Involuntary outpatient commitment (OPC) is a legal intervention designed to benefit persons with serious mental illness (SMI) who need ongoing psychiatric care and support to prevent relapse, hospital readmissions, homelessness, or incarceration but have difficulty following through with community-based treatment. Virtually all states in the US permit some form of OPC. Forty states and the District of Columbia have explicit OPC statutes, while several states are currently considering enacting or modifying existing OPC legislation (1–4). OPC has been enacted or is being considered in several other countries, including Israel, Canada, the UK, Australia, and New Zealand (5–11). OPC is also referred to as assisted outpatient treatment, community treatment orders (CTOs), and mandated outpatient treatment. In this paper, we refer to it generically as OPC. We discuss the empirical evidence for the effects of OPC on treatment outcomes.
OPC can be distinguished from other, related mechanisms of court-mandated treatment, including conditional release or guardianship. Under conditional release from a hospital, an involuntarily committed patient is released into community care under the ongoing supervision of the hospital. Conditional release is usually restricted to previously hospitalized and involuntarily committed patients. A limited number of naturalistic studies of conditional release indicate that it does appear to effectively reduce rehospitalization and violent behaviour (12). Under guardianship, the court appoints a guardian for a patient judged to be incompetent. The guardian consents to treatment for the patient, who then may be compelled to adhere to treatment that may include forced medication and hospitalization. Geller and coworkers found that mandated treatment under guardianship appeared to reduce rehospitalizations and total hospital days (13).
OPC orders typically require compliance with recommended outpatient treatment, that is, keeping scheduled appointments with a mental health provider. Some OPC statutes stop short of permitting forced medication of legally competent individuals. In every jurisdiction, OPC orders have limited duration. For example, in North Carolina, a psychiatrist may recommend to the court that an individual initially be placed on OPC for not longer than 90 days, after which a hearing must be held to renew the order for up to 180 days. When a person on OPC fails to comply with treatment, the responsible clinician may request that law officers transport the individual to an out- patient facility for persuasion to accept treatment or evaluation for inpatient commitment (3).
Several studies of OPC have been conducted in North Carolina, where the existing OPC statute (NC General Statute, section 122C) was modified in 1984 to lessen restrictions on the use of mandated outpatient treatment. Criteria for OPC in North Carolina now include the presence of SMI, the capacity to survive in the community with available supports, a clinical history indicating a need for treatment to prevent deterioration that would predictably result in dangerousness, and a mental status that limits or negates the individual’s ability to make informed decisions to seek or to comply voluntarily with recommended treatment. While similar to other states in encouraging OPC as a less restrictive alternative to hospitalization, North Carolina is unusual in lowering the threshold for OPC to allow its use as a preventive measure to avert relapse and hospitalization (3). The following sections review outcome studies of OPC grouped by naturalistic, quasi-experimental, and randomized controlled trials (RCTs).
Naturalistic and Quasi-Experimental Studies of OPC
Assessing OPC outcomes poses the problems of separating the effects of legal coercion (for example, the effect of the moral power of the court) from other attempts to influence behaviour, from the effects of treatment, and from additional factors such as selection effects. To improve treatment compliance, a myriad of attempts to influence behaviour may be brought to bear on individuals with SMI (14). For example, a family member serving as a representative payee for disability benefits may attempt to leverage treatment compliance as a condition of further financial support. Such informal and formal coercion may exert powerful effects in concert with or independent of OPC. Selection and treatment factors are also important potential confounds to interpreting empirical evidence regarding OPC.
For example, an early study in North Carolina, the first to report OPC effects, based selection of patients for OPC on characteristics, such as family support and employment, that were likely to increase the patient’s potential success in treatment (15). Only 12.5% of the patients were involuntarily hospitalized during a 90-day commitment period. However, confounding of selection effects with the effects of OPC made it impossible to assess the effectiveness of the court order. A second North Carolina study found that clinicians in a mental health centre rated OPC effective in 46% of cases during a 6-month follow-up period (16). However, inconsistent enforcement of the order when patients failed to comply made the findings difficult to evaluate. Greeman and McClellan compared the community adjustment of 3 groups: patients whose involuntary hospitalization was stayed and who were ordered by the court to receive community-based treatment, patients who were released after 72-hour emergency admissions, and patients involuntarily hospitalized (17). At 1-year follow-up, few patients in any group did well on measures of compliance with medication, appointments kept, and absence of disruptive symptoms. However, a higher proportion of patients in court-ordered community treatment (24%) did well, compared with patients held for 72 hours (14%) and those involuntarily admitted to the hospital (4%). As in the study described above (16), Greeman and McClellan’s results are confounded by selection bias (17).
