Extensive New Independent Support for Assisted Outpatient Treatment from AHRQ Report “Management Strategies to Reduce Psychiatric Hospitalizations” May 2015

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In May, 2015, the Agency for Healthcare Research and Quality (AHRQ), located within HHS, released “Management Strategies to Reduce Psychiatric Hospitalizations” focused on reducing readmission and Length of Stay (LOS) in psychiatric hospitals for adults over 18 with two or more previous psychiatric hospital admissions or who were at high risk of readmission.FN 1 The report evaluated Assisted Outpatient Treatment (AOT), referred to as Outpatient Commitment (OPC) and Compulsory Community Treatment Orders (CTOs). They often lumped them together.

OPC [AOT], as it is known in the United States, and CTO, as it is known in the United Kingdom, Canada, New Zealand, and Australia, are based on the principle that people with severe mental disorders who are at risk of becoming dangerous or gravely disabled without treatment and reluctant or unable to follow through with community-based treatment, can be required to engage in outpatient treatment as the less restrictive long-term approach for reducing inpatient rehospitalization. The literature implies that some individuals may need involuntary treatment to prevent readmission because of the high prevalence of anosognosia (i.e., lack of insight as part of the disease process) with severe and persistent mental illness.(71,72) OPC laws in the US require a judge’s order, supported by clinician input, and generally do not allow patients to be given medications forcibly. CTOs can often be implemented by a clinician, without the need for court involvement, and in some countries, such as Australia and Canada, the administration of intramuscular forced medication is allowed.

Eighteen studies assessed its effectiveness 10 were labeled as an OPC( 67,72,84,88,98,100,112,113,116,117) and 8 (in 11 articles) were labeled CTOs. (66,69-71,74,108 ,114,115,120-122) Of the 18 studies, 3 were RCTs,(66,72,117) 3 (reported in 6 articles) were a retrospective cohort design,)74,84,114,115, 120-122) 3 were a case control design(,6 9,71,100) and 9 were pre-post testing of the same group.(67,70,88,98,108,112-114,116) OPC/CTO was generally designed to target individuals with serious mental illness (as opposed to the general psychiatric population) and, accordingly, is most frequently used for patients with primary psychotic disorders. This approach is supported by data that OPC/CTOs may be most effective for individuals with nonaffective psychoses(72) and/or individuals without insight or with severe functional impairment.67

After being placed under an OPC, patients experienced reductions in numbers of readmissions,(67,98,108,112-114,116) readmission rates,(70,114) and LOS.67,108,112 ,113,114,116) One study was able to demonstrate that involuntary outpatient commitment decreased homelessness during the 4-month period following hospital discharge for participants with severe functional impairment at baseline.(73) Another study reported that patients with extended OPC/CTO and a prior history of multiple hospitalizations and prior arrests/violent behavior (≥180 days) had a lower probability of arrest than before OPC/CTO(.86) In yet another study, patients receiving OPC/CTO and long-acting injectables demonstrated a higher adherence rate and lower readmission rate than patients receiving OPC/CTO and oral medications.(74) Because the comparison group did not experience the same effect, the authors suggested that OPC/CTO may be particularly advantageous when combined with long-acting injectable medications.(74) Additionally, two included studies identified increased engagement in community treatment during the course of the order as a positive, albeit predictable, outcome of OPC/CTO(.84,87 Finally, one study suggested that OPC/CTO was associated with decreased episodes of seclusion and restraint in addition to decreased episodes of hospitalization(.88)

One study compared the combination of Assertive Community Treatment (ACT) and OPC/CTO with the combination of Intensive Case Management (ICM) and OPC/CTO and with ACT alone(.84) Aside from the interventions’ effects on hospitalization, patients receiving either combined intervention were more engaged in outpatient services as rated by case managers than patients receiving ACT alone. (Note: This shows that it is not the provisioning of services, but the presence of the court order that helps. –MIPO)

In Iowa, the State code allows a person who had been committed to inpatient treatment to be transferred to OPC upon written petition documenting the absence of being “gravely disabled.” Compliance with a set schedule of followup treatment visits determines whether the patient can remain out of the hospital.(87) Massachusetts has a similar involuntary outpatient treatment procedure with distinct eligibility criteria and treatment plan ordered by the court.(100 These programs improve adherence with outpatient treatment87 and have been shown to lead to significantly fewer emergency commitments,(98) hospital admissions(,87) and hospital days(100) as well as a reduction in arrests and violent behavior.)8)

1 For study and footnote references included in Excerpts Section, see actual study at http://effectivehealthcare.ahrq.gov/ehc/products/596/2082/psychiatric-readmissions-report-150521.pdf.


Prepared by Mental Illness Policy Org. https://mentalillnesspolicy.org