Services Effectiveness Research Program, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
Department of Mental Health Law and Policy, Florida Mental Health Institute, University of South Florida, Tampa, FL
Department of Sociology, North Carolina State University, Raleigh, NC, USA
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See editorial pp.
307311, this issue.
Correspondence: Jeffrey Swanson, Assistant Professor in Psychiatry and Behavioral Sciences, Duke University Medical Center, Box 3071, Brightleaf Square Suite 23-A, Durham, NC 27710, USA. Tel: (919) 682 4827; Fax: (919) 682 1907; e-mail: Jeffrey.Swanson{at}Duke.edu
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ABSTRACT |
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Aims To test whether involuntary out-patient commitment (OPC) may help to reduce the incidence of violence among persons with SMI.
Method One-year randomised trial of the effectiveness of OPC in 262 subjects with psychotic or major mood disorders and a history of hospital recidivism. Involuntarily hospitalised subjects awaiting OPC were randomly assigned to release or court-ordered treatment after discharge. Those with a recent history of serious assault remained under OPC until expiry of the court order (up to 90 days); then OPC orders were renewed at clinical/court discretion. Control subjects had no OPC. Four-monthly follow-up interviews with subject, case manager and collateral informant took place and service records were collected.
Results A significantly lower incidence of violent behaviour
occurred in subjects with 6 months' OPC. Lowest risk of violence was
associated with extended OPC combined with regular out-patient services,
adherence to prescribed medications and no substance misuse.
Conclusions OPC may significantly reduce risk of violent behaviour in persons with SMI, in part by improving adherence to medications while diminishing substance misuse.
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INTRODUCTION |
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Background
Serious violent acts committed by individuals with mental illnesses are
statistically rare events (Monahan,
1992). Still, the potential for violence in a proportion of
persons with severe, persistent and often untreated psychiatric disorders
stimulates public fear, prevents general acceptance and inclusion of persons
with psychiatric disabilities and limits normalisation and effectiveness of
community-based mental health services. The risk of violence creates dilemmas
in the clinical realm by interrupting community tenure and continuity of care,
in the legal realm by increasing concerns about professional liability, and in
the public realm by heightening fear and stigma associated with mental illness
(Link et al, 1987;
Angermeyer & Matschinger,
1996; Borum et al,
1996; Simon,
1998).
With the advent of managed care in both public and private mental health systems, and with clinicians increasingly held liable for the behaviour of patients inadequately treated, concerns about the risk of violence have increased (Cuffel, 1997; Simon, 1998). Individuals suffering from SMI with a history of violence are disproportionately high users of the most expensive mental health services in the most restrictive settings (e.g. involuntary in-patient treatment) (Borum et al, 1996). However, clinicians' efforts to prevent violence through conventional out-patient treatment are impeded: patients at risk often do not adhere to medication regimens or keep scheduled appointments, they may misuse substances and they tend to live in impoverished, dangerous environments with inadequate social support (Swartz et al, 1998b; Silver et al, 1999). Some studies have reported increased violent behaviour among mentally ill persons suffering from psychotic symptoms that involve perceived threat and override of internal cognitive controls (threat/control-override: TCO) (Link et al, 1998), and particularly among those with TCO symptoms and substance misuse who have not had recent contact with a community mental health provider (Swanson et al, 1997a).
Involuntary OPC is a promising legal intervention that may significantly reduce violent behaviour associated with these particular problems by improving compliance with medications that mitigate high-risk psychotic symptoms; by improving access to substance misuse treatment for persons with dual diagnoses; by increasing clinical surveillance; and by augmenting case management intensity, thus leveraging scarce resources in community care systems (Swanson et al, 1997b).
Out-patient commitment statutes exist in 35 states and the District of Columbia (Torrey & Kaplan, 1995). In North Carolina, where the present study was conducted, OPC statutes require compliance with recommended treatment, excluding forced medication in the out-patient setting. Under OPC, the responsible clinician may request that law officers escort the non-adherent patient to a community mental health centre for examination and hopeful persuasion to accept treatment. Evidence from naturalistic studies (Fernandez & Nygard, 1990; Geller et al, 1998), as well as the current randomised study (Swartz et al, 1999), suggests that OPC may decrease hospital readmission rates and total days hospitalised. However, OPC is strongly opposed by some mental health consumers and mental health law advocates, who argue that coerced out-patient treatment infringes on civil liberties, extends unwarranted social control into the community and may actually drive people away from needed treatment (Mulvey et al, 1987; Stefan, 1987).
