Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Meta-Analysis
. 2011 Feb 16:(2):CD004408.
doi: 10.1002/14651858.CD004408.pub3.

Compulsory community and involuntary outpatient treatment for people with severe mental disorders

Steve R Kisely  1 , Leslie Anne Campbell, Neil J Preston
Affiliations
Meta-Analysis

Compulsory community and involuntary outpatient treatment for people with severe mental disorders

Steve R Kisely et al. Cochrane Database Syst Rev. .

Update in

Abstract

Background: There is controversy as to whether compulsory community treatment for people with severe mental illnesses reduces health service use, or improves clinical outcome and social functioning. Given the widespread use of such powers it is important to assess the effects of this type of legislation.

Objectives: To examine the clinical and cost effectiveness of compulsory community treatment for people with severe mental illness.

Search strategy: We undertook searches of the Cochrane Schizophrenia Group Register 2003, 2008, and Science Citation Index. We obtained all references of identified studies and contacted authors of each included study.

Selection criteria: All relevant randomised controlled clinical trials of compulsory community treatment compared with standard care for people with severe mental illness.

Data collection and analysis: We reliably selected and quality assessed studies and extracted data. For binary outcomes, we calculated a fixed effects risk ratio (RR), its 95% confidence interval (CI) and, where possible, the weighted number needed to treat/harm statistic (NNT/H).

Main results: We identified two randomised clinical trials (total n = 416) of court-ordered 'Outpatient Commitment' (OPC) from the USA. We found little evidence that compulsory community treatment was effective 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 1.2); social functioning (2 RCTs, n = 416, RR for arrested at least once by 11-12 months 0.97 CI 0.62 to 1.52); mental state; quality of life (2 RCTs, n = 416, RR for homelessness 0.67 CI 0.39 to 1.15) or satisfaction with care (2 RCTs, n = 416, RR for perceived coercion 1.36 CI 0.97 to 1.89). However, risk of victimisation may decrease with OPC (1 RCT, n = 264, RR 0.5 CI 0.31 to 0.8). In terms of numbers needed to treat (NNT), it would take 85 OPC orders to prevent one readmission, 27 to prevent one episode of homelessness and 238 to prevent one arrest. The NNT for the reduction of victimisation was lower at six (CI 6 to 6.5). A new search for trials in 2008 did not find any new trials that were relevant to this review.

Authors' conclusions: Compulsory community treatment results in no significant difference in service use, social functioning or quality of life compared with standard care. People receiving compulsory community treatment were, however, less likely to be victims of violent or non-violent crime. It is unclear whether this benefit is due to the intensity of treatment or its compulsory nature. Evaluation of a wide range of outcomes should be considered when this type of legislation is introduced.

PubMed Disclaimer

Figures

Figure 1
Figure 1
Risk of bias graph: review authors’ judgements about each risk of bias item presented as percentages across all included studies
Figure 2
Figure 2
Risk of bias summary: review authors’ judgements about each risk of bias item for each included study
See this image and copyright information in PMC

Update of

Comment in

References

References to studies included in this review

    1. Steadman HJ. Final report: Research study of the New York City involuntary outpatient commitment pilot program. Policy Research Associates Inc.; Delmar, NY: 1998.

    2. *

    3. Steadman HJ, Gounis K, Dennis D, Hopper K, Roche B, Swartz M, Robbins P. Assessing the New York City involuntary outpatient commitment pilot program. Psychiatric Services. 2001;52(3):330–6. - PubMed
    1. Compton SN, Swanson JW, Wagner HR, Swartz MS, Burns BJ, Elbogen EB. Involuntary outpatient commitment and homelessness in persons with severe mental illness. Mental Health Services Research. 2003;5(1):27–38. - PubMed
    2. Hiday VA, Swartz MS, Swanson JW, Borum R, Wagner HR. Impact of outpatient commitment on victimization of people with severe mental illness. American Journal of Psychiatry. 2002;159:1403–11. - PubMed
    3. Swanson JW, Borum R, Swartz MS, Hiday VA, Ryan Wagner H, Burns BJ. Can involuntary outpatient commitment reduce arrests among persons with severe mental illness? Criminal Justice and Behaviour. 2001;28(2):156–89.
    4. Swanson JW, Swartz MS, Wagner HR, Burns BJ. Involuntary out-patient commitment and reduction of violent behaviour in persons with severe mental illness. British Journal of Psychiatry. 2000;174:324–31. - PubMed
    5. Swartz MS, Hiday VA, Swanson JW, Wagner HR, Borum R, Burns B. Measuring coercion under involuntary outpatient commitment. Initial findings from a randomised controlled trial. Research in Community and Mental Health. 1999;10:52–77.
    6. Swartz MS, Swanson JW, Ryan Wagner H, Burns BJ, Hiday VA. Effects of involuntary outpatient commitment and depot antipsychotics on treatment adherence in persons with severe mental illness. Journal of Nervous and Mental Disease. 2001;189(9):583–92. - PubMed
    7. Swartz MS, Swanson JW, Wagner HR, Burns BJ, Hiday VA, Borum R. A randomised controlled trial of outpatient commitment in North Carolina. Psychiatric Services. 2001;52(3):325–9. - PubMed

