Assisted Outpatient Commitment (Involuntary Outpatient Treatment/Assisted Outpatient Treatment)
Reduces Hospital Recidivism and Costs.
Outpatient Commitment for “Revolving Door” Patients: Compliance and Treatment.
Hiday, V.A. and Scheid-Cook, T.L. (1991).
The Journal of Nervous and Mental Disease 179:2. 83-88.
OUTPATIENT COMMITMENT (OPC) AND COMPLIANCE TO TREATMENT
The purpose of this study was to provide data to assess treatment and compliance for patients on OPC. A comparison of compliance and treatment of subjects in OPC, involuntary hospitalization, or outright release indicated that most subjects in all situations refused medication at least once during the 6-month period. Records of number of medication refusals were not available. However, those patients in OPC were significantly less likely than those involuntarily hospitalized or released to have other forms of noncompliance. Almost all subjects in OPC (93%) were still in treatment 6 months after their hearings, despite the fact that the OPC had not been extended after the initial 3 months. This finding was significant in comparison to the percentages of the involuntarily hospitalized (44.7%) and the released (45.5%).
To study the treatment, enforcement, and compliance of OPC, the authors limited the OPC sample to those who began OPC at a County Mental Health Center (CMHC). Although most of the OPC group (77.4%) received individual therapy at the CMHC, only 38.7% received any additional support or activities beyond psychotherapy.
Rather than discussing compliance to treatment and medication as a process, Hiday and Scheid-Cook viewed compliance as an outcome of OPC. The purpose of OPC is to avoid the revolving door syndrome of recommitment and re-hospitalization for those patients with severe mental illness. Criteria outlined in North Carolina statutes that permit court ordered OPC were defined as follows:
Mental illness, capacity to survive safely in the community with supervision from family or friends, treatment history indicative of need for treatment in order to prevent deterioration which would predictably result in dangerousness; and the illness-limiting or –negating ability to make an informed decision to seek or comply voluntarily with recommended treatment (pp. 83 – 84).
Identified in this study were chronically mentally ill patients who go off medication, become dangerous, and revolve through the court and mental hospital doors. Specifically the group exhibited a severe mental illness (diagnosis of schizophrenia, paranoia, affective disorder, or other psychosis), chronic hospitalizations, prior dangerousness, and medication refusal. Of the total group of patients who met these 4 criteria, some were ordered to OPC while others were either involuntarily hospitalized or released. The resulting sample sizes were OPC (N= 31), involuntarily hospitalized (N= 50), and released (N=11). The groups were followed for 6 months after their hearings.
In North Carolina, the court can order OPC for 90 days initially and can renew for successive 180- day periods. The primary clinician at the treatment facility is responsible for obtaining treatment compliance, and if the patient fails to appear for treatment, the clinician may request help from the sheriff. In this study, most clinicians either never called or threatened to call the sheriff either because these did not know this was an option or they preferred to use persuasion rather than force. Approximately half (45.2) of all patients never failed to show for appointment without providing acceptable excuses and rescheduling; after a second no show, over three fourths (77.4%) met scheduled appointments and activities. Although medication may not be forced under OPC, this study reported that all target group members on OPC received medication. In addition, the 38.7% who received support beyond psychotherapy from the CMHC most frequently participated in day treatment and vocational rehabilitation.
In conclusion, the researchers stated that “Primary clinicians repeatedly stated that OPC serves to keep the patient on medication and out of the hospital.” (p.88). However, some clinicians expressed concern “that OPC ‘lacked teeth,’ that is, did not give enough power over patients who were non compliant” (p. 88).
A Follow-up of Chronic Patients Committed to Outpatient Treatment.
Hiday, V.A., Scheid-Cook, T.L. (1989).
Hospital and Community Psychiatry 40:1. 52-59.
FOLLOW-UP INDICATES OUTPATIENT COMMITMENT A VIABLE OPTION
This 1989 North Carolina study evaluated the effectiveness of outpatient commitment, a less restrictive environment than involuntary hospitalization, in curtailing future hospitalization and arrests in a six-month period after the subjects were placed under outpatient commitment orders. The 168 patients met the following four criteria:
- They were severely mentally ill, most with diagnoses of schizophrenia, paranoia, affective disorder, or other psychotic disorders.
- They had been hospitalized one or more times in the past.
