Involuntary out-patient commitment : 2-year follow-up {

Aims and method To evaluate the impact of involuntary out-patient commitment (OPC) in patients with severe mental disorder who use hospital services. This is a retrospective-observational study in a population of 91 patients under OPC. The psychiatric diagnosis, sociodemographic variables, who requested the court order and for what motive were studied. The study also looked at the use of the available health services (emergency room visits, admissions, average length of hospital stay) for the period beginning 2 years before and ending 2 years after the initiation of the OPC. Results The number of emergency room visits, admissions and the length of hospitalisation diminished in the 2 years following the initiation of the OPC. In terms of diagnosis, the OPC has the most impact on individuals with schizophrenia and delusional disorder. Clinical implications The OPC can be useful for certain patients with severe mental disorder, particularly individuals with schizophrenia and delusional disorder.

of Legal Psychiatrics (Sociedad Espan ˜ola de Psiquiatrı ´a Legal) are in favour of OPC, 3 the Spanish Association of Neuropsychiatry (Asociacio ´n Espan ˜ola de Neuropsiquiatrı ´a) is against it. 4Box 1 shows the main arguments for and against. 5

OPC in Spain
In Spain, there is currently no specific legislation on OPC.There have been several attempts in parliament to legislate on this matter, but ultimately they have failed for lack of agreement.The OPC is applied on a discretionary basis as interpreted by each court in charge of incapacity and guardianship.In general, the courts use the law of involuntary admission, Article 763 of the Civil Procedure Act of 2000.Out-patient commitment is seen as a less restrictive alternative to hospitalisation.
The measure can be requested in court by a physician or the patient's family, with a favourable medical report.The initial duration of OPC is 18 months, and it is renewable for an additional 18 months.Stated in the court ruling are the mental health centre that attends to the patient and the treatment provided.The responsible clinician has to submit a report to the court every 3 months on the patient's progress and on the desirability of maintaining the court's measures.Although it may be requested directly from the mental health centre, in practice most OPC applications are made during admission, as a step preceding hospital discharge.Aims and method To evaluate the impact of involuntary out-patient commitment (OPC) in patients with severe mental disorder who use hospital services.This is a retrospective-observational study in a population of 91 patients under OPC.The psychiatric diagnosis, sociodemographic variables, who requested the court order and for what motive were studied.The study also looked at the use of the available health services (emergency room visits, admissions, average length of hospital stay) for the period beginning 2 years before and ending 2 years after the initiation of the OPC.

Results
The number of emergency room visits, admissions and the length of hospitalisation diminished in the 2 years following the initiation of the OPC.In terms of diagnosis, the OPC has the most impact on individuals with schizophrenia and delusional disorder.

Clinical implications
The OPC can be useful for certain patients with severe mental disorder, particularly individuals with schizophrenia and delusional disorder.
Declaration of interest None.

Involuntary out-patient commitment: 2-year follow-up {
There are doubts in Spanish legal circles about the legality of using OPC, given that there is no specific legislation regulating its use.Attorneys who specialise in the protection of persons with disabilities and tutorship 6 consider it to be the Justice Ministry that initiates the request for an OPC, either by the modification of a patient's capacity or through the issuance of precautionary measures.Moreover, the Justice Ministry establish the minimum conditions before an OPC is to be issued.
The results that are available about the effectiveness of OPC are contradictory.Consequently, more information on this subject is needed.The aim of the present study was to determine the impact of OPC on the use of hospital services.If OPCs succeed at stabilising the medical condition of patients with severe mental illness and lower the number of relapses, their use will lead to lowering the number of emergency room visits, lowering the number of hospital admissions and shortening the length of hospital stay.

Method
This is a retrospective-observational study.The study population consisted of all the patients in the city of Valencia who have been under an OPC for at least 2 years at the initiation of the study (August 2009).Access to the population data was granted by the 13th Court of Valencia, which is in charge of internment processes and civil incapacitation.The study compared the use of healthcare services (emergency room visits, admissions and average length of hospitalisation) 2 years before and 2 years after the start of the OPC.The sociodemographic information recorded for each patient was: age, gender, civil status, residence, social and family support, work status, psychiatric diagnosis according to the DSM-IV-TR, 7 comorbidities, number of psychiatric emergencies, number of hospital admissions and average length of hospital stay.
The data come from the records of hospitals in the city of Valencia.Emergencies include psychiatric emergencies only.Admissions include all admissions, voluntary and involuntary, registered in the psychiatry services during the study period.

