Skip to main content

Advertisement

SpringerLink
Log in

Protecting Health and Safety with Needed-Treatment: the Effectiveness of Outpatient Commitment

  • Review Article
  • Published:
Psychiatric Quarterly Aims and scope Submit manuscript

Abstract

Outpatient civil commitment (OCC) requires the provision of needed-treatment, as a less restrictive alternative (LRA) to psychiatric-hospitalization in order to protect against imminent-threats to health and safety associated with severe mental illness (SMI). OCC-reviews aggregating all studies report inconsistent outcomes and interpret such as intervention failure. This review, considering those studies whose outcome criteria are consistent with the provisions of OCC-law, seeks to determine OCC-effectiveness in meeting its legislated objectives. This review incorporated studies from previous systematic-reviews, used their search methodology, and added investigations through August 2020. Selected OCC-studies evaluated samples of all eligible patients in a jurisdiction. Their outcome-measures were threats to health or safety or the receipt of needed-treatment exclusive of post-OCC-assignment- hospitalization, the latter being the OCC-default for providing needed-treatment in the absence of an LRA and dependent on bed-availability. A study’s evidence-quality was evaluated with the Berkeley Evidence Ranking and the New Castle Ottawa systems. Thirty-nine OCC-outcome-studies in six-outcome-areas directly addressed OCC-statute objectives: 21 considered imminent threats to health and safety, 10 compliance with providing needed-treatment, and 8 conformity to the LRA-standard. With the top evidence-rank equal to one, the studies M = 2.55. OCC-assignment was associated with reducing mortality-risk, increasing access to acute-medical-care, and reducing risks of violence and victimization. It enabled reaching these objectives as a LRA to hospitalization and facilitated the use of community-services by individuals refusing such assistance when outside of OCC-supervision. OCC’s appears to enable recovery by reducing potentially life-altering health and safety risks associated with SMI.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

Abbreviations

ACT:

Assertive community treatment, a form of intensive case management based on psychosocial intervention focused on maintaining severely mentally ill patients in the community.

BER:

Berkeley Evidence Rating— Ranks comparison group studies according to an evidence hierarchy based on the quality of the study’s design implementation upon completion.

ICC:

Involuntary inpatient commitment.

LRA:

Less Restrictive Alternative to psychiatric hospitalization.

MPR:

medication-possession-ratio.

NA:

Not applicable. Study does not have a comparison group. It is pre/post or a pre/during- intervention/post-intervention study and not ranked in the BER system, which only ranks comparison-group designs.

NR:

Not ranked by either the BER or NOS systems.

NOS:

Newcastle-Ottawa Score. Ranks studies according to an evidence hierarchy based on the quality of the study’s design.

OCC:

Outpatient civil commitment; Also called: CTO-Community Treatment Order; OPC - Outpatient commitment; OC-Outpatient commitment; AOT-Assisted Outpatient Treatment.

RCT:

Randomized Controlled Trial.

References

  1. Bazelon Center for Mental Health Law. Involuntary outpatient commitment: summary of state statutes. Washington DC: Bazelon Center for Mental Health Law; 2004. http://www.bazelon.org.

  2. O'Connor v. Donaldson 422 U.S. 563 (1975). https://supreme.justia.com/cases/federal/us/422/563/.

  3. Glover-Thomas NR. Reconstructing mental health law and policy. London: Lexis Nexis Butterworths Tolley; 2002.

    Google Scholar 

  4. U.S. Civil Commitment Laws by State. Downloaded 30 December, 2017 from http://www.treatmentadvocacycenter.org/browse-by-state;. ViCTO/OCCria Mental Health Act 1986, No. 59 of 1986, Version No. 098;Version incorporating amendments as at 24 August 2010. http://www.legislation.vic.gov.au/Domino/Web_Notes/LDMS/LTObject_Store/LTObjSt5.nsf/DDE300B846EED9C7CA257616000A3571/A7D40FD608D61455CA2577890007FEB8/$FILE/86-59a098.pdf. Mental Health Act 1996 (Tas) s 24. http://www.dhhs.tas.gov.au/mentalhealth/mental_health_act/mental_health_act_2013_new_mental_health_act/information_for_consumers,_carers_and_the_community_seCTO/OCCr/fact_sheets/treatment_orders_under_the_mental_health_act_2013. Mental Health Act 2000 (NSW) s 14(1)(b). Mental Health Act 1998 (WA) s 26(2). Mental Health Act 2000 (Qld) s 14(1)(f). ttps://www.legislation.qld.gov.au/view/pdf/2002-07-19/act-2000-016. U.K. Mental Health Act 2007-8, www.legislation.gov.uk/ukpga/2007/12/pdfs/ukpga_20070012_en.pdf;. Norwegian Act No. 62 of 2 July 1999 relating to the provision and implementation of mental health care (the Mental Health Care Act), with later amendments, app.uio.no/ub/ujur/oversatte-lover/data/lov-19990702-062-eng.pdf. Israel: Treatment of Mental Patients Law, 1991, S.H. no. 1339, p. 58. Canada: Legal Line. Ca https://www.legalline.ca/legal-answers/involuntary-hospital-admission-of-mentally-ill-people-and-length-of-stay/.