- They had committed one or more dangerous actions before the commitment.
- They had been noncompliant with medication prior to commitment (p. 54).
Of the 168 patients in the target group, 84 patients were involuntarily committed to the hospital, 3 voluntarily underwent hospitalization, and 69 were committed to outpatient treatment. Of these 69, 31 patients actually began the outpatient treatment while the remaining either never appeared at the mental health center or had symptoms of mental illness or characteristics of dangerousness that precluded their participation in outpatient commitment. Those patients who began treatment “tended to remain in treatment for six months, even without continued court orders, tended to have more social interaction, tended not to be rehospitalized, and tended not to exhibit dangerous behaviors” (p. 57). Moreover, those subject to outpatient orders were more likely to utilize aftercare services and to continue in treatment even when no longer under court outpatient orders. Researchers concluded that “outpatient commitment is thus a viable less-restrictive alternative to involuntary hospitalization” (pp. 57-8).
The researchers cited four main problems at the time of this study that limited outpatient commitment as an alternative to involuntary hospitalization (p.52-53). First in many states, criteria for both types of commitment have been identical. Second, provisions to enforce outpatient commitment statutes have been lacking. Third, mental health professionals have expressed liability concerns; finally, many state officials have not been knowledgeable about outpatient options. In 1984, outpatient commitment as a less restrictive environment for treating the chronically mentally ill became a viable alternative in North Carolina when the state legislature worked to remove some of these deterrents. Criteria for outpatient commitment were made less restrictive than for involuntary hospitalization; to be eligible for outpatient commitment, the person
“must be mentally ill but must have the capacity to survive safely in the community with available supervision from family members, friends, or others. The person must have a history that indicates the need for treatment to prevent further disability or deterioration that would predictably result in dangerousness and must have a current mental status that limits or negates the person’s ability to make an informed decision to seek or to comply voluntarily with recommended treatment.” (p. 53)
In addition, a mechanism for enforcing outpatient commitment was established, mental health faculties and staff were provided with immunity for liability issues, and funds were allocated to community mental health centers for each outpatient commitment.
Clients in the target group of this study (N=168) tended to be male, non-elderly, non-white, and single. They had low educational and employment status, were from rural areas or small towns, and had exhibited dangerous behavior in the week prior to their commitment.
During the six-month follow-up, the researchers evaluated the differences in several variables among the three groups: outpatient commitment (OPC), involuntary hospitalization (IVH), and released (R). Researchers stressed that the OPC and R clients were at risk in the community for re-hospitalization, arrest, medication refusal, and non-compliance for a longer period of time than the IVH.
Results indicated that the majority of the target group was not re-hospitalized during the six-month follow-up period (OPC, 65.8%; IVH, 72%; and R, 72.7%) with no statistical difference among the three groups. Of those patients who were re-hospitalized, a smaller percentage of OPC (5.3%) returned to the hospital more than once compared with the R (9.1%) and the IVH groups (14%). Only 28.3% of the target group exhibited any dangerous behavior during the six-month period. Clients in OPC were not significantly different from the other two groups in incidence of dangerous behavior or arrests.
As for functioning in the community, OPC clients compared favorably to the other two groups.
At the six-month follow-up, the OPC clients were more likely to be working and exhibiting greater social interaction outside the home. They significantly made more visits to community mental health centers and tended to be in treatment at the end of the follow-up period despite expired court orders. Although a majority of all patients refused medication at least once, OPC clients were less likely to refuse medications than the released and no more likely to refuse than the IVH group.
Researchers reported that the most successful centers in dealing with OPC clients encouraged compliance through “aggressive case management” that included seeking other community resources to supplement their own and reminding recalcitrant clients that involuntary hospitalization was the other alternative (p.58)
The Efficacy of Involuntary Outpatient Treatment in Massachusetts.
Geller, J., Grudzinskas, A.J. Jr., McDermeit, M., Fisher, W.H., and Lawlor, T. (1998).
Administration and Policy in Mental Health 25:3. 271- 285.
