Is Voluntary Bipolar Treatment as Effective as Outpatient Commitment?

Severe mental illness (SMI), which usually occurs in patients with bipolar disorder and schizophrenia, is debilitating and costly to society. These patients often become homeless, destitute, or involved with the legal system.

Outpatient commitment, or compulsory community treatment (CCT), consists of court-ordered involuntary treatment for patients diagnosed with SMI. When the court orders CCT, patients may need to take medication as directed or under direct supervision and participate in care designed to improve their symptoms. Most states allow CCT for the purpose of reducing institutionalization and incarceration in this patient demographic.

The success of CCT depends on a number of factors, not the least of which is adequate state funding for the program. To date, few studies have examined whether CCT meets its goals of improved clinical outcomes, better social functioning, and reduced health service use.

The advance access issue of Schizophrenia Bulletin included a review of relevant randomized controlled clinical trials that compared CCT with voluntary community treatment or supervised discharge for patients with SMI. The researchers included trials with a total of 752 patients in the meta-analysis.

CCT was no more likely to result in better health service use, social functioning, mental state, or quality of life compared with either standard voluntary or supervised care. Additionally, similar numbers of patients were readmitted to the hospital, became homeless, got arrested, and felt satisfied with care. Translated into numbers-needed-to-treat, it would take 27 CCT orders to prevent 1 episode of homelessness, 85 to prevent 1 readmission, and 238 to prevent 1 arrest.

One finding on CCT was quite positive. Patients receiving CCT were half as likely to be victims of crime as those receiving voluntary care. However, the researchers could not determine whether this finding was linked to treatment intensity or the fact that it was compulsory.

These data suggest that further research is needed to develop definitive conclusions about CCT. Perhaps, these programs just need more funding or better structures. However, the study also suggests that heightened awareness and attention to adherence issues could be just as effective as CCT.