Compulsory Community and Involuntary Outpatient Treatment for People With Severe Mental Disorders

Abstract

There is controversy as to whether compulsory community treatment (CCT) for people with severe mental illness (SMI) reduces health service use or improves clinical outcome and social functioning. To examine the effectiveness of CCT for people with SMI. We searched the Cochrane Schizophrenia Group’s Trials Register and Science Citation Index (2003, 2008, 2012, and 2013). We obtained all references of identified studies and contacted authors where necessary. All relevant randomized controlled clinical trials (RCTs) of CCT compared with standard care for people with SMI (mainly schizophrenia and schizophrenia-like disorders, bipolar disorder, or depression with psychotic features). Standard care could be voluntary treatment in the community or another preexisting form of compulsory community treatment such as supervised discharge. We found 3 trials with a total of 752 people. Two trials compared a form of CCT called ‘Outpatient Commitment’ (OPC) versus standard voluntary care, whereas the third compared Community Treatment Orders with intermittent supervised discharge. CCT was no more likely to result in better service use, social functioning, mental state, or quality of life compared with either standard voluntary or supervised care. However, people receiving CCT were less likely to be victims of crime than those on voluntary care. Further research is indicated into the effects of different types of CCT as these results are based on 3 relatively small trials.

Background

There is controversy as to whether compulsory community treatment for people with severe mental illness (SMI) reduces health service use, or improves clinical outcome and social functioning.

Objectives

To examine the effectiveness of compulsory community treatment (CCT) for people with SMI.

Search Methods

We searched the Cochrane Schizophrenia Group’s Trials Register and Science Citation Index (2003, 2008, and 2012). We obtained all references of identified studies and contacted authors where necessary. We further updated this search in November 2013.

Selection Criteria

All relevant randomized controlled clinical trials (RCTs) of CCT compared with standard care for people with SMI (mainly schizophrenia and schizophrenia-like disorders, bipolar disorder, or depression with psychotic features). Standard care could be voluntary treatment in the community or another preexisting form of compulsory community treatment such as supervised discharge.

Data Collection and Analysis

Review authors independently selected studies, assessed their quality and extracted data. We used The Cochrane Collaboration’s tool for assessing risk of bias. For binary outcomes, we calculated a fixed-effect risk ratio (RR), its 95% CI and, where possible, the weighted number needed to treat statistic (NNT). For continuous outcomes, we calculated a fixed-effect mean difference and its 95% CI. We used the Grading of Recommendations Assessment, Development and Evaluation approach to create a “Summary of findings” table for outcomes we rated as important and assessed the risk of bias of included studies.

Main Results

All studies (n = 3) involved patients in community settings who were followed up over 12 months (n = 752 participants).

Two RCTs from the United States (total n = 416) compared court-ordered “Outpatient Commitment” (OPC) with voluntary community treatment. OPC did not result in significant differences compared to voluntary treatment in any of the main outcome indices: health service use (2 RCTs, n = 416, RR for readmission to hospital by 11–12 months = 0.98, CI = 0.79 to 1.21, low grade evidence, figure 1); social functioning (2 RCTs, n = 416, RR for arrested at least once by 11–12 months = 0.97, CI = 0.62 to 1.52, low grade evidence); mental state; quality of life (2 RCTs, n = 416, RR for homelessness = 0.67 CI = 0.39 to 1.15, low grade evidence) or satisfaction with care (2 RCTs, n = 416, RR for perceived coercion = 1.36, CI = 0.97 to 1.89, low grade evidence). However, the risk of being criminally victimized decreased with OPC (1 RCT, n = 264, RR = 0.50, CI = 0.31 to 0.80). Other than perceived coercion, no adverse outcomes were reported. In terms of numbers NNT, it would take 85 OPC orders to prevent 1 readmission, 27 to prevent 1 episode of homelessness and 238 to prevent 1 arrest. The NNT for the reduction of victimization was lower at 6 (CI = 6 to 6.5).

Fig. 1.

Readmission to hospital by 12 months.

One further RCT compared community treatment orders with less intensive supervised discharge in England and found no difference between the 2 for either the main outcome of readmission (1 RCT, n = 333, RR for readmission to hospital by 12 months 0.99 CI = 0.74 to 1.32, medium grade evidence, figure 1), or any of the secondary outcomes including social functioning and mental state. It was not possible to calculate the NNT. The English study met 3 out of the 7 criteria of The Cochrane Collaboration’s tool for assessing risk of bias, the others only 1, the majority being rated unclear.

Authors’ Conclusions

CCT results in no significant difference in service use, social functioning or quality of life compared with standard voluntary care. People receiving CCT were, however, less likely to be victims of violent or nonviolent crime. It is unclear whether this benefit is due to the intensity of treatment or its compulsory nature. Short periods of conditional leave may be as effective (or noneffective) as formal compulsory treatment in the community. Evaluation of a wide range of outcomes should be considered when this legislation is introduced. However, conclusions are based on 3 relatively small trials, with high or unclear risk of blinding bias, and evidence we rated as low to medium quality. Details are fully reported in the Cochrane review.¹