COMPARISON OF ADMISSIONS DATA FOR IOT AND CTS GROUPS
The purpose of this Massachusetts study was to learn whether IOT was effective in reducing the number of psychiatric admissions and inpatient days for patients who in the past had an excessive use of inpatient treatment. Nineteen patients with court orders for IOT were matched with CTS data from the Massachusetts Department of Mental Health that provided information on the demographic, clinical, and utilization of services for clients statewide. First the researchers matched the IOT patients using demographic data. Researchers also matched the 19 IOT patients with other clients according to inpatient service use (ISU). The following comparisons were made:
1. Pre-treatment data with post-treatment data for IOT;
2. Pre-treatment data with post-treatment data for CTS Demographic and ISU patients (All and Best Matches); and
3. Post-treatment data for IOT with CTS Demographic and ISU (All and Best Matches))
Based on these comparisons, the researchers evaluated whether the IOT group after treatment showed a greater decrease in number of admissions and inpatient days as compared to the CTS and ISU study groups.
Results indicated that the IOT group showed significantly greater decreases in number of admissions and days than did either the All/Best Demographic groups.
The IOT patients went from 1.63 to .58 admissions, a decrease of 1.05 and from 112.73 to 44.3 days, a decrease of 68.43. The All Demographic matched group went from .49 to .21 admissions, a decrease of .28, and from 19.42 to 22.1 days, a gain of 2.68 days. The Best Demographic group demonstrated a .1 decrease in admissions (.21 to .11) and a 3.7 decrease in days (15.1 to 11.4).
Can Involuntary Outpatient Commitment Reduce
Findings From a Randomized Trial With Severely Mentally Ill Individuals
Swartz, M., Swanson, J., Wagner, H., Burns, B., Hiday, V., 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. 1968-1975.
SUSTAINED OUTPATIENT COMMITMENT REDUCED HOSPITAL RECIDIVISM
This North Carolina study investigated the following research questions:
- Can involuntary outpatient commitment reduce hospital readmissions?
- To be effective, must outpatient commitment be sustained?
- For which clinical populations is OPC most effective?
- How might community treatment intensity affect results?
Seriously mentally ill subjects were randomly assigned to either outpatient commitment (OPC) or to the control group with no outpatient commitment. After a one-year follow-up, researchers reported no differences in number of hospitalization admissions or days for clients assigned to either the OPC or the control group. After initial commitment periods ranging typically from 30 to 60 days, OPC clients were re-evaluated by clinicians with some clients receiving longer periods of commitment. Thus, the OPC group was subdivided into two groups, those with sustained or high levels of commitment (180 days or more) and those with low levels of commitment (less than 180 days).
Compared to the control group, clients in the high-OPC group had approximately 57% fewer readmissions to the hospital (mean of 1.04 for control compared to .45 for high-OPC) and 20 fewer hospital days (mean of 27.92 for control compared to 7.51 high-OPC) ( pp. 1971, 1973).
The benefits of high OPC were observed primarily among subjects with nonaffective psychotic diagnoses (schizophrenia, schizoaffective, or other psychotic disorder). In these non-affective psychotic diagnoses, the high-OPC group had a reduction of 72% in mean total hospital admissions (mean of .34 for high-OPC compared to 1.23 for control) requiring 28 fewer days (mean of 4.57 for high-OPC compared to 32.84 for control). There were no significant differences reported for total admissions and hospital days for affective diagnoses (bipolar or major depression).
Researchers also examined the levels of community treatment in light of the three levels of OPC (no, low, high). High-OPC and higher intensity of outpatient service use combined to reduce hospital statistics. The researchers concluded, “Outpatient commitment can work to reduce hospital readmissions and total hospital days when court orders are sustained and combined with intensive treatment, particularly for individuals with psychotic disorders” (p. 1968).
Severely mentally ill individuals leaving a regional state hospital or one of three other inpatient facilities in the North Central region of North Carolina under an OPC order were asked to participate in the study. Those that consented were then randomly assigned to either continue under their OPC orders (N=129) or to be released from OPC (control group, N=135). The demographic characteristics of the two groups were similar except for two measures. Subjects in the OPC group had lower measures in both insight into illness and medication compliance. Multivariable analyses indicated additional relationships. Subjects with lower insight into their illness and lower medication compliance at baseline received longer periods of OPC. Higher levels of education and global functioning were associated with lower odds on any psychiatric admission. The OPC group was further subdivided into low-OPC (less than 180 days) and high-OPC (more than 180 days).
All subjects were assigned a case manager and intensity of treatment was allowed to vary clinically. As a result, level of outpatient service use was divided into two groups: less than 3 service events per month and more than 3 service events per month.