The positive effects of OPC are more clearly seen in a study by Zanni and deVeau, who compared patients’ hospital experiences 1 year before and after receiving an OPC order (18). This pretest–posttest study design avoided selection bias. Patients who received both inpatient and outpatient treatment from the same team and hospital (n = 42) had significantly fewer hospitalizations per patient (0.95 vs 1.81) and shorter hospital stays (38 vs 55 days) during the year after OPC, compared with the prior year.
Van Putten and colleagues evaluated OPC by comparing outcomes for 3 groups of patients identified at various times before and after the 1983 implementation of new legislation authorizing OPC in Arizona (19). Group 1 comprised patients involuntarily hospitalized in a county hospital in the 6 months before the legislation’s enactment. Group 2 comprised patients who were involuntarily hospitalized and eligible for OPC in the first 6 months after changes to the law. Group 3 comprised patients who were involuntarily hospitalized and eligible for OPC in the second 6 months after changes to the law. Positive outcomes included shorter hospital stays following initial OPC for groups 2 and 3 and a lack of violent acts or victimization while the patients were under the court order. In addition, a higher proportion of patients in groups 2 and 3 voluntarily used community mental health services after their court orders expired, compared with patients in group 1. After the new legislation was enacted, both patients who were and patients who were not on OPC had significantly increased voluntary community aftercare. Therefore, it is likely that improved services for both groups partly accounts for the outcomes.
Hiday and Scheid-Cook report on the revised, lower-threshold OPC statute in North Carolina that allows preventive commitment (20). They compared persons committed to outpatient treatment who began treatment, persons involuntarily hospitalized and later released, and persons released instead of being involuntarily hospitalized and found no differences in living situation, rates of rehospitalization, days rehospitalized, level of social interaction outside the home, employment, level of dangerousness, or number of arrests. Patients on OPC who began treatment showed significantly improved compliance with medication and other treatment, increased visits to the community mental health centre, and higher retention in treatment 6 months after their hearings even after their OPC orders expired. OPC was more likely to influence treatment compliance than social, clinical, and systems outcomes. A similar analysis conducted among individuals with SMI showed comparable outcomes, except that differences in compliance with medication and other treatments were not significant, likely because of limitations in the sample size (21).
A subsequent North Carolina study found that outpatient commitment dramatically reduces rehospitalization rates. Fernandez and Nygard studied all patients in the state who had a first outpatient commitment in the 3-year period after the less restrictive commitment statute was enacted (22). The patients’ average number of involuntary hospitalizations declined from 3.7 before their initial OPC to 0.7 after the order; and mean standardized total length of stay declined from 57.6 days before the OPC order to 38.4 days after. These findings represent decreases in readmission and lengths of stay of 82% and 33%, respectively.
In contrast to the above studies, a study by Bursten found no differences in readmission rates between patients ordered to mandatory treatment after involuntary hospitalization and patients in a control group (23). He concluded that mandatory outpatient treatment had no effect on hospital readmissions; this conclusion may be qualified, however, because there is evidence that the outpatient law was not enforced.
A more recent study by Munetz and colleagues examined community tenure and social functioning in a group of high- recividist patients placed on OPC in Ohio (24). In a 12-month follow-up period, outpatient-committed patients demonstrated reduced emergency room visits, reduced hospital readmission, and reduced lengths of stay. These authors also found a higher number of visits with psychiatrists.
Rohland conducted a 5-year retrospective study of Iowa’s outpatient commitment statute, wherein 39 patients who met study criteria were matched with control subjects. Positive findings included improved treatment compliance in approximately 80% of committed patients, with reduced hospital and emergency room use (25).
Several international studies of outpatient commitment have also been conducted. Preston and colleagues examined the use of mental health services in a complete cohort of 228 patients treated under CTOs in Western Australia between 1997 and 1998, compared with a set of matched control subjects (7). There were no significant differences in inpatient admissions and use of bed days, both of which were reduced in each cohort. Subjects under CTOs did show a significant increase in outpatient service use. This study, although carefully conducted to match subjects and control subjects, may still have been affected by selection bias.
In Israel, an uncontrolled naturalistic study under the 1991 Treatment of Mental Health Patient Act authorizing OPC attempted to examine whether OPC reduced involuntary admissions across the country. Acknowledging a lack of specific outcome data, the authors conclude that OPC appeared to have little effect on overall rates of involuntary hospitalization in the country (5).
In New Zealand, Dawson and Roman combined a retrospective uncontrolled study of regional mental health records with a survey of psychiatrists (26). They found that one-fifth of patients remained under a CTO for more than 1 year without rehospitalization. Psychiatrists surveyed also responded that appropriate use of CTOs promoted compliance with medication.
