Outpatient commitment: When it improves patient outcomes
1 year after Virginia Tech, many states’ statutes remain ambiguous and ineffective.
Control and experimental groups showed no statistically significant differences in hospitalizations, arrests, quality of life, symptoms, homelessness, or other outcomes. The authors interpreted these findings to suggest that in this study intensive services—and not OPC court orders—reduced hospital recidivism and other poor outcomes in seriously mentally ill patients.
Study limitations. Statute implementation and OPC enforcement were haphazard, and in most cases sanctions for noncompliance—such as orders to law enforcement to detain noncompliant patients—were not put into effect. Patients and providers often did not clearly distinguish between the control and experimental groups. And finally, the study likely was too small to demonstrate a positive effect for OPC. Nevertheless, the findings suggest that OPC might provide no added benefit if persons with serious mental illnesses have access to enhanced outpatient services.4
Do OPC laws prevent violence?
The North Carolina and New York controlled studies of OPC yielded contradictory findings and are difficult to compare. Even within North Carolina—where OPC has been shown most consistently to be effective—OPC orders’ duration (the “dose”) varies widely, as do the services patients receive.
No further randomized, controlled trials of OPC are underway. Our group is participating in a study supported by the MacArthur Foundation Research Network on Mandated Community Treatment and New York State Office of Mental Health to intensively review patient outcomes under New York’s OPC statute.
Given that most states permit OPC, attempts to standardize and implement OPC are needed. To make OPC effective, evidence indicates that states also must provide intensive community services to keep patients in treatment.
Strategies for using OPC
OPC is controversial in society and among clinicians. Some mental health organizations oppose outpatient commitment orders as coercive and intrusive, and some mental health professionals have concerns about legal or malpractice liability, increased paperwork, and administrative burden. Others may view OPC as:
- ineffective —providing weak sanctions that are impractical to enforce
- detrimental to the therapeutic alliance
- a less-desirable substitute for making high-quality voluntary treatment more widely available for the seriously mentally ill.
Select appropriate candidates. Our group’s experience suggests that patients with severe mental illness—especially schizophrenia spectrum disorders—are those most likely to benefit from OPC. There is no evidence that outpatient commitment helps patients with personality disorders or substance abuse without comorbid severe mental illness.
Maximize effectiveness. Evidence from the North Carolina studies suggests keeping OPC in place for ≥6 months and providing relatively intensive outpatient services. For schizophrenia-spectrum patients, combining OPC with depot antipsychotics may be more effective than oral agents for ensuring adherence and improving function.19
Decide when to terminate. OPC orders probably should last at least 6 months, but little evidence exists to guide discontinuing an order after 6 months. This dilemma is similar to deciding when a depot antipsychotic can or should be converted to an oral agent in previously nonadherent patients.
Our approach is to consider terminating the order in patients with restored insight who have ≥6 months of consistent treatment compliance without a need for or threat of OPC enforcement. In some cases, other leverage may preempt the need for continuing an order, such as:
