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Abstract

French

Objective:

Involuntary outpatient commitment (OPC)—also referred to as ‘assisted outpatient treatment’ or ‘community treatment orders’—are civil court orders whereby persons with serious mental illness and repeated hospitalisations are ordered to adhere to community-based treatment. Increasingly, in the United States, OPC is promoted to policy makers as a means to prevent violence committed by persons with mental illness. This article reviews the background and context for promotion of OPC for violence prevention and the empirical evidence for the use of OPC for this goal.

Method:

Relevant publications were identified for review in PubMed, Ovid Medline, PsycINFO, personal communications, and relevant Internet searches of advocacy and policy-related publications.

Results:

Most research on OPC has focussed on outcomes such as community functioning and hospital recidivism and not on interpersonal violence. As a result, research on violence towards others has been limited but suggests that low-level acts of interpersonal violence such as minor, noninjurious altercations without weapon use and arrests can be reduced by OPC, but there is no evidence that OPC can reduce major acts of violence resulting in injury or weapon use. The impact of OPC on major violence, including mass shootings, is difficult to assess because of their low base rates.

Conclusions:

Effective implementation of OPC, when combined with intensive community services and applied for an adequate duration to take effect, can improve treatment adherence and related outcomes, but its promise as an effective means to reduce serious acts of violence is unknown.

Keywords

involuntary outpatient commitment assisted outpatient treatment community treatment orders

In almost every metropolitan community in the United States and Canada, there is a subpopulation of persons with severe mental illness (often accompanied by alcohol or illicit drug use) that is difficult to serve by resource-poor community mental health programs.^1

–4 The pressing need to improve community treatment engagement and outcomes has led policy makers and clinicians to focus on keys points of leverage to promote treatment adherence, including the use of involuntary outpatient commitment (OPC)—court orders compelling persons with severe mental illness to adhere to treatment.^1

–4 Many US states have implemented outpatient commitment statutes as a remedy for these so-called revolving door patients, although there has been growing opposition from some mental health advocacy groups about the potential coerciveness of OPC and its use in place of other clinical efforts to engage such patients.^5,6 At the same time, unfortunately, public concern about the effectiveness of mental health care in the United States is often focused on rare but tragic acts of violence committed by persons with severe mental illness, for which OPC is also promoted as a remedy.^7
–9 This article reviews existing evidence about OPC’s overall effectiveness and the extent to which OPC can reduce violent behaviour by persons under these court orders.

Involuntary outpatient civil commitment (OPC), as implemented in the United States, is a civil court procedure wherein a judge directs a person with severe mental illness to adhere to an outpatient treatment plan designed to prevent relapse and dangerous deterioration.^1,4,10 Typically, enforcement of compliance with an OPC order involves law enforcement transporting a noncompliant patient to a treatment facility for clinical reevaluation and an attempt to persuade the patient to comply with the treatment plan. Involuntary administration of medication is usually explicitly prohibited under the authority of OPC and, if indicated, requires separate legal authority and procedures for administration of involuntary medication.¹⁰ As of 2016, 46 states and the District of Columbia had commitment statutes permitting some form of OPC. Despite some evidence of participant benefit and public cost savings associated with outpatient commitment, however, the practice has been inconsistently implemented.^11
–13 Many states make little use of OPC laws and do not specifically fund or evaluate OPC programs.^12,14

In 1983, North Carolina enacted a “preventive” form of outpatient commitment that became the prototype for the “assisted outpatient treatment” laws that were enacted in other states and often named for homicide victims—notably “Kendra’s Law” in New York, “Laura’s Law” in California, and “Kevin’s Law” in Michigan.^15
–17 Under a preventive outpatient commitment law, a person with mental illness, while not currently dangerous, could be ordered to OPC if the patient’s condition 1) impaired his or her ability to comply voluntarily with recommended treatment, 2) would deteriorate if left untreated, and 3) would eventually result in dangerousness to self or others if left untreated.¹⁶ In 1999, New York State enacted its similar preventive outpatient commitment program, “Kendra’s Law,” as a memorial to Kendra Webdale, a young woman who had been pushed into the path of an oncoming subway train by a man with schizophrenia. New York’s OPC law became the nation’s best-funded, explicitly implemented, and extensively evaluated program of mandated community mental health treatment.¹⁸