Ethical aspects
The study design and execution meet the requirements of the Helsinki Declaration and the ethics laws related to the medical profession.The study is free from any institutional influence and has received no external financing.

Results
The cases and percentages presented correspond to the cases and valid percentages, excluding cases without information (missing cases).Arguments for . The lack of recognition of the illness is a symptom in and of itself . Place of residence (n = 78): 63% (n = 49) lived with their family, 32% (n = 25) lived alone and 5% (n = 4) lived in medium-or long-term care centres. .Family support (n = 79): 70% of patients (n = 55) had some family support, whereas 30% (n = 24) did not. .Occupational activity (n = 43): the majority were on pensions (65%, n = 28); 28% (n = 12) were unemployed or without a pension and only 5% (n = 2) were actively employed; 2% (n = 1) were temporarily unable to work.
The most frequent Axis I diagnosis was schizophrenia (Table 1), followed by delusional disorder and bipolar disorder.
Approximately a third of the patients had a secondary diagnosis of substance misuse or dependency.In one out of three patients diagnosed with schizophrenia (n = 21) or delusional disorder (n = 3) and in a half of those with bipolar disorder (n = 5), there was a secondary diagnosis of substance use disorder.
On Axis II, the diagnosis for four patients was personality disorder not otherwise specified (personality disorder NOS); for three patients, antisocial personality disorder; for one patient, paranoid personality disorder; and one other patient, dependent personality disorder (Table 1).
In the majority of cases (78%, n = 69), the OPC request came from the in-patient unit, during the patient's stay in hospital.In the rest of the cases, the request came from the mental health centre (17%, n = 15), the family (3%, n = 3) and from the addictive behaviour community unit (1%, n = 1).In three cases we did not find this information.
The most frequent motives for requesting an OPC were frequent relapses (57% of the cases, n = 50), therapeutical non-adherence or no intention to take the treatment (23%, n = 21) and because of the appearance of violent behaviour (19%, n = 17).In three cases we did not have this information.
Tables 2-4 show the use of hospital services (number of emergencies, number of hospital admissions and average length of hospital stay for those admitted) for the 1 and 2 years before and during the initiation of the OPC.The tables also present the results for the different diagnoses.
For the total sample (n = 91), there was a significant decrease in the three variables in the first and second year of OPC, compared with the same period before the initiation of the OPC.For diagnosis, only the individuals with schizophrenia and delusional disorder had a significant decrease in the number of admissions over the 2 years after the initiation of OPC.In those with bipolar disorder, the number of admissions also fell but not significantly.The average length of stay in hospital decreased considerably in all diagnoses, except for psychotic disorder NOS.The number of emergencies also fell over the 2 years of OPC but only significantly in the cases of schizophrenia (first year) and delusional disorder (second year).

Discussion
Data on the effectiveness of OPC  1 which consider there to be no significant differences in the use of healthcare services, social functioning or quality of life between OPC and standard treatment.Nevertheless, there was a lesser probability to be the victim of crime, violent or non-violent, in patients under an OPC.
In another review about international experiences, Churchill et al 9 conclude that the efficacy measurements for OPC are inconsistent, and that there is no good evidence that it is effective at reducing the rate of hospital admittance.
In the first of two Australian studies, Ingram et al 10 state that OPC may contribute to a better quality of life for the patient not only by cutting in half the occurrence of violent behaviour 1 year after the implementation of an OPC (P50.05), but also by significantly reducing the number of homeless patients (P50.05).In the second study, Segal & Burgess 11 found that community treatment orders can prevent the use of hospital services in those patients who are at risk of prolonged psychiatric hospitalisation.
Swartz et al 12 evaluated the effectiveness of the OPC programme in New York.They found that while under OPC there is a reduction in the number of admissions and in the length of hospital stay.Furthermore, there is a reduction in the probability of being arrested.This study also evaluated the perceptions of stigma, coercion and satisfaction with treatment during the OPC and found no changes.Once the OPC was terminated, there was a sustained improvement (lower rates of hospitalisation and medication nonadherence) in those patients who received intensive treatment or whose treatment lasted for more than 6 months.Another noteworthy result is that patients who underwent a combined treatment of OPC and assertive community treatment (ACT) had a lower risk for hospitalisation than did those who received only ACT.

