Hospital Utilization Outcomes Following Assignment to Outpatient Commitment


Outpatient civil commitment (OCC) requires people with severe mental illness (SMI) to receive needed-treatment addressing imminent-threats to health and safety. When available, such treatment is required to be provided in the community as a less restrictive alternative (LRA) to psychiatric-hospitalization. Variance in hospital-utilization outcomes following OCC-assignment has been interpreted as OCC-failure. This review seeks to specify factors accounting for this outcome-variation and to determine whether OCC is used effectively. Twenty-five studies, sited in seven meta-analyses and subsequently published investigations, assessing post-OCC-assignment hospital utilization outcomes were reviewed. Studies were grouped by structural pre-determinants of hospital-utilization and OCC-implementation—i.e. deinstitutionalization (bed-availability), availability of a less restrictive alternative to hospitalization, and illness severity. Design quality at study completion was ranked on causal-certainty. In OCC-follow-up-studies, deinstitutionalization associated hospital-bed-cuts, when not taken into account, ensured lower hospital-bed-day utilization. OCC-assignment coupled with aggressive case-management was associated with reduced-hospitalization. With limited community-service, hospitalizations increased as the default option for providing needed-treatment. Follow-up studies showed less hospitalization while on OCC-assignment and more outside of it. Studies using fixed-follow-up periods usually found increased-utilization as patients spent less time under OCC-supervision than outside it. Comparison-group-studies reporting no between-group differences bring more severely ill OCC-patients to equivalent use as less disturbed patients, a success. Mean evidence-rank for causal-certainty 2.96, range 2–4, of 5 with no study ranked 1, the highest rank. Diverse mental health systems yield diverse OCC hospital-utilization outcomes, each fulfilling the law’s legal mandate to provide needed-treatment protecting health and safety.

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    Barnett et al. (2018) searched three electronic databases (PsychINFO, for articles published between Jan 1, 1806, and the fourth week of December, 2017; Embase, between Jan 1, 1974, and the first week of January, 2018; and MEDLINE, between Jan 1, 1946, and the fourth week of January, 2018) for publications in English, using the search terms “community treatment order” or “CTO” or “outpatient commitment” or “‘compulsory’ or ‘mandatory’ outpatient commitment” or “civil commitment” AND “SMI” or “psychiatric” or “manic” or “schizophrenia” or “bipolar”. They then applied a backwards reference search to the studies identified by manually searching reference lists of eligible studies. They also searched for articles that cited eligible studies using Scopus, and assessed those for eligibility. They searched review articles identified through the search to identify additional studies. Bursten (1986) and Kallapiran et al. (2010) are not considered herein. Though reported on in Barnet et al’s review, they were outside the scope of review criteria specified for that review and all previous reviews since they included forensic patients.



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


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


Less Restrictive Alternative to psychiatric hospitalization




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


Outpatient civil commitment; also referred to as: CTO-Community Treatment Order; AOT-Assisted Outpatient treatment


Randomized Controlled Trial


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Funding was provided by National Institute of Mental Health (Grant No. MH 18828B).

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Segal, S.P. Hospital Utilization Outcomes Following Assignment to Outpatient Commitment. Adm Policy Ment Health (2021).

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  • Community treatment order
  • Outpatient civil commitment
  • Law and psychiatry
  • Involuntary treatment