Does involuntary out-patient treatment work?

Richard L O'Reilly

doi:10.1192/pb.25.10.371

Abstract

There has been considerable debate in the UK in recent years about the propriety of using various forms of ‘involuntary out-patient treatment’ for some individuals with serious mental illness (Eastman, 1995; Dyre, 1998; Burns, 1999; Moncrieff & Smyth, 1999; Sugarman, 1999). While most jurisdictions in the US have statutes that support involuntary out-patient treatment (Torrey & Kaplan, 1995), its use remains controversial (Slobogin, 1994; Diamond, 1995; Torrey, 1997). Involuntary outpatient treatment was originally proposed as a solution to the ‘revolving door syndrome’ (Geller, 1996). It has also been recognised, however, that it may provide a solution to the clinical and ethical dilemmas of allowing individuals who are incapable of making treatment decisions to discontinue treatment, with predictable deterioration to the point where they may harm themselves or others (Geller, 1990). This paper provides a review of controlled studies that have examined whether involuntary treatment in the community is effective.

Highlights

In this article I will use the term involuntary outpatient treatment for all forms of compulsory out-patient treatment except provisions that apply to individuals who are charged with, or have been found not criminally responsible for, a criminal offence
The most common outcome measure used in involuntary out-patient treatment research, is the amount of hospitalisation an individual experiences, measured either as the total number of admissions or the cumulative days spent in hospital over a given period
The use of hospitalisation as a primary outcome measure may not be appropriate for patients who receive involuntary outpatient treatment because some of these individuals may benefit from extended hospital stays (Draine, 1997)

Summary

Hospitalisation as the outcome measure

Most studies have demonstrated a reduction in hospital utilisation associated with involuntary out-patient treatment (Bursten, 1986; Zanni & deVeau, 1986; Van Putten et al, 1988; Fernandez & Nygard, 1990; Sensky et al, 1991; Munetz et al, 1996; O'Keefe et al, 1997; Geller et al, 1998; Steadman et al, 2001) in some this reduction was not statistically significant (Steadman et al, 2001). Every study that has used patients as their own controls demonstrated a significant reduction in hospital utilisation (Zanni & deVeau, 1986; Fernandez & Nygard, 1990; Sensky et al, 1991; Munetz et al, 1996; O'Keefe et al, 1997; Rohland, 2000). Swartz et al examined the clinical characteristics of patients who did best on involuntary out-patient treatment and reported that patients with psychoses or with serious mental illness associated with substance misuse and violent behaviour showed the greatest reduction in hospital utilisation

Other outcome measures

Conclusion

Adshead Can deception ever be therapeutic?

Findings

GWEN ADSHEAD