Abstract
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.
Similar content being viewed by others
Notes
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.
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
- LRA:
-
Less Restrictive Alternative to psychiatric hospitalization
- MPR:
-
Medication-possession-ratio
- 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 referred to as: CTO-Community Treatment Order; AOT-Assisted Outpatient treatment
- RCT:
-
Randomized Controlled Trial
References
Awara, M. A., Jaffar, K., & Roberts, P. (2013). Effectiveness of the community treatment order in streamlining psychiatric services. Journal of Mental Health, 22, 191–97.
Barnett, P., Matthews, H., Lloyd-Evans, B., Mackay, E., Pilling, S., & Johnson, S. (2018). 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. https://doi.org/10.1016/S2215-0366(18)30420-6.
Burgess, P., Bindman, J., Leese, M., Henderson, C., & Szmukler, G. (2006). Do community treatment orders for mental illness reduce readmission to hospital? An epidemiological study. Social Psychiatry Psychiatric Epidemiology, 41, 574–579.
Burns, T., Rugkåsa, J., Molodynski, A., Dawson, J., Yeeles, K., Vazquez-Montes, M., et al. (2013). Community treatment orders for patients with psychosis: A randomised controlled trial. Lancet, 381(9878), 1627–33. https://doi.org/10.1016/S0140-6736(13)60107-5.
Bursten, B. (1986). Posthospital mandatory outpatient treatment. American Journal of Psychiatry, 143(10), 1255–1258.
Carroll, M. (2018). Mental Health Review Tribunal Annual Report 2017–18. Mental Health Review Tribunal: Victoria.
Castells-Aulet, L., Hernández-Viadel, M., Jiménez-Martos, J., et al. (2015). Impact of involuntary out-patient commitment on reducing hospital services: 2-year follow-up. BJPsych Bulletin, 39, 196–99.
Christy, A., Petrila, J., McCranie, M., & Lotts, V. (2009). Involuntary outpatient commitment in Florida: Case information and provider experience and opinions. International Journal of Forensic Mental Health, 8, 122–130.
Churchill, R., Owen, G., Hotopf, M., & Singh, S. (2007). International experiences of using community treatment orders. London: Institute of Psychiatry. Retrieved from: http://psychrights.org/research/Digest/OutPtCmmtmnt/UKRptonCTO/OCC.pdf.
Fernandez, G. A., & Nygard, S. (1990). Impact of involuntary outpatient commitment on the revolving-door syndrome in North Carolina. Psychiatric Services, 41(9), 1001–1004.
Fisher, R. A. (1966). The design of experiments (8th ed.). New York, NY: Hafner Publishing Company.
Frank, D., Fan, E., Georghiou, A., & Verter, V. (2019). Community treatment order outcomes in Quebec: A unique jurisdiction. Canadian Journal of Psychiatry [Revue canadienne de psychiatrie], 65(7), 484–491. https://doi.org/10.1177/0706743719892718.
Geller, J. L., McDermeit, M., Grudzinskas, A. J., Jr., Lawlor, T., & Fisher, W. H. (1997). A competency-based approach to court-ordered outpatient treatment. New Directions for Mental Health Services, 75, 81–95.
Geller, J., Grudzinskas, A. J., Jr., McDermeit, M., Fisher, W. H., & Lawlor, T. (1998). The efficacy of involuntary outpatient treatment in Massachusetts. Administration & Policy in Mental Health, 25(3), 271–85.
Gerrand, V. (2005). Transfonning mental health services from 1993 to 1998 in Victoria, Australia: A case study of policy implementation. Department of Political Science: University of Melbourne.
Harris, A., Chen, W., Jones, S., Hulme, M., Burgess, P., & Sara, G. (2018). Community treatment orders increase community care and delay readmission while in force: Results from a large population-based study. Australian & New Zealand Journal of Psychiatry. https://doi.org/10.1177/0004867418758920.
Hunt, A., da Silva, A., Lurie, S., & Goldbloom, D. (2007). Community treatment orders in Toronto: The emerging data. Canadian Journal of Psychiatry, 52(10), 647–655.
ISD Scotland National Statistics. (2016). Annual trends in available beds by NHS Board of treatment and hospital. ISD Pubilication. Downloaded 11.5.17. http://www.isdscotland.org/Health-Topics/Hospital-Care/Beds/.
Kallapiran, K., Sankaranarayanan, A., & Lewin, T. (2010). A pilot investigation of the relationship between community treatment orders and hospital utilization rates. Australas Psychiatry, 18, 503–505.
Keown, P., Weich, S., Bhui, K. S., & Scott, J. (2011). Association between provision of mental illness beds and rate of involuntary admissions in the NHS in England 1988–2008: ecological study. BMJ (British Medical Journal), 343, d3736.
Kisely, S., & Hall, K. (2014). An updated meta-analysis of randomized controlled evidence for the effectiveness of community treatment order. Canadian Journal of Psychiatry, 59(10), 561–564.
Kisely, S. R., Xiao, J., & Preston, N. J. (2004). Impact of compulsory community treatment on admission rates: Survival analysis using linked mental health and offender databases. British Journal of Psychiatry, 184, 432–38.
