Outpatient Civil Commitment Reduces Safety-Risks Associated with Episodes of Severe Mental Illness

Background and Purpose: Outpatient civil commitment (OCC) provisions are part of mental health law worldwide. This study considers whether and by what means OCC provides statutorily required “needed-treatment” addressing two aspects of its legal mandate to protect the safety of self (exclusive of deliberate-self-harm) and others. In fulfilling these objectives, it was hypothesized that after taking account of potential confounding factors including race, language, and social disadvantage, OCC would be associated with reduced-risks of experiencing imminent-safety-threats including perpetrations and victimizations by homicides, rapes, assaults/abductions, and robberies.

Method: The Victorian Psychiatric Case register records all mental health services received in Victoria, Australia. Records of all 11,424 patients who experienced psychiatric-hospitalization and their first OCC between 2000-2010, and 16,161 matched and randomly selected comparison-cohort-patients who experienced psychiatric-hospitalization without OCC-assignment were linked with the Victoria Police Law Enforcement Assistance Program records of all police contacts in the State. Additionally, all records were linked to records of: Corrections Victoria (documenting detention in police custody or prison), the Socio-Economic Indexes for Areas (documenting neighborhood disadvantage), and the Australian Mental Health Outcomes and Classification Network’s Health of the Nation Outcome Scale (HoNOS) independent assessments of symptom-severity-profiles (documenting potential need for treatment). Hierarchical Logistic regressions, with propensity-score-adjustment and control for 46 potential confounding-factors, were used to evaluate the association of OCC-assignment with occurrence-risk of perpetrations and victimizations.

Results: The numbers of hospitalized patients that engaged in at least one perpetration or experienced a victimization was proportionally greater in the OCC vs the Non-OCC-cohort. From these statistics, it would appear that OCCs are not likely to address the frequency of crime even within the hospitalized population. These statistics are, however, crude figures that do not take into account the fact that the OCC-cohort was characterized by more risk-factors associated with violent crime and victimization than the non-OCC-cohort. The OCC-cohort included younger unemployed males living in more socially disadvantaged neighborhoods. Its HoNOS severity-profiles appeared to validate a need for treatment exceeding that of the non-OCC-cohort, particularly in areas of potentially dangerous behavior. The Logistic models enabled adjustment for between group differences. They controlled for prior crimes and gave explanatory priority to alternative-risk-factors over the OCC in assessing perpetration and victimization risk. After these potentially confounding factors were taken into account, OCC-assignment was associated with reduced safety-risk: 17% in initial-perpetrations, 11% in initial-victimizations, and 22% for repeat-perpetrations. Each ten-community-treatment-days in interaction with OCC-assignment was associated with a 3.4% reduced-perpetration-risk. OCC-initiated-re-hospitalization was associated with a 13% reduced-initial-perpetration-risk, a 17% reduced-initial-victimization-risk, and a 22% reduced-repeat-victimization-risk. All risk-estimates appear to be the unique contributions of the OCC, OCC-initiated-re-hospitalization, or the provision of ten-community-treatment-days—i.e. after accounting for the influence of prior crimes and victimizations, ethnic-bias, neighborhood disadvantage and other between-group differences in the analysis.

Conclusions: OCC assignment’s association with reduced criminal-victimization and perpetration-risk, in conjunction with requiring participation in needed-treatment via re-hospitalization and community-service, adds support to the conclusion that OCC is to some extent fulfilling its legal objectives related to protecting safety of self (exclusive of deliberate-self-harm), and others.