Follow-up of Chronic Patients Committed to Outpatient Treatment

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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).

SUMMARY

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)