patient's SDM doesn't live in Canada, so it takes and the current legislation requires the substitute decision maker if it's a family member, to receive rights advice every time. So it's a challenge trying to get somebody in Dubai to get straight rights advice and all the forms need to be signed and the sequence that needs to be signed again. I think it's very important to be patient centred and you affect someone's rights, so they should have the tools at their disposal to challenge if they want to. But the current system in Ontario is very, very challenging and clunky. Mm hmm. Mm hmm.
Alex Raben: [00:34:25] And it's interesting that the patient's SDM also gets rights advice. I can understand that you are encroaching on the rights of the patient. Therefore they should be allowed to call a hearing. But do you have any sense of the rationale for the SDM?
Dr. Arash Nakhost: [00:34:39] I mean, a good thing is that, you know, these things are evolving. So the initial CTO legislation in Ontario came to effect in 2000 and they're subject to review every five years. So far there have been two reviews and they have made some changes in the legislation, small amounts. And I think these things were done with good intentions, but I think at some point it can provide in care challenging because somebody can even question the fact that why do you need somebody to be hospitalised twice in a short period of time? Because effectively by putting this some of these barriers, you make it impossible for someone who is maybe a first episode psychosis kid to receive the services. Maybe Mohammad would have been better off if somebody could have issued a CTO three years before. But because you need to meet these specific criteria, you're effectively excluding some of these folks from getting the treatment. And again, I'm not necessarily saying that everybody needs a CTO. It works. For some people it's a tool. But I think with some of these barriers, we may make it more difficult for patients to actually access service. Right?
Alex Raben: [00:35:41] So let's say we get through all of these barriers and that Muhammad does end up on a CTO. You mentioned earlier that for some people it fails. I know you said you can't predict it, but is there a typical reason why people fail in a CTO?
Dr. Arash Nakhost: [00:35:55] I mean, I often find it's the, you know, where somebody is in their life and what is it that they need? So one of the clients that comes to my mind that we weren't able to help with the community treatment order is that someone who we had a very difficult time housing because significant substance use issues. And then he kind of started moving further and further out from downtown core because he was being chased away by various dealers he owed money to. And then we couldn't. Help him. And a part of it is that I don't think he also viewed this as a problem. So there was substantial substance use problems. There were housing challenges. He couldn't connect them to services. He was not interested. He had very little insight and he wasn't improving substantially. I think the treatment had helped him. He was less symptomatic and somewhat better, but we didn't manage to bring him to a place where he was well enough to kind of appreciate what was going on. And effectively, at some point he just moved far away from downtown core and was smart enough to not meet with the case managers and basically hide. And then we were not able to renew the CTO. So, as you know, not everybody responds to treatment and some people can have partial response. And, you know, it's kind of hard to think about why would you even try to issue a CTO for someone who is not at all responding to treatment, Like, what's the point of this? And that may be some of the folks that ACT on its own is not sufficient. But then I think if you can provide a package of care that includes other things that people need, then you can have a different discussion.
Alex Raben: [00:37:31] And can the CTO, even if those that package is not included in treatment, can it be used as leverage for getting that package surrounding patients? Is it a tool in that way?
Dr. Arash Nakhost: [00:37:41] Not necessarily, no. I mean, it can in some places may, May, may be expedient your access to an ACT or an ICM team. But I don't think on its own, just because you're not acting doesn't mean you're going to get housing. But just because you are on a CTO doesn't mean that you're going to immediately get off the hook from the legal system. Now, I think sometimes it's interesting because one of the things that just came to my mind was this patient that she wasn't really meeting the criteria for a CTO but wasn't well enough. And that was one of those people who hasn't really had that many hospitalisation but wasn't well enough. And then we were trying to work with her for quite some time unsuccessfully, and she had a lot of legal charges for small things, like she wasn't doing anything dangerous to anybody, but she was just getting into trouble. And at some point I think she had a, she had a couple of short hospitalisations. And then right after that, we ended up in jail and then somehow spoke to a court diversion worker and the division court worker said, you know, why don't you go and ask your psychiatrist to put you on a CTO? And then she basically came to my office and she said, you know, I need to be on a CTO, okay? I think now you meet the criteria. She mostly did it in order to kind of appease the legal system because she thought they would send her to diversion and it would help with her case. But she's done beautifully and I am. And she she requested it. And it's funny because I actually had to tell her when we had to renew. I'm like, I really don't think you need this. Just like, No, I need it. I'm like, okay, I renew it one more time, but I really don't think you need this. You're doing really, really well. And, you know, she's quite insightful and has a good sense of what had happened. So it can it can work in odd ways for different people.
Alex Raben: [00:39:14] It makes sense. We are running low on time. So for my last question, we've talked about a lot of different things, but I'm wondering if you had to choose one thing or a few things that you think would make the biggest difference in the system right now for the patients who are on our ACT teams and on our on CTOs, what would that look like to you?
Dr. Arash Nakhost: [00:39:36] I think housing is a is a huge challenge. I think adequate financing, I think we are in some ways is force poverty that many patients with mental illness are. You know, what is paid for them to live on on a yearly basis is completely inadequate. You know, you're living in a place like Toronto where, you know, I have patients who, after they paid their cost of their housing and the food, they have like literally $20 to live on for the rest of the month. And I think it's to me, it's kind of backward because my understanding is the cost of a day of an admission to an inpatient unit is about $2,000, and we're paying people like $1,000 to live on. And I think in some extent it's just not necessarily the smartest way of supporting people. I think, you know, the measure of civility in a place for me is how they take care of the least advantaged people. So how do you take care of your elderly, how to take care of your children, how to people who are ill? And I think if you look at it that way, then we need a lot more support. And in an absence of adequate housing and adequate finances, what's the point of some of these things if you can't really look at the patient as a totality of who they are and try to help them? I mean, if you look at somebody like Muhammad right now, you know, he's going to have all sorts of ongoing issues, vocational training, educational needs, financial need, housing. So, you know, yeah, it's good to put him on an ACT and it's good to give him a give me a CTO and maybe you can help me with his med compliance. But if he can't really help me with every other thing that he needs, then I'm not quite sure how patient centre is the care you're providing.
Alex Raben: [00:41:14] So it's a big question of where we're putting our tax dollars and that kind of thing. Obviously big systems issues. Well, thank you so much. For joining us today and sharing your wisdom about ACT teams and CTOs. I've learned a lot. I'm sure our listeners have as well, and we really appreciate you being on the show.
Dr. Arash Nakhost: [00:41:32] Thank you.
Alex Raben: [00:41:33] Thank you. Bye bye.
Henry Barron: [00:41:38] The site is a resident driven initiative led by residents at the University of Toronto, where affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. This episode was produced and hosted by Alex Rabeon. Our theme song is Working Solutions by Olive Music. A special thanks to the Incredible Dr Arash Nakhost for serving as our expert on this episode. You can contact us at Info@Psych.Podcast or visit us at PsychEdPodcast.org Thank you so much for listening.