Study results
In the present work, and in agreement with the medical literature (Steadman et al, 8 Swanson et al, 13 Gilbert et al 14 ), we have shown that OPC is applied with greater frequency to persons who are diagnosed with schizophrenia (69%), those who have frequent relapses (57%), show violent behaviour (19%) or do not adhere to therapy (23%).Given the most frequent sociodemographic variables, it is possible to determine the profile of a person put on an OPC: usually a male, 40 years of age on average, single, on a pension and who lives with his family.This remarkable consistency among users of OPC can help when considering which patients might benefit the most from this intervention.
In the present study, there was a significant decrease in the number of emergencies (from 2.1 to 1.5), admissions (from 1.7 to 0.7) and days hospitalised (from 21.4 to 7.1) in the 2 years following the initiation of the OPC.These results are similar to the results reported in other observational studies 12,15,16 which compared different periods pre/post intervention and found a decreased use of hospital services following the initiation of the OPC.
The greatest impact of OPC was observed for the average hospital stay, with a significant decrease for all diagnoses except for psychotic disorder NOS.The decrease in the number of admissions over the 2 years of OPC was significant only for people with schizophrenia and delusional disorder, which may suggest the type of patients who may benefit the most from this type of measure.The impact of OPC on emergencies for diagnosis is less clear, since decreasing the number of emergencies is significant only for delusional disorder.
Among other factors, the possible influence of OPC at the time of discharge and the development of enhanced community services, such as home treatment teams, could have influenced the results.
Despite the methodological weakness of observational studies, we consider the information offered by the present study to be of interest, given the long observation period.8][19][20] Therefore, the OPC may benefit a group of patients with a severe mental disorder, since it assures the continuation of treatment, avoids relapses and stabilises the illness.
The application of OPC should not be a generalised measure, but should be limited to those patients with a severe mental disorder, to those in whom a lack of therapeutic adherence will lead to a severe deterioration of the illness or the appearance of violent behaviour, things which would seriously compromise the patient's ability to live in the community.
It is possible that some patients could benefit from the use of intensive follow-up programmes such as ACT.Nevertheless, Swartz et al 12 found that receiving ACT in combination with OPC reduces the risk of hospitalisation when compared with ACT alone.In conclusion, it is not a matter of one treatment replacing the other, but using them both in a complementary manner.Even though OPC may have advantages for some patients, the scientific evidence is still controversial.Therefore, new studies that offer more information about the effectiveness of OPC are required.

About the authors
Laura Castells-Aulet is a psychiatric registrar, Miguel Herna¤ ndez-Viadel is a consultant psychiatrist, Pedro Asensio-Pascual is a consultant psychiatrist and Carlos Ca•ete-Nicola¤ s is a consultant psychiatrist, all at the Psychiatry Department, University Clinic Hospital, Valencia, Spain.Carmen Bellido-Rodr|¤ guez is a forensic physician, Medical-Legal Institute of Valencia.Guillem Lera-Calatayud is a consultant psychiatrist, Psychiatry Department, La Ribera Hospital, Valencia.Roman Calabuig-Crespo is a consultant psychiatrist and chief of the Psychiatry Department, Doctor Peset University Hospital, Valencia.

.
The study population comprises 91 patients with at least 2 years of OPC; 67% (n = 61) were males and 33% (n = 30) were females.The average age was 41 years; the youngest person was 22 and the oldest 71.. Civil status (n = 53 valid cases): the majority of patients were single (81%, n = 43), 9% (n = 5) were married and 9% (n = 5) were divorced or separated.CURRENT PRACTICE Castells-Aulet et al Involuntary out-patient commitment Box 1 Principal arguments for and against out-patient commitment 4 In a Cochrane systematic review in 2008, Kisely et al 2 included the studies of Steadman et al 8 and of Swartz & Swanson,

Table 1
Diagnosis on Axes I and II (DSM-IV-TR) 7

Table 2
Number of admissions according to primary diagnoses

Table 3
Mean duration of stay according to primary diagnosis NOS, not otherwise specified; OPC, out-patient commitment.a. n = number of days.b.Mean by t-test.

Table 4
Number of emergency visits according to primary diagnoses NOS, not otherwise specified; OPC, out-patient commitment.a. Mean by t-test.