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

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.

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

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

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

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).

We identified two randomised clinical trials (total n=416) of court-ordered 'Outpatient Commitment' (OPC) from the USA. We found little evidence to indicate that compulsory community treatment was effective in any of the main outcome indices: health service use (2 RCTs, n=416, RR readmission to hospital by 11-12 months 0.98 CI 0.79 to 1.2), social functioning (2 RCTs, n=416, RR outcome '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 homelessness 0.67 CI 0.39 to 1.15) or satisfaction with care (2 RCTs, n=416, RR 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, NNT 6 CI 6 to 6.5). In terms of numbers needed to treat, it would take 85 OPC orders to prevent one readmission, 27 to prevent one episode of homelessness and 238 to prevent one arrest.

Based on current evidence, community treatment orders may not be an effective alternative to standard care. It appears that compulsory community treatment results in no significant difference in service use, social functioning or quality of life compared with standard care. There is currently no evidence of cost effectiveness. People receiving compulsory community treatment were, however, less likely to be victim of violent or non-violent crime. It is, nevertheless, difficult to conceive of another group in society that would be subject to measures that curtail the freedom of 85 people to avoid one admission to hospital or of 238 to avoid one arrest. We urgently require further, good quality randomised controlled studies to consolidate findings and establish whether it is the intensity of treatment in compulsory community treatment or its compulsory nature that affects outcome. Evaluation of a wide range of outcomes should be included if this type of legislation is introduced.