The potential of OPC to prevent violent behaviour warrants empirical investigation. The present study addresses the question of whether and how OPC reduces the risk of violence among people with SMI, using prospective longitudinal data from a sample of 262 people with psychotic or major mood disorders who were placed on OPC combined with case management in the Piedmont region of North Carolina.
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METHOD |
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Study group assignment
By special arrangement with the court, subjects randomly assigned to a
control group were released from OPC. Subjects in the experimental group, by
law, received an initial period of OPC no longer than 90 days. Thereafter, the
commitment order could be renewed for up to 180 days if a psychiatrist and the
court determined that the subject continued to meet the legal criteria for
OPC. However, subjects in the control group received immunity from any OPC
during the year of the study. All subjects received case management and other
out-patient treatment at one of four participating area mental health
programmes representing nine contiguous urban and rural counties. An exception
to the randomisation procedure was necessary in the case of subjects with a
history of serious assault involving weapon use or physical injury to another
person within the preceding year. These subjects (the seriously violent group)
were required to undergo at least the initial period of OPC as ordered.
Renewals were left to the discretion of the clinician and court.
Refusal, attrition, and differences in length of time on OPC
Of the identified eligible patients, 12% refused consent to participate.
Rates of refusal did not vary significantly by gender, race or diagnosis.
Subjects over age 45 years were more likely to refuse than those under 45
years (14% v. 7%). The baseline sample consisted of 331 subjects. At
the 12-month follow-up, 69 subjects (20.9%) had withdrawn or were lost to
follow-up, with 262 remaining: 114 controls, 102 in the OPC group and 46 in
the OPC violent group. Attrition did not differ significantly by group. There
was no evidence of sample bias in renewal of OPC orders, except that subjects
with a baseline history of medication non-compliance were somewhat more likely
to receive extended OPC (renewed court orders); 40.0% v. 18.75%. (The
potential implications of this difference for interpretation of the results
will be discussed below.) Approximately one-third of subjects in both the OPC
and violent OPC groups received overall more than 180 days of court-ordered
treatment.
Data collection
At baseline, structured interviews were conducted with each subject and
with a family member or other informant who knew the respondent well. Hospital
records were reviewed for additional information regarding clinical history.
Follow-up interviews were conducted every four months with the subjects, case
manager and collateral informant. Out-patient service records and hospital
admissions were recorded as well.
Measurement
Violence
Incidence of violence was assessed from three data sources. Subjects were
asked every four months whether they had been picked up by police or arrested
for physical assault on another person, had been in fights involving physical
contact or had threatened someone with a weapon. Family members and case
managers were asked comparable questions about the subject's behaviour. A
composite index was constructed measuring whether at least one violent act was
reported by any source during the year of the study
(Swanson et al,
1999).
Psychiatric symptoms
Psychiatric symptoms were assessed using the Brief Symptom Inventory (BSI;
Derogatis & Melisaratos,
1983). The BSI total score and a sub-scale for paranoid symptoms
were used in the present analysis. An additional sub-scale was constructed
from BSI items measuring TCO symptoms
(Link et al,
1998).
Functional impairment
Functional impairment was assessed using the Global Assessment of
Functioning scale (GAF), which is a measure of functional status and severity
of psychiatric disturbance rated on a continuum of 0-100 from most to least
impaired (Endicott et al,
1976).
Insight
Insight was measured by the Insight and Treatment Attitudes Questionnaire
(ITAQ; McEvoy et al,
1989). The ITAQ assesses the ability of subjects with SMI to
recognise their need for treatment.
Social support
Social support was assessed using a sub-scale of the Duke Social Support
Scale (George et al,
1989), measuring respondents' subjective perception of their
status and value in a social network, whether the network would provide help
if needed and satisfaction with the quantity and quality of received
support.
Substance use and misuse
Substance use and misuse were assessed by combining interview data from
three sources and (at baseline) the hospital record. Substance use was defined
as drinking alcohol or using illicit drugs once to several times per month or
more frequently. Substance misuse was defined as the occurrence of any
problems related to alcohol or drug use: problems with family, friends, job,
police, physical health or any recorded diagnosis of psychoactive substance
use disorder (Swartz et al,
1998a).
Medication adherence
Medication adherence was measured from three interview sources: subject,
case manager and collateral informant. Respondents were defined as
non-adherent if they were prescribed psychotropic medications but reportedly
never took them or only sometimes took them as prescribed
(Swartz et al,
1998b).