Kisely, S. R., Campbell, L.A., & O’Reilly, R. (2017). Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Cochrane Database of Systematic Reviews Issue 3, 2017. https://doi.org/10.1002/14651858.CD004408.pub5. www.cochranelibrary.com Downloaded 2/22/18.
Kisely, S. R., Yu, D., Maehashi, S., & Siskind, D. (2020). A systematic review and meta-analysis of predictors and outcomes of community treatment orders in Australia and New Zealand. Australian and New Zealand Journal of Psychiatry, 53, 228–235.
Lake v. Cameron. (1966). 364 F.2d 657. 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
Lera-Calatayud, G., Hernández-Viadel, M., Bellido-Rodriguez, C., et al. (2014). Involuntary outpatient treatment in patients with severe mental illness: A one-year follow-up study. International Journal of Law Psychiatry, 37, 267–71.
Marshall, M., Lockwood, A. (1998). Review: assertive community treatment is an effective alternative in severe mental disorders. (Cochrane Review, latest version 25 Feb 98). In: the Cochrane Library. Oxford. Downloaded from http://ebmh.bmj.com/ on October 23, 2017.
Maughan, D., Molodynski, A., Rugkåsa, J., & Burns, T. (2014). A systematic review of the effect of community treatment orders on service use. Social Psychiatry and Psychiatric Epidemiology., 49(4), 651–663.
Nakhost, A., Perry, J. C., & Frank, D. (2012). Assessing the outcome of compulsory treatment orders on management of psychiatric patients at 2 McGill University-associated hospitals. Canadian Journal of Psychiatry, 57(6), 359–365.
O’Brien, A., & Farrell, S. (2005). Community treatment orders: beyond hospital utilization rates examining the association of community treatment orders with community engagement and supportive housing. Canadian Journal of Psychiatry, 50(1), 27–30.
Ozgul, S., & Brunero, S. (1997). A pilot study of the utilisation and outcome of CTOs: Client, care, case manager and MHRT perspective. Australasian Mental Health Review, 20, 70–83.
Patel, M. X., Matonhodze, J., Baig, M. K., Taylor, D., Szmukler, G., & David, A. S. (2013). Naturalistic outcomes of community treatment orders: Antipsychotic long-acting injections versus oral medication. Journal of Psychopharmacology, 27(7), 629–637.
Power, P. (1992). 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.pdf.
Rawala, M., & Gupta, S. (2014). Use of community treatment orders in an inner-London assertive outreach service. Psychiatric Bulletin, 38, 13–18.
Rohland, B. M., Rohrer, J. E., & Richards, C. C. (2000). The long-term effect of outpatient commitment on service use. Administration and Policy in Mental Health, 27(6), 383–394.
Rugkåsa, J. (2016). Effectiveness of community treatment orders: The international evidence. Can J Psychiatry, 61(1), 15–24. https://doi.org/10.1177/0706743715620415PMCID:PMC4756604.
Rugkåsa, J., Dawson, J., & Burns, T. (2014). CTO/OCCs: What is the state of the evidence? Social Psychiatry & Psychiatric Epidemiology, 49, 1861–1871.
Segal, S. P. (2020). The utility of outpatient civil commitment: Investigating the evidence. International Journal of Law and Psychiatry, 70, 101565.
Segal, A. P. (2021). Protecting health and safety with needed-treatment: The effectiveness of outpatient commitment. Psychiatric Quarterly, https://doi.org/10.1007/s11126-020-09876-6
Segal, S. P., & Burgess, P. (2006). The utility of extended outpatient civil commitment. International Journal of Law Psychiatry, 29(6), 525–534.
Segal, S. P., & Burgess, P. (2006). Conditional release, a less restrictive alternative to hospitalization? Psychiatric Services, 57, 1600–1606.
Segal, S. P. & Jacobs, L. (2013). Deinstitutionalization. Encyclopedia of social work. 21st edition Co-published by the NASW Press and Oxford University Press.
Segal, S. P., Watson, M., & Akutsu, P. (1998). Factors associated with involuntary return to a psychiatric emergency service within twelve months. Psychiatric Services, 49(9), 1212–7.
Segal, S. P., Lauri, T., & Segal, M. J. (2001). Factors in the use of coercive retention in civil commitment evaluations in psychiatric emergency services. Psychiatric Services, 52(4), 514–521. https://doi.org/10.1176/appi.ps.52.4.514.
Segal, S. P., Hayes, S. L., & Rimes, L. (2017). The utility of outpatient commitment: I. A need for treatment and a least restrictive alternative to psychiatric hospitalization. Psychiatric Services, 68(12), 1247–54.
Segal, S. P., Hayes, S. L., & Rimes, L. (2019). The utility of outpatient commitment: Reduced-risks of victimization and crime perpetration. European Psychiatry, 56, 97–104. https://doi.org/10.1016/j.eurpsy.2018.12.001.
Slade, E. P., & Goldman, H. H. (2015). The dynamics of psychiatric bed use in general hospitals. Administration and Policy in Mental Health, 42(2), 139–46. https://doi.org/10.1007/s10488-014-0554-4.