The Contested Relationship between Violence and Mental Illness

Although proposed OPC statutes tap into public fear about the potential for violence among persons with mental illness, serious violent acts by persons with severe mental illness are uncommon.¹⁹ Major psychiatric conditions like schizophrenia and mood disorders, by themselves, contribute relatively little—about 4%—to the overall risk of interpersonal violence in the population, and most perpetrators of commonplace violent acts do not have serious psychopathology.¹⁹ Studies indicate that although there is a slightly elevated risk of violence in persons with severe mental illness, such serious acts are still rare.^19,20 The factors that contribute to violence in the mentally ill are often as varied and complex as those in the general population.^19,21,22 In fact, it has been demonstrated that persons with mental illness are more frequently subjected to physical or sexual victimization, and these experiences compounded by other psychosocial factors may increase the risk of violence perpetration in these populations.^23

–26

A study of 802 patients with mental illness found that the factors associated with violence included a history of violent victimization, homelessness, cohabitation, exposure to community violence, substance abuse, poor mental health status, and a history of psychiatric hospitalisation.²⁷ None of these risk factors, alone, explained an elevated risk, and patients with one or none of these risk factors had violence risks equal to that of the general population without mental illness.²⁷ Addition of a second risk factor doubled the risk of violence, and those with 3 or more risk factors were most likely to be violent, indicating that the risks for violent behaviour are multifactorial and compounded by social factors throughout the life course.

However, the prospect of a violent act by a person with a severe mental illness generates grave public concern and fear, which is often compounded by media coverage of these acts.²⁸ Clinicians are faced with increasing legal liability and responsibility for the actions and behaviours of their inadequately treated or noncompliant patients, adding to concerns about the risk of violence among their patients.²⁹ Such concerns negatively affect the care of a disenfranchised population while stoking an existing stigma and fear surrounding mental illness.^28
–30 These patients are often high users of services often requiring involuntary commitment, but psychiatrists are often limited in their ability to care for these patients due to lack of sufficient intensive outpatient services.³¹

Some of the controversy over OPC involves the potential for violence by persons with severe mental illness and how inflated views of violence potential fuels stigmatizing views of mental illness. Attitude surveys in the United States reliably document the popular belief that mental illness ‘causes’ violence^1,3,19 and the strong correlation of this belief with public endorsement of the use of legal mandates to require treatment adherence.^1,3,19 Drawing on public opinion, political advocates of OPC in recent years have ‘sold’ OPC by capitalizing on the publicity surrounding sensational acts of violence by people with mental disorders—explicitly promoting involuntary outpatient treatment as a needed measure to ensure public safety.¹ But even proponents of OPC express caution about OPC’s public safety promise. Indeed, the recent resource document on OPC developed by the American Psychiatric Association states, “The goal of involuntary outpatient commitment is to mobilise appropriate treatment resources, enhance their effectiveness and improve an individual’s adherence to the treatment plan. Involuntary outpatient commitment should not be considered as a primary tool to prevent acts of violence” (emphasis added).³² Despite these cautions about assigning OPC the task of violence prevention, the recent scourge of mass shootings in the United States have led many US lawmakers, wary of the powerful gun lobby, to implicate mental illness as the chief cause of gun violence in the United States.³³

Evidence of the Effectiveness of Involuntary Outpatient Commitment

Over the past several decades, multiple observational, quasi-experimental, and randomised controlled studies have evaluated the effectiveness of outpatient commitment, including some positive findings in Canada.^12,32

–35 On the whole, they do provide evidence that outpatient commitment can be effective in reducing recidivism and improving other outcomes.^12,32 The first randomised controlled trial of outpatient commitment was the Duke Mental Health Study in North Carolina.^13,36,37 Patients with severe mental illness who were involuntarily admitted to a psychiatric hospital with planned discharge on outpatient commitment were randomly assigned to remain on the outpatient commitment combined with case management or be released from commitment and receive case management services alone. Patients with a recent history of serious violence being discharged on outpatient commitment were placed in a nonrandomised comparison group for ethical reasons.

