The utility of outpatient civil commitment: Investigating the evidence

Int J Law Psychiatry. May-Jun 2020;70:101565. doi: 10.1016/j.ijlp.2020.101565. Epub 2020 May 23.


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.

Publication types

  • Research Support, N.I.H., Extramural
  • Review

MeSH terms

  • Ambulatory Care / legislation & jurisprudence*
  • Case Management
  • Commitment of Mentally Ill / legislation & jurisprudence*
  • Community Mental Health Services / legislation & jurisprudence*
  • Crime Victims
  • Harm Reduction
  • Hospitalization
  • Humans
  • Length of Stay
  • Medication Adherence
  • Outcome Assessment, Health Care*
  • Patient Readmission
  • Violence