Smith, G. H. (1992). The rise and decline of mental health hospitals in the State of Michigan. Dissertations. 1995. https:// scholarworks. wmich.edu/ dissertations/1995
State of Victoria (2018–2019) Royal Commission into Victoria’s Mental Health System, Interim Report, Parl Paper No. 87. ISBN 978-1-925789-38-6. https://rcvmhs.vic.gov.au/download_file/view_inline/2198.
Steadman, H. J., Gounis, K., Dennis, D., Hopper, K., Roche, B., Swartz, M., & Robbins, P. C. (2001). Assessing the New York City involuntary outpatient commitment pilot program. Psychiatric Services, 52(3), 330–336.
Swartz, M. S., Swanson, J. W., Wagner, H. R., Burns, B. J., Hiday, V. A., & Borum, R. (1999). Can involuntary outpatient commitment reduce hospital recidivism?: Findings from a randomized trial with severely mentally ill individuals. American Journal of Psychiatry, 156(12), 1968–75.
Swartz, M. S., Swanson, J. W., Hiday, V. A., Wagner, H. R., Burns, B. J., & Borum, R. (2001). A randomized controlled trial of outpatient commitment in North Carolina. Psychiatric Services, 52(3), 325–329.
Swartz, M. S., Wilder, C. M., Swanson, J. W., Van Dorn, R. A., Robbins, P. C., Steadman, H. J., et al. (2010). Assessing outcomes for consumers in New York’s assisted outpatient treatment program. Psychiatric Services, 61(10), 976–981.
Taylor, M., Macpherson, M., Macleod, C., & Lyons, D. (2015). Community treatment orders and reduced time in hospital: A nationwide study, 2007–2012. BJPsych Bulletin, 39(5), 1–3.
Torrey, E. F., Entsminger, K., Geller, J., et al. (2008). The shortage of public hospital beds for mentally ill persons. Arlington, VA: Treatment Advocacy Center.
Torrey, E. F., Fuller, D. A., Geller, J., & Jacobs, C. (2012). No room at the Inn: trends and consequences of closing public psychiatric hospitals. Washington. DC: Treatment Advocacy Center.
U.K. Parliament Health Committee. (2013). 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.
U.S. Civil Commitment Laws by State. Downloaded 30 December, 2017 from http://www.treatmentadvocacycenter.org/browse-by-state; Mental Health Act 1986 (VIC), No. 59 of 1986, Version No. 098; Version incorporating amendments as at 24 August 2010. (Victoria Australia). http://www.legislation.vic.gov.au/Domino/Web_Notes/LDMS/LTObject_Store/LTObjSt5.nsf/DDE300B846EED9C7CA257616000A3571/A7D40FD608D61455CA2577890007FEB8/$FILE/86-59a098.pdf; Mental Health Act 1996 (Tasmania, Australia) s 24. http://www.dhhs.tas.gov.au/mentalhealth/mental_health_act/mental_health_act_2013_new_mental_health_act/information_for_consumers,_carers_and_the_community_seCTO/OCCr/fact_sheets/treatment_orders_under_the_mental_health_act_2013; Mental Health Act 2007 (New South Wales, Australia) s 14(1)(b). https://www.legislation.nsw.gov.au/view/whole/html/inforce/current/act-2007-008#; Mental Health Act 2013 (Western Australia) s 26(2). https://www.parliament.wa.gov.au/Parliament/Bills.nsf/A963C9962D511B3748257C0D001EE2FA/$File/Bill041-2.002.pdf; Mental Health Act 2000 (Queensland) 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 https://www.health.gov.il/English/Topics/Mental_Health/treatment/Hospitalization/Pages/Involuntary.aspx; Canada: Legal Line. Ca https://www.legalline.ca/legal-answers/involuntary-hospital-admission-of-mentally-ill-people-and-length-of-stay/
Wagner, H. R., Swartz, M. S., Swanson, J. W., & Burns, B. J. (2003). Does involuntary outpatient commitment lead to more intensive treatment? Psychological Public Policy Law, 9, 145–58.
Bazelon Center for Mental Health Law. (2004). Involuntary outpatient commitment: summary of state statutes. Washington D.C.: Bazelon Center for Mental Health Law. http://www.bazelon.org.
Wells, G., Shea, B., O’Connell, D., Robertson, J., Peterson, J., Welch, V., Losos, M., Tugwell, P. (2018). The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analysis. http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp.
Zanni, G., & deVeau, L. (1986). Inpatient stays before and after outpatient commitment in Washington, DC. Hospital and Community Psychiatry, 37, 941–942.
Zanni, G., & Stavis, P. (2007). The effectiveness and ethical justification of psychiatric outpatient commitment. American Journal of Bioethics, 7(11), 31–41.
Funding
Funding was provided by National Institute of Mental Health (Grant No. MH 18828B).
Author information
Authors and Affiliations
Corresponding author
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Segal, S.P. Hospital Utilization Outcomes Following Assignment to Outpatient Commitment. Adm Policy Ment Health 48, 942–961 (2021). https://doi.org/10.1007/s10488-021-01112-y
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10488-021-01112-y