title: Compulsory community and involuntary outpatient treatment for people with severe mental disorders.
abstract: BACKGROUND
  There is controversy as to whether compulsory community treatment for people with severe mental illnesses reduces health service use, or improves clinical outcome and social functioning. Given the widespread use of such powers it is important to assess the effects of this type of legislation.
  
  
  OBJECTIVE
  To examine the clinical and cost effectiveness of compulsory community treatment for people with severe mental illness.
  
  
  METHODS
  We undertook searches of the Cochrane Schizophrenia Group Register 2003, 2008, and Science Citation Index. We obtained all references of identified studies and contacted authors of each included study.
  
  
  METHODS
  All relevant randomised controlled clinical trials of compulsory community treatment compared with standard care for people with severe mental illness.
  
  
  METHODS
  We reliably selected and quality assessed studies and extracted data. For binary outcomes, we calculated a fixed effects risk ratio (RR), its 95% confidence interval (CI) and, where possible, the weighted number needed to treat/harm statistic (NNT/H).
  
  
  RESULTS
  We identified two randomised clinical trials (total n = 416) of court-ordered 'Outpatient Commitment' (OPC) from the USA. We found little evidence that compulsory community treatment was effective in any of the main outcome indices: health service use (2 RCTs, n = 416, RR for readmission to hospital by 11-12 months 0.98 CI 0.79 to 1.2); social functioning (2 RCTs, n = 416, RR for arrested at least once by 11-12 months 0.97 CI 0.62 to 1.52); mental state; quality of life (2 RCTs, n = 416, RR for homelessness 0.67 CI 0.39 to 1.15) or satisfaction with care (2 RCTs, n = 416, RR for perceived coercion 1.36 CI 0.97 to 1.89). However, risk of victimisation may decrease with OPC (1 RCT, n = 264, RR 0.5 CI 0.31 to 0.8). In terms of numbers needed to treat (NNT), it would take 85 OPC orders to prevent one readmission, 27 to prevent one episode of homelessness and 238 to prevent one arrest. The NNT for the reduction of victimisation was lower at six (CI 6 to 6.5). A new search for trials in 2008 did not find any new trials that were relevant to this review.
  
  
  CONCLUSIONS
  Compulsory community treatment results in no significant difference in service use, social functioning or quality of life compared with standard care. People receiving compulsory community treatment were, however, less likely to be victims of violent or non-violent crime. It is unclear whether this benefit is due to the intensity of treatment or its compulsory nature. Evaluation of a wide range of outcomes should be considered when this type of legislation is introduced.
authors.affiliation: The University of Queensland, Queensland Centre for Health Data Services, Room 518(A) McGregor Building (No 64), Brisbane, Queensland, Australia, Qld 4072.
authors.forename: Steve R
authors.initials: SR
authors.lastname: Kisely
authors.forename: Leslie Anne
authors.initials: LA
authors.lastname: Campbell
authors.forename: Neil J
authors.initials: NJ
authors.lastname: Preston
mesh_terms: D000553:Ambulatory Care / Q000592:standards / Q000706:statistics & numerical data; D003134:Commitment of Persons with Psychiatric Disorders / Q000331:legislation & jurisprudence*; D003156:Community Mental Health Services / Q000331:legislation & jurisprudence; D019548:Crime Victims; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D001523:Mental Disorders / Q000628:therapy*; D017060:Patient Satisfaction; D016032:Randomized Controlled Trials as Topic; D016896:Treatment Outcome