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Impact of involuntary out-patient commitment on reducing hospital services: 2-year follow-up

  • Laura Castells-Aulet (a1), Miguel Hernández-Viadel (a2), Jesús Jiménez-Martos (a2), Carlos Cañete-Nicolás (a2), Carmen Bellido-Rodríguez (a3), Roman Calabuig-Crespo (a4), Pedro Asensio-Pascual (a5) and Guillem Lera-Calatayud (a6)...
Abstract
Aims and method

To evaluate whether involuntary out-patient commitment (OPC) in patients with severe mental disorder reduces their use of hospital services. This is a retrospective case-control study comparing a group of patients on OPC (n = 75) and a control group (n = 75) which was composed of patients whose sociodemographic variables and clinical characteristics were similar to those of the OPC group. Each control case is paired with an OPC case, so the control case must have an involuntary admission in the month that the index OPC case admission occurred. Emergency room visits, admissions and average length of hospital stay over a 2-year follow-up after the initiation of OPC were compared.

Results

No statistically significant evidence was found in the use of mental healthcare services between the two groups. Different reasons for admission found between the groups limit similarity when comparing the two.

Clinical implications

The findings cast doubt over the effectiveness of this legal measure to reduce emergency visits, the number of admissions and the length of stay in the hospital.

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Copyright
This is an open-access article published by the Royal College of Psychiatrists and distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
Correspondence to Laura Castells Aulet (lcastells@hospitalbenitomenni.org)
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Declaration of interest

None.

Footnotes
References
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Impact of involuntary out-patient commitment on reducing hospital services: 2-year follow-up

  • Laura Castells-Aulet (a1), Miguel Hernández-Viadel (a2), Jesús Jiménez-Martos (a2), Carlos Cañete-Nicolás (a2), Carmen Bellido-Rodríguez (a3), Roman Calabuig-Crespo (a4), Pedro Asensio-Pascual (a5) and Guillem Lera-Calatayud (a6)...
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Author reply: Naturalistic studies evaluating "real world" OPC patients are welcome

Laura Castells, Psychiatrist
15 February 2015

There is a lack of scientific evidence evaluating the efficacy of OPC [out-patient commitment] (1) and doubt around whether randomised controlled trials are realistically the best method of evaluating the impact of OPC (2). Our work is a retrospective case-control study with its limitations and we welcome any contribution that could offer us some improvement for further studies.Responding to the issues raised by Dr Mustafa I would like to comment:

Firstly, we had considered in our study that there were differences in the motives for index admissions between the groups. In the OPC group the main reason was clinical decompensation due to non-adherence to treatment (78%) and aggressive behaviour (22%). In the control group, admission occurred mainly due to clinical decompensation without a clear non-adherence to treatment (47%); these reasons were: inconsistent use of medication, changes in the pharmacological pattern or substance misuse (3). This could undermine the similarity of the two study groups and, therefore, the suitability for comparison.

Secondly, due to the nature of the study, a retrospective case-control, patients eligible for the control group were automatically excluded if within the subsequent two years of the study they started to undergo OPC.

Thirdly, we agree there is a trend of reduced hospitalisation over the 4 year period study in both groups. This may have been driven by factors such as the improvement of community services or home services that could potentially confound the results of this study.

References:1.Kisely S and Campbell LA. Does compulsory or supervised community treatment reduce "revolving door" care? Legislation is inconsistent with recent evidence. Br J Psychiatry 2007; 191: 373-374.

2.Swanson JW, Swartz MS. Why the evidence for outpatient commitment is good enough. Psychiatr Serv. 2014; 65: 808-11.

3.Castells-Aulet L, Hernandez-Viadel M, Jimenez-Martos J, Canete-Nicolas C, Bellido-Rodriguez C, Calabuig-Crespo R, Asensio-Pascual P and Lera-Calatayud G. Impact of involuntary out-patient commitment on reducing hospital services: 2 year follow-up. Psyciatric Bulletin 2014; 38: 1-4
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Conflict of interest: None declared

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Naturalistic studies evaluating "real world" OPC patients are welcome

Feras A. Mustafa, Psychiatrist
19 January 2015

Debate ensues as to whether randomised controlled trials are realistically the best method of evaluating the impact of out-patient commitment (OPC) on hospitalisation (1). Even a large and well-funded prospective randomised controlled study such as the OCTET (2) has been demonstrated to be potentially fundamentally flawed (3).

In this context, naturalistic studies evaluating "real world" patients, like the one reported by Castells-Aulet et al (4) are welcome and potentially useful. However, I would like to point out three issues that the authors may wish to respond to.

Firstly, given that both controls and OPC patients had their index admissions within the same month; one could reasonably assume that the treating physicians must have had clinical grounds for choosing to place only patients forming the latter group on OPC. Those physicians may have drawn on their knowledge of individual patients (which is not necessarily reflected by the general characteristics described in the study) in reaching their decisions. For instance, the treatment adherence status prior to the index admission (which remarkably differs between the two groups) may have probably been used, understandably, as an indication of the suitability of patients for the OPC. Hence, one could justifiably doubt the similarity of the two groups, undermining any conclusions that could be drawn from the results.

Secondly, there potentially could have been another detrimental selection bias in the control group. Patients who were initially discharged informally, but were subsequently readmitted within the following two years and then discharged again on an OPC, would have been automatically excluded from the control group, which eventually comprised only patients who even when re-hospitalised, were not considered by their physicians as requiring OPC, and thus introducing a type II error.

Thirdly, the authors fail to elaborate on the apparent general trend of reduced hospitalisation over the 4 year period, which may have been driven by factors that could potentially confound the results of this study.

References:

1. Swanson JW, Swartz MS. Why the evidence for outpatient commitment is good enough. Psychiatr Serv. 2014; 65: 808-11.

2. Burns T, Rugkasa J, Molodynski A, Dawson J, Yeeles K, Vazquez-Montes M, et al. Community treatment orders for patients with psychosis (OCTET): a randomised controlled trial. Lancet 2013; 381: 1627-33.



3. Mustafa FA. On the OCTET and supervised community treatment orders. Med Sci Law 2014; 54: 116-7.

4. Castells-Aulet L, Hernandez-Viadel M, Jimenez-Martos J, Canete-Nicolas C, Bellido-Rodriguez C, Calabuig-Crespo R, et al. Impact of involuntary out-patient commitment on reducing hospital service: 2-year follow-up. Psychiatr Bull. 2014 [epub ahead of print] 0: pb.bp.114.047464v1

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Conflict of interest: None declared

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