Evidence-Based Reviews

Outpatient commitment: When it improves patient outcomes

Current Psychiatry. 2008 April;7(4):25-35

References

1. Swartz M. Taking issue: can mandated outpatient treatment prevent tragedies? Psychiatr Serv 2007;58(6):737.-

2. Swartz MS, Burns BJ, Hiday VA, et al. New directions in research on involuntary outpatient commitment. Psychiatr Serv 1995;46:381-5.

3. Torrey EF, Kaplan R. A national survey of the use of outpatient commitment. Psychiatr Serv 1995;46:778-84.

4. Swartz MS, Swanson JW. Involuntary outpatient commitment, community treatment orders, and assisted outpatient treatment: what’s in the data? Can J Psychiatry 2004;49(9):585-91.

5. Monahan J, Swartz M, Bonnie R. Mandated treatment in the community for people with mental disorders. Health Aff 2003;22:28-38.

6. Munetz MR, Grande T, Kleist J, Peterson GA. The effectiveness of outpatient civil commitment. Psychiatr Serv 1996;47:1251-3.

7. Rohland BM, Rohrer JE, Richard C. The long-term effects of outpatient commitment on service use. Adm Policy Ment Health 2000;27:383-94.

8. Keilitz I. Empirical studies of involuntary outpatient civil commitment: is it working? Ment Phys Disabil Law Rep 1990;14:368-79.

9. Hiday VA, Scheid-Cook TL. Outpatient commitment for revolving door patients: compliance and treatment. J Nerv Ment Dis 1991;179:83-8.

10. Moloy KA. Analysis: critiquing the empirical evidence. Does involuntary outpatient commitment work?. Washington, DC: Mental Health Policy Resource Center; 1992.

11. Ridgely MS, Borum J, Petrilla J. The effectiveness of outpatient commitment: empirical evidence and experience of eight states. Santa Monica, CA: RAND Corporation; 2001.

12. Kendra’s Law: final report on the status of assisted outpatient treatment. Albany, NY: New York State Office of Mental Health; 2005. Available at: http://www.omh.state.ny.us/omhweb/Kendra_web/finalreport. Accessed February 19, 2008.

13. Swartz MS, Swanson JW, Hiday VA, et al. A randomized controlled trial of outpatient commitment in North Carolina. Psychiatr Serv 2001;52:330-6.

14. Swartz MS, Swanson JW, Wagner RR, et al. Can involuntary outpatient commitment reduce hospital recidivism? Findings from a randomized trial in severely mentally ill individuals. Am J Psychiatry 1999;156:1968-75.

15. Compton SN, Swanson JW, Wagner HR, et al. Involuntary outpatient commitment and homelessness in persons with severe mental illness. J Ment Health Serv Res 2003;5:27-38.

16. Hiday VA, Swartz MS, Swanson JW, et al. Impact of outpatient commitment on victimization of people with severe mental illness. Am J Psychiatry 2002;159:1403-11.

17. Swanson JW, Borum R, Swartz MS, et al. Can involuntary outpatient commitment reduce arrests among persons with severe mental illness? Criminal Justice & Human Behavior 2001 28;156-89.

18. Swanson JW, Swartz MS, Borum R, et al. Involuntary outpatient commitment and reduction of violent behaviour in persons with severe mental illness. Br J Psychiatry 2000;176:324-31.

19. Swartz MS, Swanson JW, Wagner HR, et al. Effects of involuntary outpatient commitment and depot antipsychotics on treatment adherence in persons with severe mental illness. J Nerv Ment Dis 2001;189:583-92.

20. Steadman HJ, Gounis K, Dennis D, et al. Assessing the New York City outpatient commitment pilot program. Psychiatr Serv 2001;52:330-6.

Most noncontrolled studies have concluded that OPC improves treatment outcomes and decreases hospital readmission rates and lengths of stay under some circumstances.^6-12 The largest study reported on New York’s initial 5 years’ experience with more than 3,000 patients under its OPC statute, known as “Kendra’s Law” (Box 2).¹² Under this law—the most intensively implemented OPC statute in the United States—the court’s order specifies a detailed plan of medications and psychosocial treatment.

