Assisted Outpatient Treatment Services and the Influence of Compulsory Treatment

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 (3–5) 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.