Randomized and non-randomized evidence for the effect of compulsory community and involuntary out-patient treatment on health service use: systematic review and meta-analysis.
BACKGROUND
There is limited randomized controlled trial (RCT) evidence for compulsory community treatment. Other study methods may clarify their effectiveness. We reviewed RCT and non-RCT evidence for the effect of compulsory community treatment on hospital admissions, bed-days, compliance and out-patient contacts.


METHODS
A systematic review of RCTs, controlled before-and-after (CBA) studies, and interrupted time series (ITS) analyses. Meta-analysis of RCTs.


RESULTS
Eight papers covering five studies (two RCTs and three CBAs) met inclusion criteria (total n=1108). There was no statistical difference in 12-month admission rates between subjects on involuntary out-patient treatment and controls. Survival analyses of time to admission were equivocal. All five studies reported decreases in the number of bed-days following involuntary out-patient treatment but this only reached statistical significance in one situation; patients receiving the intervention were less likely to have admissions of over 100 days. There was no difference in treatment adherence between the intervention and control groups in either RCT or two of the CBA studies. However, the third CBA study reported a statistically significant increase of nearly five visits in the mean number of overall contacts in the involuntary out-patient treatment group.


CONCLUSIONS
The evidence for involuntary out-patient treatment in reducing either admissions or bed-days is very limited. It therefore cannot be seen as a less restrictive alternative to admission. Other effects are uncertain. Evaluation of a wide range of outcomes should be included if this type of legislation is introduced.
Kisely
Stephen
S
Department of Psychiatry, Dalhousie University, Canada.
Campbell
Leslie Anne
LA
Scott
Anita
A
Preston
Neil J
NJ
Xiao
Jianguo
J
D000553:Ambulatory Care / Q000592:standards* / Q000706:statistics & numerical data; D003134:Commitment of Persons with Psychiatric Disorders / Q000331:legislation & jurisprudence* / Q000592:standards / Q000706:statistics & numerical data; D003156:Community Mental Health Services / Q000331:legislation & jurisprudence* / Q000592:standards / Q000706:statistics & numerical data; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data*; D001523:Mental Disorders / Q000628:therapy*; D016032:Randomized Controlled Trials as Topic; D016896:Treatment Outcome