Based on the findings of the OCTET study, ^{Reference Burns and Molodynski1} Burns & Molodynski reject observations of consultants who reported directly observable benefits from community treatment orders (CTOs). They argue that it is not possible to ‘see with one's own eyes’ a probabilistic outcome that takes months to manifest itself.

This is a false analogy. In a subgroup of patients, CTOs result in a striking improvement in treatment adherence: if the CTO is lifted, patients discontinue treatment; re-implement the CTO (following relapse and re-hospitalisation) and treatment adherence is achieved again. In such cases, clinicians are able to ‘see’ the effect of CTOs on treatment adherence and reasonably expect improved clinical outcomes in the longer term. With such a dramatic response (treatment adherence) to the intervention (CTO), it would be scientifically unnecessary, ^{Reference Glasziou, Chalmers, Rawlins and McCulloch2} and ethically unacceptable, to refer patients to a randomised controlled trial (RCT).

A number of previous reports have highlighted the potentially detrimental flaws in the methodology of the OCTET, ^{Reference Mustafa3,Reference Segal4} which could explain the apparent paradox between the naturalistic observational studies that have shown significant benefit from CTOs, ^{Reference Rawala and Gupta5} and the negative findings of the OCTET.

Take the scenario of a young man with chronic schizophrenia, who attends the psychiatric out-patient department escorted by his carer. He has a long history of non-adherence to treatment, as well as multiple formal admissions. The patient is known to discontinue treatment immediately after discharge from hospital, invariably leading to rapid relapse and hospitalisation. Since discharge from hospital on CTO 3 months earlier, his mental stability has been maintained and he has been accepting his fortnightly antipsychotic depot injections. His positive psychotic symptoms are minimal. He has become more sociable and has applied for a part-time college course. The psychiatrist tells the patient and his carer that he is going to lift the CTO. To his dismay, the carer asks the psychiatrist ‘Have you not seen with your own eyes that the CTO works?’ The psychiatrist replies, ‘Yes I have, but an RCT says this could not have been possible’. Would this be evidence-based practice?