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Letters to the Editor   |    
Assisted Outpatient Treatment Services and the Influence of Compulsory Treatment
Tom Burns, F.R.C.Psych.
Am J Psychiatry 2014;171:228. doi:10.1176/appi.ajp.2013.13091223
View Author and Article Information

The author reports no financial relationships with commercial interests.

From the Department of Psychiatry, Oxford University, Oxford, U.K.

Copyright © 2014 by the American Psychiatric Association

Accepted November , 2013.

To the Editor: The article by Swanson et al. (1) in the December 2013 issue reports reduced inpatient care and costs with the New York assisted outpatient treatment program. Assisted outpatient treatment comprises two distinct components: enhanced multidisciplinary community outreach service and court-ordered compulsion to comply with treatment. Unfortunately, the article fails to adequately distinguish these two components or set either of them in their full research context. The result is that many readers will draw the wrong conclusions.

Coordinated multidisciplinary mental health care with outreach to psychotic patients has been researched thoroughly for over 3 decades, repeatedly demonstrating reduced rates of relapse and hospital readmissions (2). In this respect, the reported results are good news for severely ill New Yorkers but no news for those familiar with the literature.

Swanson et al. comment that opposition to assisted outpatient treatment arises from a range of consumer advocates and stakeholder resistance, omitting the resistance stemming from the absence of convincing evidence for their effectiveness. None of the three published randomized controlled trials of compulsory community treatment (35) found an advantage in their stated primary outcome of reduced readmissions. In addition, there are nearly a dozen controlled before and after studies (6) of the form. These are predominantly drawn from two large databases: New York, with 3,576 individuals in assisted outpatient treatment and 2,025 matched comparison subjects (7), and Victoria, Australia, with 8,879 individuals in assisted outpatient treatment (community treatment order) and 16,694 matched comparison subjects (8). Australian practice does not actively privilege intensive treatment for individuals in assisted outpatient treatment, and their findings are the opposite of those in New York. The Australian assisted treatment was associated with significantly increased admissions.

International findings support the authors’ conclusions that reductions in hospital admissions need well-funded and coordinated community services. However, the findings also currently indicate that coercion itself does nothing to reduce readmissions, and this study does not alter that conclusion.

Swanson  JW;  Van Dorn  RA;  Swartz  MS;  Robbins  PC;  Steadman  HJ;  McGuire  TG;  Monahan  J:  The cost of assisted outpatient treatment: can it save states money? Am J Psychiatry 2013; 170:1423–1432
[CrossRef] | [PubMed]
 
Burns  T;  Catty  J;  Dash  M;  Roberts  C;  Lockwood  A;  Marshall  M:  Use of intensive case management to reduce time in hospital in people with severe mental illness: systematic review and meta-regression.  BMJ 2007; 335:336
[CrossRef] | [PubMed]
 
Steadman  HJ;  Gounis  K;  Dennis  D;  Hopper  K;  Roche  B;  Swartz  M;  Robbins  PC:  Assessing the New York City involuntary outpatient commitment pilot program.  Psychiatr Serv 2001; 52:330–336
[CrossRef] | [PubMed]
 
Swartz  MS;  Swanson  JW;  Wagner  HR;  Burns  BJ;  Hiday  VA;  Borum  R:  Can involuntary outpatient commitment reduce hospital recidivism? findings from a randomized trial with severely mentally ill individuals.  Am J Psychiatry 1999; 156:1968–1975
[PubMed]
 
Burns  T;  Rugkåsa  J;  Molodynski  A;  Dawson  J;  Yeeles  K;  Vazquez-Montes  M;  Voysey  M;  Sinclair  J;  Priebe  S:  Community treatment orders for patients with psychosis (OCTET): a randomized controlled trial.  Lancet 2013; 381:1627–1633
[CrossRef] | [PubMed]
 
Maughan  D;  Molodynski  A;  Rugkasa  J;  Burns  T:  A systematic review of the effect of community treatment orders on service use.  Soc Psychiatry Psychiatr Epidemiol  (Epub ahead of print, Oct 18, 2013)
 
Swartz  MS;  Wilder  CM;  Swanson  JW;  Van Dorn  RA;  Robbins  PC;  Steadman  HJ;  Moser  LL;  Gilbert  AR;  Monahan  J:  Assessing outcomes for consumers in New York’s assisted outpatient treatment program.  Psychiatr Serv 2010; 61:976–981
[CrossRef] | [PubMed]
 
Segal  SP;  Burgess  PM:  Conditional release: a less restrictive alternative to hospitalization? Psychiatr Serv 2006; 57:1600–1606
[CrossRef] | [PubMed]
 
References Container
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References

Swanson  JW;  Van Dorn  RA;  Swartz  MS;  Robbins  PC;  Steadman  HJ;  McGuire  TG;  Monahan  J:  The cost of assisted outpatient treatment: can it save states money? Am J Psychiatry 2013; 170:1423–1432
[CrossRef] | [PubMed]
 
Burns  T;  Catty  J;  Dash  M;  Roberts  C;  Lockwood  A;  Marshall  M:  Use of intensive case management to reduce time in hospital in people with severe mental illness: systematic review and meta-regression.  BMJ 2007; 335:336
[CrossRef] | [PubMed]
 
Steadman  HJ;  Gounis  K;  Dennis  D;  Hopper  K;  Roche  B;  Swartz  M;  Robbins  PC:  Assessing the New York City involuntary outpatient commitment pilot program.  Psychiatr Serv 2001; 52:330–336
[CrossRef] | [PubMed]
 
Swartz  MS;  Swanson  JW;  Wagner  HR;  Burns  BJ;  Hiday  VA;  Borum  R:  Can involuntary outpatient commitment reduce hospital recidivism? findings from a randomized trial with severely mentally ill individuals.  Am J Psychiatry 1999; 156:1968–1975
[PubMed]
 
Burns  T;  Rugkåsa  J;  Molodynski  A;  Dawson  J;  Yeeles  K;  Vazquez-Montes  M;  Voysey  M;  Sinclair  J;  Priebe  S:  Community treatment orders for patients with psychosis (OCTET): a randomized controlled trial.  Lancet 2013; 381:1627–1633
[CrossRef] | [PubMed]
 
Maughan  D;  Molodynski  A;  Rugkasa  J;  Burns  T:  A systematic review of the effect of community treatment orders on service use.  Soc Psychiatry Psychiatr Epidemiol  (Epub ahead of print, Oct 18, 2013)
 
Swartz  MS;  Wilder  CM;  Swanson  JW;  Van Dorn  RA;  Robbins  PC;  Steadman  HJ;  Moser  LL;  Gilbert  AR;  Monahan  J:  Assessing outcomes for consumers in New York’s assisted outpatient treatment program.  Psychiatr Serv 2010; 61:976–981
[CrossRef] | [PubMed]
 
Segal  SP;  Burgess  PM:  Conditional release: a less restrictive alternative to hospitalization? Psychiatr Serv 2006; 57:1600–1606
[CrossRef] | [PubMed]
 
References Container
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