Are Randomized Control Trials the Best Method to Assess the Effectiveness of Community Treatment Orders?

Many jurisdictions have enacted community treatment order (CTO) legislation that requires a person, who suffers from a severe mental disorder, to follow a treatment plan when living in the community. CTOs have been a source of debate because of controversies on whether evidence of effectiveness should only be considered from randomized controlled trials (RCTs). RCTs are considered the "gold standard" method to evaluate effectiveness of simple therapeutic interventions such as medication, but they are problematic for evaluation of complex interventions because valid attribution of causation in complex interventions is not guaranteed with RCTs. CTOs are complex interventions that require the interaction of many individuals and organizations to achieve their effects and effectiveness research must measure these complexities of delivery and outcomes. This paper examines conceptual, methodological and analytical challenges of CTO research within the context of RCTs and other research designs. It also discusses the current state of knowledge on effectiveness of CTOs. Finally, we suggest a way forward by presenting alternative causal inference approaches and potential models for evaluation complex interventions, such as CTOs. We propose that these approaches should be used alongside other research designs in a nuanced approach that may involve using findings from initial studies to refine the intervention and/or its implementation.