Objective

This study considers three hypotheses regarding the impact of extended involuntary outpatient commitment orders on services utilization.

Method

Service utilization of Victorian Psychiatric Case Register (VPCR) patients with extended (> or =180 day) outpatient commitment orders was compared to that of a diagnostically-matched treatment compliant group with similarly extended (> or =180 day) periods of outpatient care (N=1182)--the former receiving care during their extended episode on an involuntary basis while the latter participated in care voluntarily. Pre/post first extended episode mental health service utilization was compared via paired t tests with individuals as their own controls. Logistic and OLS regression as well as repeated measures ANOVA via the GLM SPSS program and post hoc t tests were used to evaluate between group and across time differences.

Results

Extended episodes of care for both groups were associated with subsequent reduced use of hospitalization and increases in community treatment days. Extended orders did not promote voluntary participation in the period following their termination. Community treatment days during the extended episode for those on orders were raised to the level experienced by the treatment compliant comparison group during their extended episode and maintained at that level via subsequent renewal of orders throughout the patients' careers. Approximately six community treatment days were required for those on orders to achieve a one-day reduction in hospital utilization following the extended episode.

Conclusion

Outpatient commitment for those on extended orders in the Victorian context enabled a level of community-based treatment provision unexpected in the absence of this delivery system and provided an alternative to hospitalization.

Objective

This study examined a sample of patients in Victoria, Australia, to identify factors in selection for conditional release from an initial hospitalization that occurred within 30 days of entry into the mental health system.

Methods

Data were from the Victorian Psychiatric Case Register. All patients first hospitalized and conditionally released between 1990 and 2000 were identified (N=8,879), and three comparison groups were created. Two groups were hospitalized within 30 days of entering the system: those who were given conditional release and those who were not. A third group was conditionally released from a hospitalization that occurred after or extended beyond 30 days after system entry. Logistic regression identified characteristics that distinguished the first group. Ordinary least-squares regression was used to evaluate the contribution of conditional release early in treatment to reducing inpatient episodes, inpatient days, days per episode, and inpatient days per 30 days in the system.

Results

Conditional release early in treatment was used for 11 percent of the sample, or more than a third of those who were eligible for this intervention. Factors significantly associated with selection for early conditional release were those related to a better prognosis (initial hospitalization at a later age and having greater than an 11th grade education), a lower likelihood of a diagnosis of dementia or schizophrenia, involuntary status at first inpatient admission, and greater community involvement (being employed and being married). When the analyses controlled for these factors, use of conditional release early in treatment was significantly associated with a reduction in use of subsequent inpatient care.

Objective

The purpose of the present study was to analyse how, for whom, under what circumstances, and with what consequences for a patient's treatment career the community treatment orders (CTOs) were used to prevent psychiatric hospitalization during the course of a decade in Victoria, Australia.

Method

Records were obtained from the Victorian Psychiatric Case Register for 8579 patients who were exposed to CTOs. Descriptive statistics and logistic regression were used to determine the characteristics of patients solely selected for placement on orders directly from the community, in lieu of hospitalization, versus patients selected for placement on orders only from the hospital or for those who experienced both hospital- and community-initiated orders. Ordinary least squares regression was used to evaluate the relationship of sole reliance on community-initiated orders and experienced changes in future hospital utilization.

Results

CTOs were infrequently issued directly from the community by comparison with outpatient orders issued at termination of inpatient episodes. Patients whose placements on orders were carried out only through direct community placement differed from those whose placement was primarily initiated from hospital or from both hospital and community. The former group, although largely consisting of people with schizophrenia, was less likely to include such patients than the comparison samples. It also included fewer male subjects and 'never married' individuals as well as more individuals with major affective disorders. Those served solely with community-initiated orders had significantly less use of subsequent inpatient care than individuals in the comparison samples, all other diagnostic and pre-morbid adjustment characteristics taken into account.

Conclusion

For patients at risk of beginning a career of long-term psychiatric hospitalization, sole reliance on community-initiated orders appeared to prevent additional hospital involvement. The issuance of orders from hospital and the combined-order strategy were associated with protective oversight throughout extended inpatient careers. Sole reliance on community-initiated outpatient orders provided a 'least restrictive' alternative to hospitalization.

Objectives

This study considered the protective value provided by conditional release. It assessed the contribution of conditional release to mortality risk among patients with mental disorders severe enough to require psychiatric hospitalization during a mental health treatment span of 13.5 years in Victoria, Australia.

Methods

Death records were obtained from the Australian National Death Index for a sample of 24,973 Victorian Psychiatric Case Register patients with a history of psychiatric hospitalizations: 8,879 had experienced at least one conditional release during community care intervals and 16,094 had not. Risk of death was assessed with standardized mortality ratios of the general population of Victoria. Relative risk of death among patients with and without past experience of conditional release was computed with risk and odds ratios. The contribution of conditional release to mortality, taking into account use of community care services, age, gender, inpatient experience, and diagnosis, as well as other controls, was assessed with logistic regression.

Results

Patients who had been hospitalized showed higher mortality risk than the general population. Sixteen percent (4,034) died. Patients exposed to conditional release, however, had a 14 percent reduction in probability of non-injury-related death and a 24 percent reduction per day on orders in the probability of death from injury compared with those not offered such oversight throughout their mental health treatment, all other factors taken into account.

Conclusions

Conditional release can offer protective oversight for those considered dangerous to self or others and appears to reduce mortality risk among those with disorders severe enough to require psychiatric hospitalization.

Objective

This study examined conditional release--that is, involuntary outpatient commitment orders upon release from hospitalization--as a least restrictive alternative to psychiatric hospitalization in Victoria, Australia.

Methods

Records were obtained from the Victorian Psychiatric Case Register for patients who experienced psychiatric hospitalization: between 1990 and 2000 a total of 8,879 patients were given conditional release and 16,094 were not.

Results

Compared with the group that was hospitalized but did not receive a conditional release, the group that received a conditional release was more likely to have more prior hospitalizations of greater than average duration. Patients with schizophrenia were more likely to be given conditional release. Patients given conditional release experienced a care pattern involving briefer inpatient episodes (8.3 fewer days per episode), more inpatient days, and longer duration of restrictive care--that is, combined inpatient and conditional release periods (5.1 more days per month in care).

Conclusions

For patients at risk of long-term hospitalization, conditional release may help to shorten inpatient episodes by providing a least restrictive alternative to continued hospitalization. However, patients who were given conditional release doubled the amount of days they spent under restrictive care, compared with the amount of time they previously spent in the hospital before entering a period of combined inpatient and conditional release commitment. Additional oversight may have led to more frequent hospitalization. This consequence raises new questions regarding the possible benefits of such extended oversight and new challenges for release planning using conditional release as a least restrictive method of care.