Most of New York’s OPC recipients stayed in assisted outpatient treatment longer than the court-mandated 6 months (average 16 months). The incidence of hospitalizations, homelessness, arrests, and incarcerations was far lower while patients participated in OPC, compared with the previous 3 years of their lives (Table). Medication adherence improved from 34% before OPC to 69% after commitment, and engagement with treatment improved from 41% to 62%, respectively.¹²

Table

Change in adverse events among OPC patients in New York

Event	Incidence during 3 years prior to OPC*	Incidence during OPC treatment	Rate of decline
Incarceration	23%	3%	87%
Arrest	30%	5%	83%
Psychiatric hospitalization	97%	22%	77%
Homelessness	19%	5%	74%
* Adverse events reported as occurring at least once
OPC: outpatient commitment
Source: Reprinted from reference 12, table 10

Conflicting controlled trials

Duke Mental Health Study. In the first controlled study of OPC, the Duke Mental Health Study (DMHS) enrolled 331 seriously mentally ill inpatients being discharged from involuntarily hospitalization to court-ordered outpatient treatment between 1993 and 1996. Patients with a history of violent behavior in the previous year were placed in a nonrandomized comparison group and remained on OPC for at least 90 days. The remaining 264 patients were randomly assigned to:

an experimental group that received OPC for ≤90 days (could be renewed for ≤180 days) plus consistent community mental health services
a control group that was released from OPC but received the same community mental health services as the experimental group.¹³

Community services included psychiatric appointments and case management. During 12-month follow-up, researchers interviewed patients, families, and clinicians to gather data on OPC’s effectiveness.

Patients ordered to OPC had fewer hospital readmissions and spent fewer days in the hospital only if they received OPC plus consistent community services for ≥6 months.¹⁴ Patients who received this model of care were:

less likely to be homeless,¹⁵ criminally victimized,¹⁶ arrested if they had past arrests,¹⁷ or violent¹⁸
more likely than the control group to comply with recommended treatment.¹⁹

Patients received no benefit from OPC

Clinical Point

Hospitalizations, homelessness, and arrests were far lower while patients participated in OPC than in the previous 3 years of their lives

Study limitations. Length of time on OPC could not be randomly assigned, even though this was a key variable in the intervention. If lower-risk subjects had been selected for longer periods of commitment, positive findings could have been overstated. Legal criteria for renewing OPC also prevented us from selecting lower-risk subjects for longer exposure to court-ordered treatment. Higher-risk subjects appeared in preliminary analyses to have received longer periods of commitment, but unknown selection factors could have affected OPC duration.

Outpatient service intensity was not controlled but varied according to clinical need and other unknown factors. As a result, selectively providing services could have influenced outcomes, although other analyses argue that this factor was not important.⁴

New York. In 1994, the state legislature established a 3-year pilot program to evaluate OPC in New York City’s Bellevue Hospital as a first step toward considering permanent OPC legislation.²⁰ The randomized, controlled study compared a court-ordered group (N=78) and a control group (N=64) during 1 year after hospital discharge. Both groups received enhanced outpatient services, such as psychiatrist appointments, intensive case management, and treatment for co-occurring substance abuse as needed.

Box 2

‘Kendra’s Law’: A legacy of assisted outpatient treatment

Andrew Goldstein and Kendra Webdale were strangers standing on a New York City subway platform as a train arrived on January 3, 1999. She was an aspiring journalist and he a troubled man with schizophrenia who had stopped taking his medication. Goldstein later admitted in court that he placed his hands on the back of her shoulders and pushed her into the train’s path.

“Kendra’s law”—first enacted in 1999 and renewed for 5 years in 2005—provides assisted outpatient treatment (AOT) for persons age ≥18 with mental illness who—in view of their treatment history—are unlikely to survive safely in the community without supervision. The patient also must:

have a history of treatment noncompliance
be unlikely to voluntarily participate in treatment
need assisted outpatient treatment to prevent a deterioration that would likely result in a substantial risk of physical harm to himself or others
be likely to benefit from assisted outpatient treatment.

Implementation starts with a petition to the court, asking that a person be evaluated for AOT suitability. Petitions can be filed by psychiatrists, psychologists, social workers, family members, adult roommates, hospital directors, mental health or social services directors, and parole or probation officers. The petition is followed by an investigation by local authorities and a court hearing.

If the patient is found to be eligible for AOT, the court orders a highly specific treatment plan. Initial orders for 6 months can be renewed at subsequent court hearings.