  5. Lake v. Cameron, 364 F.2d 657- Court of Appeals, Dist. of Columbia Circuit (1966). https://scholar.google.com/scholar_case?case=8826406800281196763&q=Lake+v.+Cameron,+364+F.2d+657+(1966).&hl=en&as_sdt=2006&as_vis=1.

  6. U.K. Parliament Health Committee. Post-legislative scrutiny of the Mental Health Act 2007 - Health Committee Contents, Sec 5 Supervised Community Treatment, 2013; #80. https://publications.parliament.uk/pa/cm201314/cmselect/cmhealth/584/58408.htm Downloaded 24/2/18/

  7. -In LaBelle, 728 P.2d 107 Wn.2d 196 (1986) 728 P.2d 138. https://law.justia.com/cases/washington/supreme-court/1986/52570-6-1.html;-State v.Dennis H., 647 N.W.2d at 863 Supreme Court of Wisconsin (12 July, 2002) https://www.casemine.com/judgement/us/59147afdadd7b04934414fff; -In re K.L., 806 N.E.2d 480 (N.Y. 2004) https://casetext.com/case/in-the-matter-of-kl; - Doe v Gallinot, 486 F Supp 983 (S D Cal 1979), aff'd 667 F 2d 1017(9th Cir 1981). https://casetext.com/case/doe-v-gallinot.

  8. Rugkåsa J, Dawson J, Burns T. CTO: What is the state of the evidence? Social Psychiat Psychiat Epidemiol. 2014;49(12):1861–71. https://doi.org/10.1007/s00127-014-0839-7.

  9. Rugkåsa J. Effectiveness of community treatment orders: The international evidence. Can J Psychiatry. 2016;61(1):15–24. https://doi.org/10.1177/0706743715620415 PMCID: PMC4756604.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Maughan D, Molodynski A, Rugkåsa J, Burns T. A systematic review of the effect of community treatment orders on service use. Soc Psychiatry Psychiatr Epidemiol. 2014;49(4):651–63. https://doi.org/10.1007/s00127-013-0781-0.

  11. Kisely SR, Campbell LA, O’Reilly R. Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Cochrane Database of Systematic Reviews Issue 3, 2017 Art. No.: CD004408. https://doi.org/10.1002/14651858.CD004408.pub5. www.cochranelibrary.com. Accessed 22 Feb 2018.

  12. Kisely S, Hall K. An updated meta-analysis of randomized controlled evidence for the effectiveness of community treatment order. Can J Psychiatry. 2014;59(10):561–4 Downloaded 2/22/18.

    Article  Google Scholar 

  13. Barnett P, Matthews H, Lloyd-Evans B, Mackay E, Pilling S, Johnson S. Compulsory community treatment to reduce readmission to hospital and increase engagement with community care in people with mental illness: a systematic review and meta-analysis. Lancet Psychiatry. 2018;18:30420–6. https://doi.org/10.1016/S2215-0366 Downloaded 12/27/18.

    Article  Google Scholar 

  14. Churchill, R., Owen, G., Hotopf, M., & Singh, S. International experiences of using community treatment orders. Institute of Psychiatry, London. 2007 Retrieved from: http://psychrights.org/research/Digest/OutPtCmmtmnt/UKRptonCTO/OCC.pdf

  15. Segal SP. The utility of outpatient civil commitment: investigating the evidence. Int J Law Psychiatry. 2020;70:101565.

    Article  Google Scholar 

  16. Wells G, Shea B, O'Connell D, Robertson J, Peterson J, Welch V, Tugwell P. The Newcastle-Ottawa scale (NOS) for assessing the quality of non-randomized studies in meta-analysis. 2018 http://www.ohri.ca/programs/clinical epidemiology/oxford.asp.

  17. Segal SP, Hayes SL, Rimes L. The utility of outpatient commitment: I. A need for treatment and a least restrictive alternative to psychiatric hospitalization. Psychiatric Services. 2017;68(12):1247–54 APPI-PS-2016-00161.R5.

    Article  Google Scholar 

  18. Segal SP, Hayes SL, Rimes L. The utility of outpatient commitment: II. Mortality risk, protecting health, safety, and quality of life. Psychiatric Services. 2017;68(12):1262–70 APPI-PS-2016-00164.R5.