Researchers found that with the low level outpatient service use, the level of OPC made no difference in follow-up mental health admissions. However, increasing service events to more than three per month was effective in maintaining low hospital readmissions only for the high-OPC group. Subjects who underwent shorter periods of outpatient commitment, regardless of outpatient service use, were as likely as those with no OPC to return to the hospital, to have multiple hospitalizations, and to have longer lengths of stay if readmitted (p.1974). Researchers suggested “that outpatient commitment is only effective when it is associated with fairly regular and sustained levels of outpatient services – averaging more than seven services per month” (p.1974).
The researchers cautioned that subjects significantly associated OPC with coercion and decreased autonomy, so that brief periods of OPC may actually have no effect or perhaps even an adverse effect by antagonizing the individual who is forced to comply with treatment. Thus, the researchers concluded, “involuntary outpatient commitment can provide some benefit in hospital outcomes but potentially at the risk of alienating some individuals from treatment. When outpatient commitment works, it operates only when it is sustained and is in concert with relatively intensive treatment” (p. 1974).
Can Involuntary Outpatient Commitment Reduce Hospital Readmissions Among Severely Mentally Ill Individuals?
Swartz, M., Swanson, J., Hiday, V., Borum, R., Burns, B., Wagner, R.
Unpublished research presented at International Congress on Law and Mental Health. July 1998. Paris.
Swartz, M. October 14, 1998 letter to C. Stuart Broad, Attorney NAMI Legal Affairs.
FAVORABLE RESULTS WITH SUSTAINED OUTPATIENT COMMITMENT
At the International Congress on Law and Mental Health in Paris in 1998, researchers presented unpublished results of a North Carolina study that investigated whether involuntary outpatient commitment could reduce hospital readmissions of the severely mentally ill. Comparing outcomes for clients assigned to either the outpatient commitment (OPC) to those of the control (no-OPC) group, researchers observed no statistical differences.
However, when dividing OPC subjects into two groups, high (180 days or more) and low (less than 180 days), “individuals in the OPC group who got longer and sustained periods of OPC …did significantly better” (Swartz, 1998).
While 48% of control and 50% of low-OPC experienced some type of psychiatric hospital admissions in the follow-up period, only 32% of the high-OPC clients were re-hospitalized. The high-OPC clients showed fewer psychiatric admissions (mean of .45 compared to 1.04 for control and .90 for low-OPC) and fewer total days of hospitalization (mean of 6.9 for high-OPC, compared to 20.1 for control and 29.2 for low-OPC). High-OPC was also related to longer periods without readmission and lower incidence of violence in the community. This improved performance for the high-OPC group was particularly strong among individuals with the psychotic diagnoses of schizophrenia, schizoaffective disorder, and psychotic disorder of non-specific origin and for the diagnoses of aggressive disorder and severe mental illness/substance abuse. No difference in performance due to OPC was observed in diagnoses of affective disorders.
A total of 252 severely mentally ill individuals leaving one of four hospitals in the North Central region of North Carolina under an OPC order were asked to participate in the study. The clients were offered remuneration, case management (CM), and a chance at random release from the OPC order. As a result, two groups were created: one with OPC plus CM and the control with CM only. The control group was “immunized” from any OPC for one year; the clients in the OPC group experienced as many days of OPC as were ordered by subsequent hearings. Consequently, the days of OPC varied, and the OPC group was separated into 2 levels: low (less than 180 days) and high (180 days or more). The number of subjects in each sub-group was not indicated.
Researchers also examined the levels of community treatment provided. With a low level of community treatment (less than 3 service events per month), the level of OPC made no difference in follow-up mental health admissions. However, having more than three service events per month was found effective in maintaining low hospital readmissions only for the high-OPC group. Swartz (1998) concluded “that OPC was only effective in individuals who got higher levels of services. Neither OPC with low services or high services alone in the absence of OPC improved these outcomes. We interpret these findings to mean that sustained use of OPC and aggressive service provision act synergistically, especially in psychotically disordered individuals.”
· March 2005 N.Y. State Office of Mental Health “Kendra’s Law: Final Report on the Status of Assisted Outpatient Treatment. “
- 77% fewer experienced psychiatric hospitalization
- Length of hospitalization was reduced 56% from pre-AOT levels.