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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Unpublished research presented at International Congress on Law and Mental Health.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.

At the International Congress on Law and Mental Health in Paris in 1998, researchers presented unpublished results of a North Carolina study that investigated whether involuntary outpatient commitment could reduce hospital readmissions of the severely mentally ill.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.

SUMMARY

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."