Rates of hospitalisation were significantly lower in the outpatient commitment group than the control group in the 12-month follow-up period in multivariate repeated-measures analysis of month-by-month risk of admission. However, other analyses comparing hospitalisation rates for the OPC versus control groups found no overall benefit of OPC in reducing hospitalisations. In contrast, patients under outpatient commitment for 180 days or more had 57% fewer admissions and 20 fewer hospital days over the study period compared to controls. Sustained outpatient commitment (OPC for 180 days or more) was most effective when combined with frequent outpatient services, emphasising the need to combine the court order with intensive outpatient services. Patients under sustained outpatient commitment also were more adherent with treatment, were less likely to be victimised, and had reduced family strain and improved subjective quality of life.³²

A randomised controlled trial of mandatory outpatient commitment in New York City in 1994 was conducted at Bellevue Hospital as a pilot for a potential statewide statute for patients with severe mental illness.³⁸ During the 11-month follow-up period, inpatients were randomised to receive intensive community treatment with outpatient commitment or intensive community treatment alone. This study found no statistically significant differences between the outpatient commitment and control groups in rates of rehospitalisation or in the number of hospital days during the study period. Limitations of the small pilot study included no enforcement of the orders for nonadherence available in New York City at the time and a small sample size.

Despite these null findings of effectiveness, in 1999, the New York State legislature enacted a statewide outpatient commitment statute that renamed the program as ‘assisted outpatient commitment’ (AOT). In this program, the treatment could be court mandated in a preventive form at a lower threshold for commitment.³⁹ An evaluation of this program by the New York State Office of Mental Health in 2005³⁹ found an 89% increase in use of case management services among AOT recipients and substantial increases in the use of substance use disorder treatment and housing support services. Significant improvements in functioning and a decline in the incidence of harmful behaviours were demonstrated as well.

Duke University, Policy Research Associates, and the MacArthur Research Network on Mandated Community Treatment conducted an evaluation of the program as well.⁴⁰ The likelihood of psychiatric hospital admission was significantly reduced by approximately 25% during the initial 6-month court order and by over one-third during a subsequent 6-month renewal period compared to the 12 months before initiation of the court order.⁴⁰ Overall, patients with AOT had multiple improved outcomes: reduced hospitalisation, reduced length of stay in the hospital, and increased compliance with medication and intensive case management services. While the study employed a rigorous quasi-experimental pre-post design, propensity score adjustments, and a large sample size of several thousand subjects, critics of the study argued that a randomised trial might have more rigorously evaluated the effectiveness of AOT.^11,18,40,41

A follow-up cost analysis of the New York program was conducted using observational data from the AOT group and a comparison group of voluntary recipients of intensive community-based treatment in New York City and 5 counties elsewhere in New York State.¹¹ In the New York City AOT group, net costs declined 43% in the first year after assisted outpatient treatment began and an additional 13% in the second year. In the 5-county AOT group, costs declined 49% in the first year and an additional 27% in the second year. The AOT-related cost declines were about twice as much as those seen for the voluntary group, indicating that although AOT requires a substantial investment of state resources, it can reduce overall service costs for individuals with serious mental illness.

A third randomised trial of outpatient commitment, the Oxford Community Treatment Order Evaluation Trial (OCTET), was conducted in the United Kingdom.⁴² Patients who were involuntarily hospitalised were randomly assigned at discharge either to be released on a community treatment order (UK equivalent of outpatient commitment) or to be released on a form of conditional release authorised under Section 17 of the United Kingdom’s 1983 Mental Health Act. Hospital readmission during the 12-month follow-up period was the primary outcome of interest. Secondary outcomes included length of time to the first readmission, number of readmissions, total amount of time spent in hospital, clinical functioning, and social functioning. No significant differences were found across any of the outcomes at the 12-month follow-up.⁴² Although this trial provided evidence of the lack of benefit of outpatient commitment, critics of this study suggest the OCTET lacked a true ‘voluntary’ treatment arm for comparison.¹²

After several generations of studies, evaluations, and legislative and systematic reviews of the evidence for involuntary outpatient commitment, there is no clear consensus about its overall effectiveness across different jurisdictions, including a recent Cochrane and systematic review.^43,44 In its recent Resource Document on Involuntary Outpatient Commitment, the American Psychiatric Association (APA) indicated that OPC programs are difficult to evaluate by the usual approaches to comparative effectiveness because such programs are complex community-based interventions whose effectiveness varies depending on context and implementation approach.³² However, in evaluating the overall evidence of OPC, the APA concluded, “The evidence on the effectiveness is mixed, with effectiveness largely a function of systematic and effective implementation, the availability of intensive community-based services and the duration of the court order. However, rather than framing the question as to whether outpatient commitment orders ‘are effective’ –as if comparing Drug A to Drug B—it appears to be more appropriate to ask, “under what conditions, and for whom, can involuntary outpatient commitment orders be effective?”³²

The Effectiveness of Involuntary Outpatient Commitment in Reducing Violence and Offending

