This competing continuation extends the Duke Mental Health Study the first randomized controlled trial (RCT) of the effectiveness of involuntary outpatient commitment (OPC) in reducing rehospitalization and improving outcomes among persons with severe mental illnesses (SMI). OPC is a promising, but controversial legal intervention designed to benefit SMI individuals who need ongoing psychiatric care and support to prevent dangerous relapse and recidivism, but who are SMI individuals who need ongoing psychiatric care and support to prevent dangerous relapse and recidivism, but who are reluctant or have difficulty seeking and following through with community-based treatment. Thirty-eight states and the District of Columbia have explicit OPC statutes. Still, key information is lacking on the advantages and drawbacks of OPC how it exerts its effects, for how long, and for which clinical subgroups. Are the coercive aspects of court-ordered treatment in the community worth the potential benefits to SMI consumers, those who care for them, and to society in general? In the RCT recently completed, involuntarily hospitalized patients awaiting OPC were randomly assigned to continue under OPC upon discharge, or be released from their court order and receive voluntary case management services. Analyses of one-year follow-up data demonstrate that subjects who received sustained periods of OPC and frequent outpatient services had significantly reduced hospitalizations and violent behavior. However, we have yet to (and propose to) examine other key outcomes (symptoms, functioning, substance abuse, homelessness, arrests, family/caregiver strain), and key intervening variables (treatment intensity, medication adherence). Mechanisms underlying OPC must also be examined as well as long-term outcomes post-OPC. Assessment of stakeholders' utilities for this controversial intervention is also needed in order to develop OPC practice guidelines. The goal of this competing continuation application is to address the priorities outlined in the NIMH National Advisory Mental Health Council's Clinical Treatment and Services Workgroup Report. """"""""Bridging Science and Service."""""""" We propose to: (1) Extend existing research on OPC's effectiveness by completing ongoing RCT analyses; (2) Gather data about consumers' and other stakeholders' preferences and attitudes regarding OPC; (3) Synthesize all available evidence on OPC effectiveness and utilities for an expert consensus panel charged with developing OPC practice guidelines; and (4) Assess strategies for guideline implementation and design practice improvement research.
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