Assessment of outpatient commitment in randomised trials

Abstract

The randomised controlled trial (RCT) is the gold standard of research and the clearest way to establish causal certainty. This design, however, was misapplied in three RCTs of involuntary outpatient civil commitment (also known as community treatment orders). 1 Swartz M Swanson JD Wagner HR Burns BJ Hiday VA Borum R Can involuntary outpatient commitment reduce hospital recidivism? Findings from a randomized trial with severely mentally ill individuals. Am J Psychiatry. 1999; 156: 1968-1975 PubMed Google Scholar , 2 Burns T Rugkåsa J Molodynski A et al. Community treatment orders for patients with psychosis (OCTET): a randomised controlled trial. Lancet. 2013; 381: 1627-1633 Summary Full Text Full Text PDF PubMed Scopus (255) Google Scholar , 3 Steadman HJ Gounis K Dennis D et al. Assessing the New York City involuntary outpatient commitment pilot program. Psychiatric Serv. 2001; 52: 330-336 Crossref PubMed Scopus (280) Google Scholar In contrast with the positive outcomes regarding outpatient commitment in epidemiological studies, 4 Segal SP Hayes SL Rimes L The utility of outpatient commitment: I. A need for treatment and a least restrictive alternative to psychiatric hospitalization. Psychiatric Serv. 2017; (published online Aug 1.)DOI:10.1176/appi.ps.201600161 Crossref Scopus (19) Google Scholar , 5 Link BG Epperson MW Perron BE Castille DM Yang LH Arrest outcomes associated with outpatient commitment in New York state. Psychiatric Serv. 2011; 62: 504-508 Crossref PubMed Scopus (39) Google Scholar a subsequent Cochrane review of these RCTs, 6 Kisely SR Campbell LA O'Reilly R Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Cochrane Database Syst Rev. 2017; 3 (CD004408.) Crossref PubMed Scopus (66) Google Scholar suggested that outpatient commitment “was no more likely to result in better service use, social functioning, mental state or quality of life compared with standard ‘voluntary’ care”. This conclusion is potentially harmful for patients in need of oversight to protect their health and safety, and that of others. The conclusion is also unjustified because the outpatient commitment RCTs have major design, measurement, implementation, and analytical flaws. Randomised controlled trials and outpatient commitmentSteven Segal's criticism1 of each of the published randomised controlled trials (RCTs)2–4 on outpatient commitment and the subsequent Cochrane systematic review5 are not new. We believe the criticisms reflect a limited understanding of: the clinical practice of outpatient commitment, the conduct of clinical effectiveness RCTs, and the stringent requirements for the inclusion of studies in Cochrane reviews. Psychiatry owes it to patients, their families, and the profession, to take uncomfortable research findings seriously and either conduct even better trials or change clinical practice. Full-Text PDF Randomised controlled trials and outpatient commitmentSteven Segal's critique1 of randomised control trials (RCTs) of outpatient commitment makes several incorrect assertions about these studies. For example, the North Carolina study did not completely exclude violent patients as Segal claims. Rather, patients with a documented history of serious violence were enrolled in a separate, non-randomised arm of the study. Participants were assigned to outpatient commitment at discharge but were followed up in the community with the same protocol as the one used for the other study participants, whether or not they remained under court-ordered treatment (many did not). Full-Text PDF