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Intervention Review

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

  1. Steve R Kisely1,*,
  2. Leslie Anne Campbell2,
  3. Neil J Preston3

Editorial Group: Cochrane Schizophrenia Group

Published Online: 16 FEB 2011

Assessed as up-to-date: 2 NOV 2009

DOI: 10.1002/14651858.CD004408.pub3


How to Cite

Kisely SR, Campbell LA, Preston NJ. Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Cochrane Database of Systematic Reviews 2011, Issue 2. Art. No.: CD004408. DOI: 10.1002/14651858.CD004408.pub3.

Author Information

  1. 1

    The University of Queensland, School of Population Health, Brisbane, Australia

  2. 2

    Capital District Health Authority, Halifax, Nova Scotia, Canada

  3. 3

    Fremantle Hospital and Health Service, Mental Health Directorate, Fremantle, Australia

*Steve R Kisely, School of Population Health, The University of Queensland, Brisbane, Australia. s.kisely@uq.edu.au.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 16 FEB 2011

SEARCH

This is not the most recent version of the article. View current version (04 DEC 2014)

 

Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary

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 methods

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.

We updated this search July 2012, five new studies added to awaiting classification section.

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.

[Note: the five citations in the awaiting classification section of the review may alter the conclusions of the review once assessed.]

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary

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

The evidence found in this review suggests that compulsory community treatment may not be an effective alternative to standard care.

We examined the effectiveness of compulsory community treatment for people with severe mental illness through a systematic review of all relevant randomised controlled clinical trials. Only two relevant trials were found and these provided little evidence of efficacy on any outcomes such as health service use, social functioning, mental state, quality of life or satisfaction with care. No data were available for cost and unclear presentation of data made it impossible to assess the effect on mental state and most aspects of satisfaction with care. In terms of numbers needed to treat, it would take 85 outpatient commitment orders to prevent one readmission, 27 to prevent one episode of homelessness and 238 to prevent one arrest.