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The Research Literature on Commitments- Forced Orders to Treat.
 
26.  Since many individuals struggling know the above to be true, they request and often demand not to be given psychiatric medications, and in turn, many to well meaning individuals at hospitals and within the court system, attempt to force individuals to take psychiatric medications in order to lower re-hospitalization, symptoms and negative effects.
 
There are few studies that have attempted to determine the effectiveness of Outpatient Commitment Orders (OPC) by comparison to the tens of thousands of OPC ordered, and I wish to highlight all these profound conclusions contained within the studies that are available for peer review.  In one of the first thorough reviews of empirical studies of OPC, Dr. Kathleen Maloy concluded in 1992, there was "almost no valid empirical evidence in support of the effectiveness of involuntary outpatient commitment vis-à-vis treatment compliance, success in the community for people with severe and persistent mental illness".[1]

This acknowledgement by Maloy in 1992 led Duke University researchers in North Carolina in 1999 and 2001 to examine if OPC reduced hospitalizations.  They, Swartz and his colleagues, concluded “outpatient commitment had no clear benefit unless it was sustained for at least six months and accompanied by high-intensity community services and supports”, despite no significant differences in hospitalizations between the non OPC controls and those under commitment at the one year mark.[2] [3]

In turn, the Bellevue Outpatient Commitment Study was conducted in 2001, which was the only controlled study that explicitly provided and offered enhanced community services to both OPC and non OPC groups.  They reviewed if commitments were necessary for individuals to continue with treatment if they were offered it without the OPC.  They concluded “individuals provided with voluntary enhanced community services did just as well as those under commitment orders who had access to the same services”.  Researchers found no additional improvement in patient compliance with treatment, no additional increase in continuation of treatment, and no differences in hospitalization rates, lengths of hospital stay, arrest rates, or rates of violent acts.[4]

This lead Drs. Kirsley and Campbell, who were highlighted by the Cochrane Database of Systematic Reviews, the gold-standard of peer reviewed psychiatric research, to look at the number of outpatient commitment orders (OPC) it would take then to prevent one re-hospitalization.  They concluded “it takes 85 OPC orders to prevent one readmission, 27 to prevent one episode of homelessness and 238 to prevent a future arrest”.[5]  Thus, 84 people would need to be subjected to a non-required forced treatment program in order to reduce just one re-hospitalization. 

This was confirmed in 2007 at the Institute of Psychiatry in Maudsley, UK, whereby they conducted “the most comprehensive and through review of outpatient commitments” ever performed at that time.  They concluded, “it is not possible to state whether or community treatment orders (CTOs) [the equivalent to OPC] are beneficial or harmful to patients”.[6]

In Contrast, the State of New York began investing their own OPC, under Kendra’s Law and the Assisted Outpatient Treatment (AOT) program; however, their results now appear mixed, whereby the New York State Office of Mental Health in 2005 and later 2009 stated the AOT drastically reduced hospitalization, homelessness, arrest, incarcerations and adherence to medication compliance[7] [8]; however, non contracted independent researchers in 2004 had indicated that their sample of the AOT group and control group “did not differ significantly (with) rates of hospitalizations, homelessness, dangerousness and arrest/incarcerations”.  One additional major conclusion drawn by both was that the AOT forced treatment group was significantly “less satisfied” with treatment than those not under commitment. [9]

This led researchers in 2012 to follow 320 patients diagnosed with schizophrenia and hospitalized.  Following initial court order to treat, patients either accepted a hospitalization order to treat (51%) or refused such order and left the hospital against the psychiatrist’s recommendation (49%).  There was no difference between the two groups at baseline for severity of symptoms or in their demographics.  Consistent with the above research, researchers found no significant difference for rates of readmission, legal status at next admission and the length of stay during the next hospitalization, for those who were readmitted.[10] 

Finally and most recently, researchers backed by the National Institute of Health Research, tracked and assessed 336 psychotic patients discharging from the hospital, whereby they randomly assigned them to either; 1) a compulsory supervision and “treatment” group, or 2) to a no forced treatment “section 17 leave” group, which only continued to meet with outpatient providers for a median of 8 days thereafter, compared to the forced order to treat group meeting for a median 183 days.[11]  Severity of symptoms, age and diagnosis were all matched between the groups; however, after 12 months, to the surprise of the researchers:

“the number of patients readmitted did not differ between groups”, whereby in both groups, 64% of the patients in both groups were not readmitted.  They concluded:            “in well coordinated mental health services the imposition of compulsory supervision does not reduce the rate of readmission of psychotic patients.  We found no support in terms of any reduction in overall hospitalization admission to justify the significant curtailment of patient’s personal liberty.”


[1] Maloy, K. (1992). Analysis: Critiquing the Empirical Evidence; Does Involuntary Outpatient Commitment Work? Washington DC: Mental health Policy Resource Center,

[2] Swartz MS, Swanson JW, Hiday VA, et al. (2001). A randomized controlled trial of outpatient commitment in North Carolina. Psychiatric Services, 52: 325-329.

[3] Swartz MS, Swanson JW, Wagner HR, et al. (1999). Can involuntary outpatient commitment reduce hospital recidivism? Finds form a randomized trial with severely mentally ill individuals. American Journal of Psychiatry, 156:1968-1975.

[4] Steadman HJ, Gounis K, Dennis D, et al. (2001). Assessing the New York City involuntary outpatient commitment pilot program. Psychiatric Services, 52:330-336.

[5] Kisely S, Campbell LA, Preston N. (2005). Compulsory community and involuntary outpatient treatment for people with severe mental disorders. The Cochrane Database of Systematic Reviews, Issue 3. 

[6] Churchill, R.. (2007). International experiences of using community treatment orders, by the Institute of Psychiatry at the Maudsley (UK), Section of Evidence based Mental Health-Serv. Research Dept.. http://www.iop.kcl.ac.uk/news/downloads/final2ctoreport8march07.pdf

[7] N.Y. State Office of Mental Health (March 2005). Kendra’s Law: Final Report on the Status of Assisted Outpatient Treatment.

[8] Duke University School of Medicine et. al. (June 2009). New York State Assisted Outpatient Treatment Program Evaluation.

[9] Perese, E.F. , Wu, Y.-W. B., & Ranganathan R. (2004). Effectiveness of Assertive Community Treatment for Patients Referred under Kendra’s Law: Proximal and Distal Outcomes International Journal of Psychosocial Rehabilitation. 9(1), 5-9.

[10] Krivoy, A. Fischel, T, Zahalka, H et al Outcomes of compulsorily admitted schizophrenic patients who agreed or disagreed to prolong their hospitalization. , Comprehensive Psychiatry, Oct;53(7):995-9.  doi: 10.1016/j.comppsych.2012.03.006. Epub 2012 Apr 18.

[11] Burns, T., Rugkasa, J. et al, Community treatment orders for patients with psychosis (OCTET): a randomized controlled trail”, The Lancet, Early Online Publication, 26, March, 2013.  doi: 10.1016/S0140-6736(13)60107-5.