There is a relative paucity of data on the effectiveness of OPC in reducing violence or criminal offending. Of the studies reviewed previously, reporting of violent behaviour or offending was inconsistent. In the New York Bellevue Hospital study, the authors reported no significant differences in overall arrest rates or rates of violent offending in the follow-up period.³⁸ The UK OCTET study did not report on violence or offending as an outcome.⁴²

In the North Carolina OPC trial, there were no overall differences in violence or arrests among the outpatient commitment or control groups.³⁷ However, patients with sustained periods of outpatient commitment had significantly fewer incidents of violence compared with controls who were released from outpatient commitment and compared to patients who underwent shorter periods of commitment (23% vs 37%, and 40% rates of violence, respectively).³⁷ In addition, if patients with sustained orders abstained from substance use and were compliant with medications, they had the lowest likelihood of any violence: 13% predicted probability versus 53% for patients who did not undergo sustained outpatient commitment, misused substances, and were medication noncompliant. Predictors of violence included younger age, being single, lack of social support, living in an urban area, homelessness, functional impairment, paranoia, and more than 2 hospital admissions in the past year. Co-occurring substance use and medication noncompliance were strongly associated with elevated violence risk. With respect to arrests, OPC was significantly associated with reduced arrest probability (12% vs 45%) in a subgroup of patients with a history of multiple hospitalisations combined with prior arrests and/or violent behaviour. Reduction in risk of violent behaviour was a significant mediating factor in the association between OPC and arrest. The study concluded that in persons with severe mental illness whose history of arrests is related directly to illness relapse, OPC may reduce criminal justice contact by increasing participation in mental health services.⁴⁵

In the Duke Study of the New York AOT Program, a subset of patients in the AOT program was directly interviewed. Of those under AOT, 10.4% reported an act of violence in the past 6 months; in contrast, 15.7% of the comparison group receiving intensive voluntary services without a current AOT order reported an act of violence.^40,41,46 The study also examined whether AOT recipients had lower odds of arrest compared to individuals who had not yet initiated AOT or intensive treatment services under a voluntary agreement. Interview data were matched with arrest records. The odds of arrest for participants currently receiving AOT were nearly two-thirds lower (odds ratio [OR], .39; P < 0.01) than for those who had not yet initiated AOT or voluntary treatment. The odds of arrest among individuals currently receiving intensive voluntary services (OR, .64) were not significantly different from those who had not yet initiated AOT or voluntary treatment. The adjusted predicted probabilities of arrest in any given month were 3.7% for individuals who had not yet initiated either arrangement of treatment (AOT or voluntary), 2.8% for individuals currently receiving intensive voluntary services, and 1.9% for individuals currently on AOT.^40,46 These findings are consistent with AOT case managers’ reports covering the entire program from 1999 to the present and roughly 9000 patients.⁴⁷ The AOT program reported that physical assaults by AOT participants were reduced by an average of 52% in the first 6 months of AOT participation (from 8% to 4%) and 56% on average over participants’ entire period of AOT participation. Threats of assault were reduced by 44% in the first 6 months (from 21% to 11%) and 53% over participants’ entire period of AOT participation. Incarceration was reduced by 61% (from 19% to 7%). Reports from New York are consistent with 2 naturalistic studies from Australia that reported reduced episodes of aggression under community treatment orders and rates of offending.^48,49

Conclusions

Despite the current interest in OPC as a means to reduce violence, rigorous empirical evidence to employ it on that basis is slim. Some stakeholders will still find New York’s reports of substantial reductions in violence in its large, well-functioning AOT program very persuasive. However, the paucity of empirical evidence is marked if the goal is reduction of larger scale acts of extreme violence. When effectively implemented, combined with intensive community services, and sustained over time, treatment adherence and provision of appropriately tailored services do appear to improve, leading to reduced relapses and improving community functioning. OPC programs should be promoted for their potential to enhance the delivery of more effective care with downstream benefits to patients, families, and the communities.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Involuntary Outpatient Commitment and the Elusive Pursuit of Violence Prevention

Abstract

Objective:

Method:

Results:

Conclusions:

Keywords

The Contested Relationship between Violence and Mental Illness

Evidence of the Effectiveness of Involuntary Outpatient Commitment

The Effectiveness of Involuntary Outpatient Commitment in Reducing Violence and Offending

Conclusions

Footnotes

Declaration of Conflicting Interests

Funding

References