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Cited by 17Healthcare Decision-Making and RestraintsPsychiatric care and mental health servicesPsychopathy, Forensic Psychiatry, Sexual Offending

The utility of outpatient civil commitment: Investigating the evidence

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Segal, Steven P.·2020·International Journal of Law and Psychiatry
DOI 10.1016/j.ijlp.2020.101565PMC PMC7394121
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Abstract

Background Outpatient civil commitment (OCC), community treatment orders (CTOs) in European and Commonwealth nations, require the provision of needed-treatment to protect against imminent threats to health and safety. OCC-reviews aggregating all studies report inconsistent outcomes. This review, searches for consistency in OCC-outcomes by evaluating studies based on mental health system characteristics, measurement, and design principles. Methods All previously reviewed OCC-studies and more recent investigations were grouped by their outcome-measures' relationship to OCC statute objectives. A study's evidence-quality ranking was assessed. Hospital and service-utilization outcomes were grouped by whether they represented treatment provision, patient outcome, or the conflation of both. Results OCC-studies including direct health and safety outcomes found OCC associated with reduced mortality-risk, increased access to acute medical care, and reduced violence and victimization risks. Studies considering treatment-provision, found OCC associated with improved medication and service compliance. If coupled with assertive community treatment (ACT) or aggressive case management OCC was associated with enhanced ACT success in reducing hospitalization need. When outpatient-services were limited, OCC facilitated rapid return to hospital for needed-treatment and increased hospital utilization in the absence of a less restrictive alternative. OCC-studies measuring "total hospital days", "prevention of hospitalization", and "readmissions" report negative and/or no difference findings because they erroneously conflate their intervention (provision of needed treatment) and outcome. Conclusions This investigation finds replicated beneficial associations between OCC and direct measures of imminent harm indicating reductions in threats to health and safety. It also finds support for OCC as a less restrictive alternative to inpatient care.

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  • Mortality was significantly lower in the community treatment order group in 3 out of 5 studies.

    “Mortality was significantly lower in the CTO group in 3 out of 5 studies.”

    From The benefits and harms of community treatment orders for people diagnosed with psychiatric illnesses: A rapid umbrella review of systematic reviews and meta-analyses (2024) · cites this paper as Segal (2020)

    The Results section, under “Mortality (Table II.A.1–5)” (page unavailable), identifies five studies and says three case-controlled studies found an association between outpatient civil commitment and reduced all-cause mortality risk. It does not state that those three reductions were statistically significant; it explicitly reports no significant difference in a fourth study and more deaths in the non-commitment group in the fifth. (LLM, conf=0.82)

    Experimental — accuracy not yet measured

  • Two systematic reviews reported that mortality rates were significantly lower in the community treatment order group compared with controls, based on data from one Western Australian and two Victorian studies.

    “Two SRs (Kisely et al., 2021; Segal, 2020) reported that mortality rates were significantly lower in the CTO group compared with controls based on data from one Western Australian (WA) and two Victorian studies”

    From The benefits and harms of community treatment orders for people diagnosed with psychiatric illnesses: A rapid umbrella review of systematic reviews and meta-analyses (2024) · cites this paper as Segal, 2020

    The Results (Mortality, Table II.A.1–3; page unavailable) report that three case-control studies found outpatient commitment associated with reduced all-cause mortality risk compared with non-committed patients. The Discussion identifies two of those studies as Victorian. Our copy does not identify the third mortality study as Western Australian or explicitly say that the reductions in all three studies were statistically significant. (LLM, conf=0.83)

    Experimental — accuracy not yet measured

  • There were non-significant mortality findings in two other studies, one unpublished, in the second systematic review.

    “However, there were non-significant findings in two other studies (one unpublished) in the second SR”

    From The benefits and harms of community treatment orders for people diagnosed with psychiatric illnesses: A rapid umbrella review of systematic reviews and meta-analyses (2024) · cites this paper as Segal, 2020

    The Results section, under “Mortality (Table II.A.1–5),” reports no significant difference between groups for one study, Pollak et al. (2005). It says a fifth study, Power (1992), found more deaths in the non-OCC group, but does not state that this finding was non-significant. The Methods say unpublished studies were eligible, but do not identify either mortality study as unpublished. (LLM, conf=0.82)

    Experimental — accuracy not yet measured

  • A third systematic review reported that people who were discharged to a treatment order immediately following their initial psychiatric admission had better outcomes than those placed on community treatment orders later in treatment.

    “a third SR reported that people who were discharged to a treatment order immediately following their initial psychiatric admission had better outcomes than those placed on CTOs later in treatment”

    From The benefits and harms of community treatment orders for people diagnosed with psychiatric illnesses: A rapid umbrella review of systematic reviews and meta-analyses (2024) · cites this paper as Segal, 2020

    The Results section, under “Early-Intervention-OCCs” (Table IV.D.1; page unavailable), reports lower subsequent hospital use among patients on outpatient commitment who experienced their first hospitalization during a ten-year period. It does not establish that they were discharged to an order immediately after their initial psychiatric admission or explicitly compare their outcomes with patients placed on orders later in treatment; it also notes that the group had more community supports. (LLM, conf=0.82)

    Experimental — accuracy not yet measured

  • Greater benefit from prolonged community treatment order placement seems inconsistent with other work where people who were discharged to a treatment order immediately following their initial psychiatric admission had better outcomes than later placement.

    “Finally, greater benefit from prolonged CTO placement seems inconsistent with other work where people who were discharged to a treatment order immediately following their initial psychiatric admission had better outcomes than later placement”

    From The benefits and harms of community treatment orders for people diagnosed with psychiatric illnesses: A rapid umbrella review of systematic reviews and meta-analyses (2024) · cites this paper as Segal, 2020

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Authors
Segal, S. P.
Affiliations
The University of Melbourne (AU)
Corresponding author
Segal, Steven P.
ORCID
Segal, Steven P.
Venue
International Journal of Law and Psychiatry
Publisher
Elsevier BV
Published
2020-05
Volume
70
Pages
101565
ISSN
0160-2527 (ISSN-L)
DOI
10.1016/j.ijlp.2020.101565
PMC
PMC7394121
OpenAlex
W3028169117
Cited by
17
References
7
Citations by year
2026: 3 · 2025: 4 · 2024: 4 · 2022: 3 · 2021: 2 · 2020: 1
FWCI
0.12
Type
journal article
Language
en
Open access
Licence
Locations
  • International Journal of Law and Psychiatry (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
  • eScholarship (California Digital Library) (submittedVersion)
Funders
National Institutes of Health
Topics
  • Social Sciences › Psychology › Clinical Psychology › Healthcare Decision-Making and Restraints
  • Social Sciences › Psychology › Clinical Psychology › Psychiatric care and mental health services
  • Social Sciences › Psychology › Clinical Psychology › Psychopathy, Forensic Psychiatry, Sexual Offending
Keywords
community treatment orders, mental health law, assertive community treatment, hospitalization, hospital readmission, medication adherence, service utilization, less restrictive alternatives, quality of evidence, outcome measurement
MeSH terms
Ambulatory Care, Commitment of Persons with Psychiatric Disorders, Community Mental Health Services, Hospitalization, Humans, Length of Stay, Patient Readmission, Violence, Outcome Assessment, Health Care, Case Management, Crime Victims, Harm Reduction, Medication Adherence

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