    Article  Google Scholar 

  19. Kisely S, Preston N, Xiao J, Lawrence D, Louise S, Crowe E. Reducing all-cause mortality among patients with psychiatric disorders: a population-based study. Can Med Assoc J. 2013;185(1):E50–6.

    Article  Google Scholar 

  20. Segal SP, Burgess P. Effect of conditional release from hospitalization on mortality risk. Psychiatr Serv. 2006;57(11):1607–14.

    Article  Google Scholar 

  21. Power P. A controlled Study of the clinical effectiveness of community treatment orders in Australia: a 'Mirror-image' analysis. 1992. Summarized in: Churchill, R., Owen, G., Hotopf, M., & Singh, S: International Experiences of Using Community Treatment Orders. Institute of Psychiatry, London. 2007 Retrieved from: http://psychrights.org/research/Digest/OutPtCmmtmnt/UKRptonCTO/OCC.pdf

  22. Barkhuizen W, Cullen AE, Shetty H, Pritchard M, Stewart R, McGuire P, et al. Community treatment orders and associations with readmission rates and duration of psychiatric hospital admission: a controlled electronic case register study. BMJ Open. 2020;10:e035121. https://doi.org/10.1136/bmjopen-2019-035121.

  23. Pollack DA, McFarland BH, Mahler JM, Kovas AE, et al. Outcomes of patients in a low-intensity, short-duration involuntary outpatient commitment program. Psychiatr Serv. 2005;56:863–6.

    Article  Google Scholar 

  24. Parks J, Svendsen D, Singer P, Foti ME. Morbidity and mortality in people with severe mental illness. Alexandria: National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council; 2006.

    Google Scholar 

  25. Segal SP, Hayes SL, Rimes L. The utility of outpatient commitment: acute medical care access and protecting health. Soc Psychiatry Psychiatr Epidemiol. 2018;53(6):597–606. https://doi.org/10.1007/s00127-018-1510-5\.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Kisely S, Xiao J, Lawrence D, Jian L. Is the effect of compulsory community treatment on preventable deaths from physical disorders mediated by better access to specialized medical procedures? Can J Psychiatry. 2014;59(1):54–8.

    Article  Google Scholar 

  27. Segal SP, Hayes SL, Rimes L. The utility of outpatient commitment: reduced-risks of victimization and crime perpetration. Eur Psychiatry. 2019;56:97–104. https://doi.org/10.1016/j.eurpsy.2018.12.001.

    Article  PubMed  Google Scholar 

  28. Link BG, Epperson MW, Perron BE, Castille DM, Yang LH. Arrest outcomes associated with outpatient commitment in New York state. Psychiatr Serv. 2011;62:504–8.

    Article  Google Scholar 

  29. Phelan JC, Sinkewicz M, Castille DM, Huz S, Link BG. Effectiveness and outcomes of assisted outpatient treatment in New York state. Psychiatr Serv. 2010;61(2):137–43.

    Article  Google Scholar 

  30. Swanson JW, Swartz MS, Borum R, Hiday VA, Wagner HR, Burns BJ. Involuntary outpatient commitment and reduction of violent behavior in persons with severe mental illness. Br J Psychiatry. 2000;176:224–31.

    Article  Google Scholar 

  31. Vaughan K, Mcconaghy N, Wolf C, Myhr C, Black T. Community treatment orders: relationship to clinical care, medication compliance, behavioural dis-turbance and readmission. Aust N Z J Psychiatry. 2000;34(5):801–8.

    Article  CAS  Google Scholar 

  32. O'Keefe CD, Potenza DP, Mueser KT. Treatment outcomes for severely mentally ill patients conditionally discharged to community based treatment. J Nerv Ment Dis. 1997;185:409–11.

    Article  CAS  Google Scholar 

  33. Hiday VA, Scheid-Cook N. The North Carolina experience with outpatient commitment: a critical appraisal. Int J Law Psychiatry. 1987;10:215–32.

    Article  CAS  Google Scholar 

  34. Erickson SK. A retrospective examination of outpatient commitment in New York. Behav Sci Law. 2005;23:627–45.

    Article  Google Scholar 

  35. Hough WG, O'Brien KP. The effect of community treatment orders on offending rates. Psychiatry Psychol Law. 2005;12(2):411–23.

    Article  Google Scholar 

  36. Hiday VA, Swartz MS, Swanson JW, Borum R, Wagner HR. Impact of outpatient commitment on victimization of people with severe mental illness. Am J Psychiatr. 2002;159:1403–11.