A study of CTOs in New South Wales, Australia, compared readmission rates of all patients given CTOs in a 4-year period with rates in a matched comparison group (27). While the authors reported that 38 of 123 patients under CTOs were readmitted during the CTO, they found the matched group inadequate for clinical comparison. They found high rates of compliance in the CTO group if subjects were prescribed depot antipsychotics. They concluded that a better-matched control group would be needed to confirm the preliminary findings that CTOs may reduce rehospitalization if combined with the use of depot antipsychotics.
Taken together, findings from these studies of selected samples suggest, although not without controversy, that OPC decreases hospital readmission rates and lengths of stay in some circumstances (20–22,28–31). These studies are limited, because criteria used to select patients for OPC are largely unspecified. Unspecified treatment characteristics, including patients’ access to, and availability of, services may also influence study outcomes. In fact, in some studies, patients under OPC received no treatment. The next step in evaluating OPC requires better specification and control of potential confounding factors, most readily addressed in an RCT.
Randomized Controlled Trials of OPC
The Duke Mental Health Study
Subjects randomly assigned to the control group were released from OPC. Subjects in the experimental group received by law an initial period of OPC not longer than 90 days. Thereafter, the commitment order could be renewed for up to 180 days if a psychiatrist and the court determined that the subject continued to meet legal criteria for OPC. All subjects received case management and other outpatient treatment at 1 of 4 participating area mental health programs representing 9 contiguous urban and rural counties. For ethical reasons, an exception to the randomization procedure was necessary in the case of subjects with a recent history of serious assault involving weapon use or physical injury to another person within the preceding year. These subjects (the seriously violent group) were required to undergo at least the initial period of OPC as ordered. Renewals were left to the discretion of the clinician and the court. The main findings from this study are discussed below.
Hospital Readmissions. Hospital readmission data included any psychiatric or substance abuse readmission during the 12-month follow-up period. In bivariate analyses comparing control and OPC random group assignment alone, groups did not differ significantly in hospital outcomes; however, in repeated-measures multivariable analyses, assignment to an OPC group did reduce the odds of readmission (43). Subjects who underwent sustained periods of OPC beyond the initial court order had approximately 57% fewer admissions and 20 fewer hospital days, compared with control subjects; sustained commitment was particularly effective among individuals with nonaffective psychotic disorders. In subsequent repeated-measures analyses examining the role of outpatient treatment, it was also found that sustained OPC reduced hospital readmissions, particularly when combined with a higher intensity of outpatient services—above a median of more than 3 service events monthly and averaging approximately 7 services monthly in the community.
Violent Behaviour. Additional analyses that included subjects who were not randomized at baseline owing to violent behaviour prior to study entry examined the potential reduction of subjects’ violent behaviour measured by self-report, case manager report, collateral reports, and record review of violent acts or serious threats or violence (38). Again, incidence of any violence during the RCT follow-up year was significantly lower among respondents receiving extended OPC, compared with those having shorter periods of OPC (26.7% vs 47.7%, respectively). Moreover, when the frequency of outpatient service events was examined, OPC was shown to be effective only for subjects averaging 3 or more visits monthly; OPC showed no effect on violence risk in respondents with fewer than 3 service events monthly. In multivariable logistic regression analyses, the predicted probability of any violent behaviour was cut in half (from 48% to 24%) as a result of extended OPC and regular outpatient services provision. This effect was not restricted to the group with psychotic disorders. Subjects who received the higher level of intervention (that is, sustained outpatient commitment and frequent services), who concurrently remained free of substance abuse, and who took medications as prescribed during the year of the study had the lowest likelihood of any violence (13% predicted probability).
Arrests. To examine arrest frequency as an outcome, we identified arrests by reviewing electronic records archived in 2 North Carolina databases, supplemented by case manager reports. During the follow-up year, 52 subjects (20%) were arrested at least once (36). In bivariate analyses, the likelihood of arrest was found to be significantly higher among subjects who were young (under age 40 years), male, African American, single, recently victimized by crime, recently homeless, or substance abusers and who had more than 2 hospital admissions in the prior year and a prior arrest. Arrest was significantly less likely among those who adhered to their prescribed medications during the study year, those who avoided substance abuse, and those who did not engage in violent behaviour throughout follow-up. OPC was not significantly associated with reduced arrests in the entire sample—only in those with a history of multiple hospitalizations combined with arrest and (or) violence. Among subjects with this history of dual-system recidivism, extended OPC (that is, 6 months or more) significantly reduced the probability of arrest from about 45% to 12% during 1 year, in a multivariable model. Reduced risk of violent behaviour was a significant mediating factor in the association between OPC and arrest. In persons with SMI whose history of arrests is plausibly related to illness relapse, OPC appears to reduce the risk of criminal justice contact by improving treatment adherence and access to mental health services.