Out-patient services utilisation
Out-patient services utilisation was obtained from service records in the
information systems of participating community mental health centers. All
service encounters for case management, medication, psychotherapy and other
out-patient services were summed in a single index. Regular treatment was
defined as three or more out-patient service encounters per month in the
community (the median amount). This rate was adjusted for time spent
hospitalised. For those receiving regular treatment according to this
definition, the median number of out-patient service events per month was
seven. For those not receiving regular treatment, the median number of events
was one per month.
Analysis
Logistic regression analysis was used to examine the relative impact of
sustained OPC and out-patient services utilisation on the incidence of violent
behaviour, controlling for baseline violence history and relevant covariates.
Odds ratios produced by this technique estimate the average change in the odds
of a predicted event (any violence) associated with the presence of a risk
factor. For independent variables measured on a continuous scale or ranking,
the odds ratio indicates the change in event likelihood per unit change in the
predictor.
Sample description
Demographic characteristics
As noted in Table 1, sample
members were predominantly young to middle-aged adults of lower educational
status and mostly not married and not cohabiting. The racial distribution of
the sample was 66% African American, 33% non-Hispanic White and 1% other.
Although the majority were city residents, a substantial proportion of the
sample lived in rural areas and small towns. This sample was representative of
the population of patients admitted to state mental hospitals in North
Carolina.
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Clinical characteristics, substance misuse, and history of violence
at baseline
The majority of the sample (68%) had diagnoses of psychotic disorders,
whereas 28% had bipolar disorder and 4% had recurrent major depression.
Thirteen per cent had a co-occurring diagnosis of a personality disorder. The
majority of the sample had moderate functional impairment (GAF median
score=47). Alcohol and drug use (57%), medication non-compliance (73%) and
violent behaviour (51%) were common in the four months prior to
hospitalisation. More than one-third (39%) had experienced two or more
psychiatric hospital admissions during the preceding year. For a more
extensive presentation of the sample and the characteristics of violent events
preceding hospitalisation, see Swanson et al
(1999).
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RESULTS |
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Key correlates of violent behaviour during the follow-up year included ongoing substance misuse problems and non-adherence with prescribed psychotropic medications. Fifty per cent of substance misusers were violent v. 26.5% of those who did not misuse substances (Fisher's exact test, two-tailed, P<0.001); and 41.6% of those who did not adhere to prescribed medication regimens were violent v. 25.5% of those who took medications as prescribed (Fisher's exact test, two-tailed, P<0.05).
Out-patient commitment and violence
Considering this study strictly as a randomised controlled trial, subjects
with a baseline history of serious violence must be excluded from analysis and
all experimental subjects must be considered as a single group (without regard
to the length of exposure to OPC). On this basis alone, the study found no
significant difference in the prospective rate of violence between the two
randomly assigned groups: 32.3% in the OPC group v. 36.8% in the
control group (Fisher's exact test, one-tailed: P=0.292; two-tailed:
P=0.567).
However, a problem with this test is that it excludes a key risk group to which OPC policy may be targeted specifically (the seriously violent group), and constricts the dependent variable by eliminating a substantial number of violent events from the analysis. Moreover, the test as specified cannot take into account varying amounts of exposure to the intervention (i.e. length of time actually spent under court-ordered treatment). Time on OPC varied considerably; it was not subject to experimental control, but depended on clinician's discretion in applying the legal criteria for renewal of expiring OPC orders. As mentioned earlier, this may have selected into the long-term OPC group a greater proportion of clients with a history of non-adherence to medication; this was indirectly associated with a higher baseline risk of violence. Clearly, however, insofar as this created a bias, its effect was conservative, that is, it would work against finding a positive effect for extended OPC in reducing violence risk.
Alternatively, when subjects with a history of serious violence were included in the analysis and the OPC intervention was redefined as receiving at least six months of court-ordered treatment, the results were striking. The extended OPC group had a significantly lower incidence of violence during the year: 26.7% v. 41.6% (Fisher's exact test, one-tailed: P=0.049; two-tailed: P=0.025).
The six-month cut-off point for categorising extended OPC is somewhat arbitrary. However, there were good reasons for dichotomising this variable. The distribution of total OPC days was highly skewed, with all members of the control group receiving zero days of OPC. The majority of the randomised experimental and violent group subjects received less than six months of OPC, whereas a large cluster remained on OPC for the entire year of the study, giving the variable a bimodal distribution. Specifically, for those with less than six months of court-ordered treatment the mean number of days on OPC was 76, whereas for those receiving extended OPC the mean number of days was 330. Using a dichotomous version of the intervention variable, a significant association was found between extended OPC and incidence of violence; this effect remained significant in multivariate analysis, as will be shown below.
