Evidence Regarding OutPatient Commitment
by Toby T. Watson, Psy.D*

  There are few studies that have attempted to determine the effectiveness of Outpatient Commitment Orders (OPC).  In one of the first thorough reviews of empirical studies of OPC, Dr. Kathleen Maloy concluded in 1992, there was "almost no valid empirical evidence in support of the effectiveness of involuntary outpatient commitment vis-à-vis treatment compliance, success in the community for people with severe and persistent mental illness".[1]

This acknowledgement by Maloy in 1992 led Duke University researchers in North Carolina in 1999 and 2001 to examine if OPC reduced hospitalizations.  They, Swartz and his colleagues, concluded “outpatient commitment had no clear benefit unless it was sustained for at least six months and accompanied by high-intensity community services and supports”, despite no significant differences in hospitalizations between the non OPC controls and those under commitment at the one year mark.[2] [3]

In turn, the Bellevue Outpatient Commitment Study was conducted in 2001, which was the only controlled study that explicitly provided and offered enhanced community services to both OPC and non OPC groups.  They reviewed if commitments were necessary for individuals to continue with treatment if they were offered it without the OPC.  They concluded “individuals provided with voluntary enhanced community services did just as well as those under commitment orders who had access to the same services”.  Researchers found no additional improvement in patient compliance with treatment, no additional increase in continuation of treatment, and no differences in hospitalization rates, lengths of hospital stay, arrest rates, or rates of violent acts.[4]

This lead Drs. Kirsley and Campbell, who were highlighted by the Cochrane Database of Systematic Reviews, the gold-standard of peer reviewed psychiatric research, to look at the number of outpatient commitment orders (OPC) it would take then to prevent one re-hospitalization.  They concluded “it takes 85 OPC orders to prevent one readmission, 27 to prevent one episode of homelessness and 238 to prevent a future arrest”.[5]  Thus, 84 people would need to be subjected to a non-required forced treatment program in order to reduce just one re-hospitalization. 

This was confirmed by researchers then in 2007 at the Institute of Psychiatry in Maudsley, UK, whereby they conducted “the most comprehensive and through review of outpatient commitments” at that time.  They concluded, “it is not possible to state whether or community treatment orders (CTOs) [the equivalent to OPC] are beneficial or harmful to patients”.[6]

In Contrast, the State of New York began investing their own OPC, under Kendra’s Law and the Assisted Outpatient Treatment (AOT) program; however, their results now appear mixed, whereby the New York State Office of Mental Health in 2005 and later 2009 stated the AOT drastically reduced hospitalization, homelessness, arrest, incarcerations and adherence to medication compliance[7] [8]; however, non contracted independent researchers in 2004 had indicated that their sample of the AOT group and control group “did not differ significantly (with) rates of hospitalizations, homelessness, dangerousness and arrest/incarcerations”.  One additional major conclusion was that the AOT forced treatment group was significantly “less satisfied” with treatment than those not under commitment. [9]

[1] Maloy, Analysis: Critiquing the Empirical Evidence ; Does Involuntary Outpatient Commitment Work? Mental health Policy Resource Center (1992).

[2] Swartz MS, Swanson JW, Hiday VA, et al: A randomized controlled trial of outpatient commitment in North Carolina. Psychiatric Services 52: 325-329, 2001.

[3] Swartz MS, Swanson JW, Wagner HR, et al: Can involuntary outpatient commitment reduce hospital recidivism? Finds form a randomized trial with severely mentally ill individuals. Am J. of Psychiatry 156: 1968-1975, 1999.

[4] Steadman HJ, Gounis K, Dennis D, et al: Assessing the New York City involuntary outpatient commitment pilot program. Psychiatric Services 52:330-336, 2001

[5] Kisely S, Campbell LA, Preston N. Compulsory community and involuntary outpatient treatment for people with severe mental disorders. The Cochrane Database of Systematic Reviews 2005, Issue 3. 

[6] Churchill, R., International experiences of using community treatment orders, by the Institute of Psychiatry at the Maudsley (UK), Section of Evidence based Mental Health-Serv. Research Dept., March 2007. http://www.iop.kcl.ac.uk/news/downloads/final2ctoreport8march07.pdf

[7] N.Y. State Office of Mental Health (March 2005). Kendra’s Law: Final Report on the Status of Assisted Outpatient Treatment.

[8] Duke University School of Medicine et. al. (June 2009). New York State Assisted Outpatient Treatment Program Evaluation.

[9] Perese, E.F. , Wu, Y.-W. B., & Ranganathan R. (2004). Effectiveness of Assertive Community Treatment for Patients Referred under Kendra’s Law: Proximal and Distal Outcomes International Journal of Psychosocial Rehabilitation. 9 (1), 5-9.

*Associated Psychological Health Services, Clinical & Doctoral Training Director
State of WI-Dept. of Corrections-KMCI: Chief Supervising Psychologist,
ISEPP Past Executive Director, www.psychintegrity.org