(Withdrawn) Accessing Acute Medical Care to Protect Health: The Utility of Community Treatment Orders Revisited

Background and Purpose: Outpatient commitment, community treatment orders (CTOs) in Victoria Australia, require patient participation in community-based-treatment in lieu of involuntary psychiatric hospitalization. A central tenet of the laws as written around the world is the assumption that people in need of treatment to protect their health are refusing or failing to access such treatment due to their mental illness. A validation of this assumption is found in the elevated morbidity and mortality experienced by people with severe mental illness (SMI), most notably those who have experienced psychiatric hospitalization. The conclusion that people with SMI require involuntary care to protect their health, however, is questioned by findings indicating that they often lack access to general health care and the assertion that they would access such care voluntarily if it were available and effective.

The single-payer health care system in Victoria, Australia that provides highly accessible medical treatment is an excellent context in which to test this assertion. This study considers whether, in an easy access single-payer health care system, patients placed on CTOs are more likely to access acute medical care addressing potentially life-threatening physical illnesses than voluntary patients with and without SMI.

Methods: Data and samples: Mental health records for the years 2010–2017 were obtained from the Victorian Psychiatric Case Register (VPCR) system, which records all mental health contacts in Victoria Australia, and were linked to three other information sources: the Victorian Emergency Minimum Dataset (VEMD), the Victorian Admitted Episodes Dataset (VAED) and the Socio-Economic Indexes for Areas (SEIFA). The study compared acute medical care access of 21,722 severely mentally ill psychiatrically hospitalized patients (7,826 with and 13,896 without CTO exposure) and 12,101 never psychiatrically hospitalized outpatients.

Measures. Chi-square, ANOVA, and difference of proportions tests were used for evaluation of group differences. Four Logistic regressions were run to determine the relative risk of receipt of at least one life threatening medical/physical illness diagnosis indicating health care need.

Results: Validating their shared elevated-morbidity-risk, 44% and 47%, respectively, of each hospitalized cohort (given CTO and not given CTO) accessed an initial acute-care diagnosis for a life-threatening condition compared to 26% of outpatients. While not under mental health system supervision, however, the likelihood that a CTO-patient would receive a physical illness diagnosis was 36% lower than for non-CTO-patients, and 1.3 times that of outpatients. While, under mental health system supervision, the likelihood that CTO-patients would receive a physical illness diagnosis was 2 times greater than non-CTO-patients and 6.6 times that of outpatients. Each CTO-episode was associated with a 14.2% increase in the likelihood of a CTO-group member receiving a diagnosis. Results replicate those found in an independent 2000-2010-cohort comparison.

Conclusion and Implications: Mental health system involvement and CTO-supervision across two independent cohorts over two decades appeared to facilitate access to an initial life-threatening physical illness diagnosis in acute-care settings for patients with severe mental illness who were refusing treatment, a group that has in the past and continues to be subject to excess morbidity and mortality.