The government has introduced legislative changes to ensure that people with serious mental illness get the care and treatment they need in a community-based system. Bill 68 (Mental Health Legislative Reform), 2000 which includes the introduction of Community Treatment Orders (CTOs), passed Third Reading on June 21, 2000 with the support of 82 out of 103 members of the Ontario Legislature representing all three political parties. It was proclaimed on December 1, 2000.

The legislative changes remove barriers to families, police and social workers by ensuring that people posing a risk to themselves or others get the care and treatment they need.

The new legislation provides that a CTO may be issued by a certified physician to provide a person with community-based treatment or care and supervision that is less restrictive to the person than being detained in a hospital environment.

CTOs are for :

• Individuals who suffer from serious mental disorders and who have a history of repeated hospitalizations and who meet the committal criteria for the completion of an application by a physician for a psychiatric assessment in the Mental Health Act;  and
• Involuntary psychiatric patients who agree to a treatment/supervision plan as a condition of their release from a psychiatric facility to the community.

The criteria for making an order include :

1. a prior history of hospitalization;
2. a community treatment plan for the person has been made;
3. examination by a physician within the previous 72 hours before entering into the CTO plan
4. ability of the person subject to the CTO to comply with it;
5. consultation of the person and the person's substitute decision-maker, if any, with a rights adviser;  and
6. consent by the person or the person's substitute decision-maker to the community treatment order.

1. by the physician upon the request of the person or his or her substitute decision-maker;
2. where the person fails to comply with the CTO;
3. when the person or his or her substitute decision-maker withdraws consent to the community treatment plan.

Safeguards have been put in place to ensure the rights of a person subject to the order are respected. The CTO process will be consent-based and all statutory protections governing "informed consent" will continue to apply.

The rights of a person subject to a CTO include :

1. a right of review by the Consent and Capacity Board with appeal to the courts each time a CTO is issued or renewed;
2. a mandatory review by the Consent and Capacity Board every second time a CTO is renewed;
3. a right to request a re-examination by the issuing physician to determine if the CTO is still necessary for the person to live in the community;
4. a right of review of findings of incapacity to consent to treatment;  and
5. provisions for rights advice.

With adequate rights advice and legal advice, the consent of a person subject to a CTO, or his or her substitute decision-maker, if he or she is incapable, must be voluntary and informed and the consent not "coerced."

Under the Health Care Consent Act, physicians cannot administer treatment unless the person or his/her substitute decision maker has given consent that relates to the treatment, is informed, is given voluntarily and not obtained through misrepresentation or fraud.

CTOs have been implemented in Saskatchewan (1995), Manitoba (1997) and British Columbia (1999). Internationally, CTOs have been implemented in the United States (41 states), in Australia, New Zealand and the United Kingdom.

Some studies show that CTOs reduce hospitalization, increase treatment compliance, decrease victimization of mentally ill persons in the community and decrease violence against members of the public.

In these studies, evidence suggests that CTOs are most effective when there are available resources and services within the community. As well, the Mental Health Act provides that in order to issue or renew a CTO, the treatment or care and supervision required under the terms of the CTO must be available in the community. In response to this, the Ontario government is committed to improving access to mental health services. Since 1995, the government has invested $263M to provide the best possible access to high quality mental health care to the people of this province.

CTOs are not intended to replace the current mechanisms for dealing with those persons charged with an offence who are found "not criminally responsible by reason of mental disorder" under the Criminal Code of Canada. Under the Criminal Code, the Ontario Review Board, an independent body, has the authority to direct a person that is determined to be not criminally responsible to be discharged absolutely if the person is not a significant threat to the safety of the public. Alternatively, if the Board is not satisfied that the person meets this criteria, then it may, by order, direct that a person be discharged subject to conditions or direct that the person continue to be detained in hospital. The system to deal with those persons affected by a mental disorder and charged with a criminal offence remains the same and is not affected by the new civil commitment provisions in the legislation.