We also re-analysed the data for high and low exposure to OPC separately for the randomised subjects and the non-randomised violent group. In the randomised study groups, control subjects did not differ significantly in their risk of violence from those with brief, discontinued OPC (36.8% v. 39.7%). However, the incidence of violence was significantly less (22.7%) among randomised OPC subjects who received extended court-ordered treatment (Fisher's exact test, one-tailed: P=0.043; two-tailed: P=0.076). Among the subjects who were violent at baseline, the effect of extended OPC was also seen at a level approaching statistical significance: among violent subjects with brief, discontinued OPC, 63.3% repeated their violent behaviour during the year of the study; of those receiving extended OPC, only 37.5% were violent (Fisher's exact test, one-tailed: P=0.086; two-tailed: P=0.126).
Multivariate analysis
Staged logistic regression analysis with stepwise inclusion was conducted
to test the effect of OPC on reduced violence in the context of relevant
covariates. A control variable was included to hold constant the effect of
baseline history of violence and initial assignment to the violent OPC group.
An initial model (see Table 2,
Model 1) showed that extended OPC was associated with significantly lower odds
of any violent behaviour during the year of the study, controlling for
baseline history of violence (odds ratio=0.42; P<0.05). In Model
2, being young, single, and having a low degree of perceived social support
were identified as significant demographic risk factors. In Model 3, among the
clinical variables substance misuse was a significant predictor of violence.
Controlling for the significant demographic variables and substance misuse,
respondents who received more than 180 days of OPC were only about one-third
as likely to commit a violent act during the year as their counterparts in the
control group (odds ratio=0.35; P<0.01). Those receiving 1-179
days of OPC did not differ from the control group with respect to risk of
violence.
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A cross-sectional analysis of baseline data from this same study showed a significant association between history of violence and history of medication non-adherence combined with substance misuse (Swartz et al, 1998b). This finding was replicated with the longitudinal follow-up data controlling for extended OPC and significant covariates. Risk of violence was found to be three times greater among subjects who misused substances and did not take medications as prescribed during follow-up (odds ratio=3.19; P<0.01); however, risk was not significantly elevated among respondents with only one of these problems alone.
Based on this finding of an interaction effect of substance misuse and non-compliance, two composite variables were coded for subsequent analysis: clinical risk status at baseline, and change in clinical risk status at follow-up. Subjects whose status on both substance misuse and medication adherence improved from baseline received the highest change scores, whereas those who deteriorated or maintained a poor status received lower scores accordingly. Change scores ranged from -3 to +4 (mean=1.2, s.d.=1.7). In bivariate analysis, subjects who received extended OPC achieved significantly better mean scores on the index (1.8 v. 1.1; mean square=14.2; F=4.79; P<0.05). Subjects who remained free of violent behaviour also were found to have significantly better scores (1.53 v. 0.76; mean square=36.7; F=12.76; P<0.01).
The staged multivariate analysis shown in Table 3 examines whether OPC interacts with the provision of out-patient services to reduce the risk of violent behaviour and, if so, whether OPC prevents violence indirectly by means of reducing substance misuse and improving medication adherence. Model 1 shows that extended OPC alone did not significantly reduce risk. Similarly, receiving frequent services alone was not associated with less violence. Rather, the combination of both variables at least 180 days of OPC with an average of three or more out-patient visits per month in the community showed a significant effect in reducing violence (odds ratio=0.37; P<0.05). In this model, the predicted probability of any violent behaviour was cut in half from 48% to 24%, attributable to extended OPC and regular out-patient services provision.
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Model 2 in Table 3 shows that combined improvement in medication adherence and substance use/misuse status was a significant predictor of reduced violent behaviour: about 20% reduction with each unit improvement in clinical risk (odds ratio=0.81; P<0.05). This model provides evidence of an indirect effect of the intervention, as mentioned above. With the clinical risk change score in the equation, the direct effect of OPC and services was suppressed from an odds ratio of 0.36 (P<0.05) in Model 1 to an odds ratio of 0.41 (P<0.10) in Model 2, and the fit of the model improved significantly.
Finally, Model 3 specifies a reduced set of predictors using stepwise selection of variables. Based on this model, subjects who received the high intervention (sustained OPC and regular services), who concurrently remained free of substance misuse and who took medications as prescribed during the year of the study had the lowest likelihood of any violence (13% predicted probability). In contrast, those who did not receive the high intervention, who continued to misuse substances and who stopped taking their medications had a 53% predicted probability of violent behaviour during the year.
