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Can involuntary outpatient commitment reduce hospital recidivism?: Findings from a randomized trial with severely
M S Swartz1, J W Swanson, H R Wagner
1Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC 27710, USA. swart001@mc.duke.edu
Insights
Sustained involuntary outpatient commitment, particularly for individuals with psychotic disorders, significantly reduces hospital readmissions and days when paired with intensive treatment.
Area of Science:
- Psychiatry
- Public Health
- Mental Health Services Research
Background:
- Severe mental illnesses are associated with high rates of rehospitalization.
- Involuntary outpatient commitment is a legal mechanism aimed at ensuring treatment adherence and reducing hospital use.
Purpose of the Study:
- To assess the efficacy of involuntary outpatient commitment in preventing rehospitalizations for individuals with severe mental illnesses.
- To identify factors influencing the effectiveness of outpatient commitment.
Main Methods:
- A randomized controlled trial comparing involuntary outpatient commitment to standard release post-hospitalization.
- 1-year follow-up of 264 individuals receiving case management and outpatient treatment.
- Collection of data on outpatient treatment intensity and hospital utilization.
Main Results:
- Sustained involuntary outpatient commitment, beyond the initial court order, led to a 57% reduction in readmissions and 20 fewer hospital days.
- This intervention was particularly effective for individuals with nonaffective psychotic disorders, reducing readmissions by 72% and hospital days by 28.
- Effectiveness was contingent on combining sustained commitment with higher intensity outpatient treatment.
Conclusions:
- Involuntary outpatient commitment can be an effective strategy for reducing hospital readmissions and days when sustained and integrated with intensive outpatient treatment.
- The benefits are most pronounced in individuals with psychotic disorders.
- Successful implementation requires significant investment in treatment resources.
Objective:
The goal of this study was to evaluate the effectiveness of involuntary outpatient commitment in reducing rehospitalizations among individuals with severe mental illnesses.
Method:
Subjects who were hospitalized involuntarily were randomly assigned to be released (N = 135) or to continue under outpatient commitment (N = 129) after hospital discharge and followed for 1 year. Each subject received case management services plus additional outpatient treatment. Outpatient treatment and hospital use data were collected.
Results:
In bivariate analyses, the control and outpatient commitment groups did not differ significantly in hospital outcomes. However, subjects who underwent sustained periods of outpatient commitment beyond that of the initial court order had approximately 57% fewer readmissions and 20 fewer hospital days than control subjects. Sustained outpatient commitment was shown to be particularly effective for individuals with nonaffective psychotic disorders, reducing hospital readmissions approximately 72% and requiring 28 fewer hospital days. In repeated measures multivariable analyses, the outpatient commitment group had significantly better hospital outcomes, even without considering the total length of court-ordered outpatient commitments. However, in subsequent repeated measures analyses examining the role of outpatient treatment among psychotically disordered individuals, it was also found that sustained outpatient commitment reduced hospital readmissions only when combined with a higher intensity of outpatient treatment.
Conclusions:
Outpatient commitment can work to reduce hospital readmissions and total hospital days when court orders are sustained and combined with intensive treatment, particularly for individuals with psychotic disorders. This use of outpatient commitment is not a substitute for intensive treatment; it requires a substantial commitment of treatment resources to be effective.