    8. *

    9. Swartz MS, Swanson JW, Wagner HR, Burns BJ, Hiday VA, Borum R. Can involuntary outpatient commitment reduce hospital recidivism? Findings from a randomised trial with severely mentally ill individuals. American Journal of Psychiatry. 1999;156:1968–75. - PubMed
    10. Swartz MS, Wagner HR, Swanson J, Hiday VA, Burns BJ. The perceived coerciveness of involuntary outpatient commitment: findings from an experimental study. Journal of the American Academy of Psychiatry and the Law. 2002;30(2):207–17. - PubMed

References to studies excluded from this review

    1. Bindman J. Involuntary outpatient treatment in England and Wales. Current Opinion in Psychiatry. 2002;15:595–8.
    1. Borum R, Swartz M, Riley S, Swanson J, Hiday VA, Wagner R. Consumer perceptions of involuntary outpatient commitment. Psychiatric Services. 1999;50(11):1489–91. - PubMed
    1. Brophy LM, Reece JE, McDermott F. A cluster analysis of people on community treatment orders in Victoria, Australia. International Journal of Law and Psychiatry. 2006;29(6):469–81. - PubMed
    1. Burgess P, Bindman J, Leese M, Henderson C, Szmukler G. Do community treatment orders for mental illness reduce readmission to hospital? An epidemiological study. Social Psychiatry and Psychiatric Epidemiology. 2006;41(7):574–9. - PubMed
    1. Bursten P. Post-hospital mandatory outpatient treatment. American Journal of Psychiatry. 1986;143:1255–8. - PubMed

References to studies awaiting assessment

    1. Burns T. Oxford community treatment order evaluation trial. 2010 http://www.controlled-trials.com
    1. Farrelly S, Thornicroft G, Birchwood M, Marshall M, Szmukler G, Waheed W. Crimson: Rct of joint crisis plans for individuals with psychosis. Psychiatrische Praxis. 2011;38:1. [DOI: 10.1055/s-0031-1277812] - PubMed
    1. ISRCTN73110773. Oxford community treatment order evaluation trial. 2011 http://public.ukcrn.org.uk
    1. Ryan A, Patel R, Russell L, Turnpenny L, Visser C. Community treatment orders on trial: The octet rct. Psychiatrische Praxis. 2011;38:1. - PubMed
    1. Thornicroft G, Farrelly S, Birchwood M, Marshall M, Szmukler G, Waheed W, et al. Crimson crisis plan impact: Subjective and objective coercion and engagement protocol: A randomised controlled trial of joint crisis plans to reduce compulsory treatment of people with psychosis. Trials. 2010;11:102. [MEDLINE: 21054847] - PMC - PubMed

References to ongoing studies

    1. [accessed 01 November 2010];ISRCTN73110773. 10PRT/0496: Oxford Community Treatment Order Evaluation Trial (OCTET): a single-outcome randomised controlled trial of compulsory outpatient treatment in psychosis. http://www.thelancet.com/protocol-reviews/10PRT-0496

Additional references

    1. Altman DG, Bland JM. Detecting skewness from summary information. BMJ. 1996;313:1200. - PMC - PubMed
    1. Begg C, Cho M, Eastwood S, Horton R, Moher D, Olkin I, Pitkin R, Rennie D, Schulz KF, Simel D, Stroup DF. Improving the quality of randomized controlled trials. The CONSORT statement. JAMA. 1996;276:637–9. - PubMed
    1. Bland JM. Statistics notes. Trials randomised in clusters. BMJ. 1997;315:600. - PMC - PubMed
    1. Churchill R. International experiences of using community treatment orders. Institute of Psychiatry; London: 2007.
    1. Cook RJ, Sackett DL. The number needed to treat: a clinically useful measure of treatment effect. BMJ. 1995;310:452–4. - PMC - PubMed

References to other published versions of this review

    1. Kisely S, Preston N. Compulsory community treatment and involuntary outpatient treatment for people with severe mental disorders. Cochrane Database of Systematic Reviews. 2004;(Issue 4) [DOI: 10.1002/14651858.CD004408.pub2] - PubMed
    1. Kisely S, Campbell LA, Preston N. Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Cochrane Database of Systematic Reviews. 2005;(Issue 3) [DOI: 10.1002/14651858.CD004408.pub2; PUBMED: 16034930] - PubMed

MeSH terms