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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.

SUMMARY

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).

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