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Can Involuntary Outpatient Commitment Reduce
Hospital Recidivism?
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.

This North Carolina study investigated the following research questions:

1. Can involuntary outpatient commitment reduce hospital readmissions?
2. To be effective, must outpatient commitment be sustained?
3. For which clinical populations is OPC most effective?
4. 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).

SUMMARY

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).