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DISCUSSION |
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Sustained OPC combined with regular community-based service
The key finding is that extended OPC (more than six months) combined with
regular out-patient services utilisation (three or more events per month)
produced a significant decrease in the incidence of violence. Neither the
court order nor services alone was effective in reducing violence.
However, with regular service use, the presence of extended OPC reduced the
probability of violence from 48% to 24%.
Improved medication adherence and diminished substance misuse
The study provides evidence for an important mechanism by which OPC may
exert its effect in preventing violent behaviour. Respondents who received
extended OPC with regular out-patient services achieved, on average, the
highest positive (improved) change scores on medication adherence and
substance use. In turn, those with high change scores in both of these risk
factors combined had a significantly reduced incidence of violent behaviour
during the year of follow-up. A multivariate model suggests that the benefit
of OPC as described is at least partly an indirect effect attributable to
change in these intervening clinical risk factors.
Deviation from randomised design
The study design deviates in two ways from a strict randomised controlled
trial. First, the sample included a subgroup of subjects with a recent history
of serious violent behaviour who could not be assigned randomly to the initial
control group (outright release from OPC). To exclude these subjects
altogether would have meant that the study findings could not be generalised
to a crucially important sub-population to which OPC policy may be targeted.
However, random assignment was not feasible for these subjects; the
Institutional Review Board, the District Court judges and the hospital
psychiatrists overseeing these patients' care and research participation would
not authorise rescinding their OPC orders at baseline citing practice
liability and other concerns. Nevertheless, over half of these subjects
did not remain on OPC, and thus were unexposed to court-ordered
treatment during a large proportion of the period of observation. Hence, the
non-renewal of many of these orders allowed an informative comparison of rates
of violent recidivism between those remaining under OPC for more than six
months (average 330 days) and those receiving less than six months of OPC
(average 76 days).
This leads to a second necessary deviation from a strict randomised controlled design. Amount of time on OPC was not random or controlled experimentally, but varied as clinicians applied the legal criteria for renewal of OPC orders. Potentially, this could have lead to a biased conclusion (i.e. attributing a positive intervention effect to subjects who might have been less violent anyway because of pre-existing lower risk). However, this could only be a problem if higher-risk subjects were less likely to get renewal of their court order. In fact, the legal criteria for OPC work in the opposite direction.
Possible conservative bias favouring not finding an effect of OPC on
reducing violence
Renewal of the court order required a second determination (by a
psychiatrist and the court) that the respondent would predictably become
dangerous (or gravely disabled) without treatment and
predictably would not comply with treatment. At the end of the initial OPC
period (up to 90 days), each case was re-evaluated systematically. Prompting
notices were sent to clinicians, reminding them that a subject's OPC order was
about to expire and summarising the OPC criteria for easy reference. If at
that point the psychiatrist and the court concluded that the respondent was no
longer likely to become dangerous without treatment or, even if so, would
comply voluntarily with treatment, then the legal criteria for OPC
were not satisfied and the order could not be renewed. (Beyond the legal
criteria, common sense suggests that clinicians would not cull out clients
assessed to be at highest risk of violence and selectively not renew
their OPC orders.)
Anecdotally, when clinicians were asked by research staff members to state their reasons for not renewing an OPC order, the most typical answer was that the patient had been compliant with treatment and was doing reasonably well at that time; hence, continuing a court order was not seen as legally justifiable. Empirically, respondents who had been mostly compliant with medications in the four months prior to hospitalisation were significantly less likely to receive extended OPC after their initial court order expired; and medication compliance was indirectly associated with lower risk of violence in these data (Swartz et al, 1998b). In summary, if bias existed in the selection of subjects for longer periods of OPC, then such a bias would seem to work against finding that extended OPC lowers the risk of violence. Thus, our results may understate the true impact of OPC in preventing violent behaviour.
Responsibility of mental health service systems using OPC
These results show that OPC may be an effective strategy for reducing
community violence among people with SMI. However, if service systems intend
to use OPC to this end, they must be prepared to monitor clients for sustained
periods. Most importantly, they must make available adequate services to
address the complex needs of persons with SMI and (often) substance misuse
comorbidity, who lack adequate social resources and experience persistent
difficulties in complying with out-patient treatment on their own. With such
provisos, OPC may assist mental health agencies in reducing violent behaviour
and costly institutional recidivism, and may significantly improve the lives
of persons suffering from severe and persistent mental illness.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication May 19, 1999. Revision received December 8, 1999. Accepted for publication December 9, 1999.