    Article  Google Scholar 

  37. Busch A, Wilder C, Van Dorn R, Swartz M, Swanson J. Changes in guideline-recommended medication possession after implementing Kendra's law in New York. Psychiatr Serv. 2010;61:1000–5.

    Article  Google Scholar 

  38. Hiday VA, Scheid-Cook TL. A follow-up of chronic patients committed to outpatient treatment. Hosp Community Psychiatry. 1989;40(1):52–9.

    CAS  PubMed  Google Scholar 

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

    Article  CAS  Google Scholar 

  40. O'Brien AM, Farrell SJ, Faulkner S. Community treatment orders: beyond hospital utilization rates examining the association of community treatment orders with community engagement and supportive housing. Community Ment Health J. 2009;45:415–9.

    Article  Google Scholar 

  41. Dye S, Dannaram S, Loynes B, Dickenson R. Supervised community treatment: 2-year follow-up study in Suffolk. Psychiatris. 2012;36:29.

    Article  Google Scholar 

  42. Van Dorn RA, Swanson JW, Swartz MS, Wilder CM, Moser LL, Gilbert AR, et al. Continuing medication and hospitalization outcomes after assisted outpatient treatment in New York. Psychiatr Serv. 2010;61(10):982–7.

  43. Swartz MS, Swanson JW, Wagner HR, Burns BJ, Hiday VA. Antipsychotics on treatment adherence in persons with severe mental illness. J Nerv Ment Dis. 2001;189:583–92.

    Article  CAS  Google Scholar 

  44. Ozgul S, Brunero S. A pilot study of the utilisation and outcome of CTOs: client, care, case manager and MHRT perspective. Australasian Mental Health Rev. 1997;20:70–83.

    CAS  Google Scholar 

  45. Frank D, Fan E, Georghiou A, Verter V. Community treatment order outcomes in Quebec: A unique jurisdiction. Canadian J Psychiat. 2019. https://doi.org/10.1177/07067/43719892718.

  46. Kisely S, Preston N, Xiao J, Lawrence D, Louise S, Crowe E, et al. An eleven-year evaluation of the effect of community treatment orders on changes in mental health service use. J Psychiatr Res. 2013;47:650–6.

  47. Segal SP, Burgess P. Conditional release, a less restrictive alternative to hospitalization? Psychiatric Services. 2006;57:1600–1606.S.

    Article  Google Scholar 

  48. Swartz MS, Wilder CM, Swanson JW, Van Dorn RA, Robbins PC, Steadman HJ, et al. Assessing outcomes for consumers in New York's assisted outpatient treatment program. Psychiatr Serv. 2010;61(10):976–81.

  49. Hunt A, da Silva A, Lurie S, Goldbloom D. Community treatment orders in Toronto: the emerging data. Can J Psychiatr. 2007;52(10):647–55.

    Article  Google Scholar 

  50. Segal S, Preston N, Kisely S, Xiao J. Conditional release in Western Australia: effect on hospital length of stay. Psychiatr Serv. 2009;60(1):94–9.

    Article  Google Scholar 

  51. Muirhead D, Harvey C, Ingram G. Effectiveness of community treatment orders for treatment of schizophrenia with oral or depot antipsychotic medication: clinical outcomes. Aust N Z J Psychiatry. 2006;40:596–605.

    Article  Google Scholar 

  52. Van Putten RA, Santiago JM, Berren MR. Involuntary outpatient commitment in Arizona: a retrospective study. Hosp Community Psychiatry. 1988;39(9):953–8.

    PubMed  Google Scholar 

  53. Gerrand V. Transfonning mental health services from 1993 to 1998 in Victoria, Australia: a case study of policy implementation. Department of Political Science: University of Melbourne; 2005.

    Google Scholar 

  54. Segal SP. Hospital utilization outcomes following assignment to outpatient commitment. Psychiatric Services underreview, 2020.

Download references

Funding

The research was supported by NIMH Grant# MH 18828B.

Author information

Authors and Affiliations

  1. University of Melbourne, Melbourne, Australia

    Steven P. Segal

  2. Mental Health and Social Welfare Research Group, School of Social Welfare, University of California, 120 Haviland Hall (MC #7400), Berkeley, CA, 94720-7400, USA

    Steven P. Segal

Authors
  1. Steven P. Segal
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Steven P. Segal.

Ethics declarations

Conflict of Interest

The author, Steven P. Segal declares no conflict of interest.

Research Involving Human Participants and/or Animals

No human subjects involved.

Informed Consent

Not required given that no human subjects were involved.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Segal, S.P. Protecting Health and Safety with Needed-Treatment: the Effectiveness of Outpatient Commitment. Psychiatr Q 93, 55–79 (2022). https://doi.org/10.1007/s11126-020-09876-6

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11126-020-09876-6

Keywords

Search

Navigation