Victimization. An additional study examined the potential effect of outpatient commitment on reduced risk of criminal victimization. For this analysis, data were available for 223 subjects who were interviewed at 12 months and asked whether they had been a victim of any violent or nonviolent crime (34). Of these respondents, 74 (33.2%) reported being criminally victimized at least once during the year: 22 (9.9%) suffered violent victimization, and 64 (28.7%) suffered nonviolent victimization (there was some overlap wherein respondents suffered both types of victimization). Subjects who were randomly assigned to OPC were significantly less likely than control subjects to experience any criminal victimization during the follow-up year (23.5% vs 42.4%, respectively). The duration of OPC was also associated with reduced risk of victimization.
Controlling for salient demographic and clinical covariates, we used staged multivariable logistic regression analysis with stepwise selection to test the net effect of OPC on reducing the risk of criminal victimization. The final model demonstrated a significant effect for number of days on OPC—about 3% less risk of victimization for each additional 10 days of court-ordered treatment—when we controlled for selected significant baseline predictors of victimization.
Additional findings from the DMHS include improved treatment adherence under OPC and increased likelihood of receiving a depot antipsychotic medication (43). Subjects under OPC reported an increase in perceived coercion associated with the duration of the court order, but the effect of OPC on coercion was also mediated by the warnings or reminders of case managers about the potential consequences of nonadherence with the court order (45). Subjects who underwent extended OPC also had significantly greater subjective quality of life (QOL) by the end of the study year, compared with their counterparts who experienced only brief OPC, or none. Multivariable analysis showed that greater treatment adherence and lower psychiatric symptom scores mediated the effect of OPC on QOL. However, perceived coercion moderated the effect of OPC on QOL (46).
Despite these findings of decreased readmission, violence, victimization, and arrests under OPC, these results have several limitations. Length of time on OPC was a key variable in the intervention but could not be randomly assigned. If lower-risk subjects were selected for longer periods of commitment, positive findings could be overstated. Legal criteria for renewal of OPC would seem to prevent selection of lower-risk subjects for longer exposure to court-ordered treatment, and in preliminary analyses, higher risk subjects did appear to receive longer periods of commitment. However, unknown selection factors may have affected OPC duration. In addition, outpatient service intensity was not controlled by the study but varied according to clinical need and other unknown factors. As a result, selective provision of services could have influenced outcomes, although other preliminary analyses argue that this was not an important factor.
From these studies, it appears that OPC can improve certain treatment outcomes when the court order is targeted toward individuals with psychotic disorders, sustained, and combined with intensive treatment. OPC cannot substitute for intensity of treatment. It appears that OPC influences the service providers, perhaps by conveying a legal directive to prioritize treatment for the individual under the order, and acts on the individual by helping to motivate improved treatment adherence. Future analyses from this RCT are expected to examine other important outcomes and more fully elucidate the mechanism of OPC’s effectiveness.
New York OPC Evaluation
While these studies appear to provide contradictory findings, both demonstrate wide variability in the implementation and practice of OPC. These differences render findings across studies difficult to compare and interpret. Even within North Carolina, where the most consistent findings of OPC’s effectiveness have been demonstrated, the “dose” of OPC varied widely, as did the services provided to patients.
Outpatient commitment will continue to be a controversial treatment intervention, regardless of empirical findings about its effectiveness or lack thereof. Advocates and opponents of OPC sometimes selectively use data about OPC’s benefits or detriments as a “straw man” to argue strongly held views about autonomy and paternalism in mental health treatment. Many opponents of OPC believe that it may serve as a barrier to improving services because policy-makers will seize upon it as a quick and inexpensive remedy for a lack of community-based services. However, current data suggest that, if OPC is effective, it can only be so when more intensive services are provided, obviating its use as an inexpensive remedy. More refined specification of the effects of OPC on subpopulations of concern under specific treatment conditions, combined with clear practice guidelines, could improve the understanding and practice of OPC. Given that most states in the US, some Canadian provinces, and several other countries explicitly permit OPC, attempts to better standardize the practice through practice improvement efforts or establishment of practice guidelines is warranted, if OPC is to be utilized appropriately.
Funding and Support
This work was supported by National Institute of Mental Health grants MH 48103 and MH 51410 and by the MacArthur Research Network on Mandated Community Treatment.
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Manuscript received and accepted May 2004.
Some portions of this paper were previously published in Swartz MS, Swanson JW. Involuntary out-patient commitment in the United States: practice and controversy in care of the mentally disordered offender in the community. In: Buchanan A, editor. Care of the mentally disordered offender in the community. New York: Oxford University Press; 2002.
1. Professor and Head, Division of Social and Community Psychiatry, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina.
2. Associate Professor, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina.
Address for correspondence: Dr MS Swartz, Division of Social and Community Psychiatry, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC 27710
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