An Overview of Outpatient Treatment for Mental Health?


If an individual is struggling with their mental health there are various ways to help, however, if the individual is facing serious issues then it may be time to consider accessing professional treatment options.

Previously, ‘treatment’ may have elicited memories of facilities where locked doors, restricted movement, and visiting hours being restricted was the norm. While this type of treatment still exists (usually for the most seriously ill individuals and can be helpful in certain circumstances) there are also less restrictive therapeutic environments that can be helpful as well.

Outpatient mental health programmes, also known as structured outpatient, offer the same quality of treatment as inpatient mental health programmes, but generally with more freedom and flexibility – but what is the difference?

Inpatient versus Outpatient

Mental health treatment programmes generally fall into one of the below categories and, while equally focused on treatment, each type has unique attributes and benefits to offer.

Inpatient1. Also known as residential treatment programmes (and other names).
2. These are intensive, residential treatment programmes designed to treat serious mental health issues.
3. They require individuals to check themselves into a controlled environment to treat their mental health issues.
4. Individuals stay at a clinic/facility with 24-hour medical and emotional support.
5. May last days, weeks, or even months (in extreme cases years).
Day Care1. Also known as Intensive Day Care.
2. Can be used as a step-down from inpatient treatment or step-up from outpatient treatment.
3. Characterised by an individual attending a clinic/facility for a set number of full or half-days each week.
4. Particularly useful for individuals who do not need intensive 24-hour care for their mental health concerns, but still require some level of structured, ongoing support.
Outpatient1. Also known as non-residential treatment programmes (and other names).
2. These are part-time programmes designed to enable the individual to keep going to work or school during the day.
3. Less restrictive than inpatient programmes.
4. Usually require several hours per week visiting the clinic/facility.
5. Sessions can include mental health education (for the individual and family/friends) and individual/group counselling.
6. Can be a useful standalone option for individual’s with mild mental health issues, or part of a longer-term treatment programme.
7. May last several months or longer (e.g. more than one year).
Mixed1. Some clinics/facilities offer mixed treatment.
2. For example, a stay as an inpatient when a mental health crisis occurs, followed by outpatient treatment when this passes.

What is Outpatient Treatment for Mental Health?

Outpatient treatment refers to non-residential treatment, in which the individual spends structured time in treatment during the day or evening and returns home each night. Individuals who choose to participate in outpatient mental health treatment do so for a variety of reasons, including:

  • They may have small children at home or businesses to run and cannot take weeks or months out of their lives to live in a residential facility.
  • They may be transitioning out of an inpatient programme but still require the support and structure that outpatient treatment provides.

Outpatient treatment programmes are most beneficial for those with mild to moderate symptoms who have a strong support system at home.

Is It The Same As Outpatient Therapy?

Outpatient therapy is defined as “any psychotherapy service offered when the client is not admitted to a hospital, residential program, or other inpatient settings.”

  • Outpatient treatment usually provides:
    • A more comprehensive treatment experience.
    • More treatment hours.
  • Outpatient therapy can be part of outpatient treatment.

Who is Outpatient Treatment For?

Outpatient care is the most common treatment for many mental health problems due to:

  • Its lower cost;
  • Better flexibility to the individual’s needs and schedules; and
  • A larger selection of providers.

Outpatient care should only be applied when constant (professional) support is unnecessary and it is healthier for the individual to remain in their environment to experience stressors and learn to cope with professional guidance. This approach is often the best course of action for individuals with problems like eating disorders, depression, and anxiety.

For individual dealing with substance abuse, both inpatient and outpatient treatment plans are an option. The best choice depends on factors like mental health history, relapse history, and commitment to change. For any cases where the health or safety of the individual or those close to them is in question, inpatient care is likely necessary.

For many who undergo inpatient treatment, a long-term outpatient treatment plan is an important part of maintaining healthy habits and learning how to cope with daily life.

If an individual is at immediate risk of harming themselves or others, outpatient treatment is not the right level of care. Generally, individuals are a good fit for outpatient treatment if they are:

  • Motivated to participate in programming;
  • Able to learn and apply recovery skills;
  • Comfortable in a group setting;
  • Driven to improve their condition and work towards recovery; and
  • Willing to verbally express their thoughts and feelings.

Which Mental Health Conditions?

Outpatient treatment can be used to treat a wide variety of mental health concerns including:

  • Addictions (some providers state their addiction service is for adults only).
  • Attention deficit hyperactivity disorder (ADHD).
  • Alcohol use disorders.
  • Anxiety disorders.
  • Anorexia nervosa.
  • Autistic spectrum disorders (ASDs).
  • Bulimia nervosa.
  • Depressive disorders.
  • Dietetics.
  • Early identification of medically unexplained symptoms (MUS).
  • Obsessive compulsive disorder (OCD).
  • Post-traumatic stress disorder (PTSD).

This form of treatment can be beneficial for individuals who require ongoing therapeutic input for their mental health difficulties, but their challenges are not severe enough to require more intensive day care or inpatient treatment.

What Types of Outpatient Treatment are Available?

Outpatient treatment is not a one-size-fits-all programme and, therefore, should be tailored to the needs of the individual. However, programmes generally include some combination of:

  • Individual, group, and/or family/friend therapy.
  • Mental health education.
  • Managing symptoms.
  • Identifying triggers.
  • Overcoming fears.
  • Developing communication skills.
  • Establishing healthy social norms.
  • Coping skills/strategies.
  • Helping the individual to learn to thrive, rather than survive, outside the therapeutic environment.
  • Medication management.
  • Aftercare.
  • Counselling.
  • Psychoeducation.
  • Psychiatric care.
  • Personalised treatment/care plan.
  • Complementary therapies, for example: art therapy, yoga, and music therapy.

The exact combination will depend on the needs of the individual, and can change as the individual’s circumstances change.

With this in mind, an important element to consider is which type of outpatient treatment programme will be most beneficial to the individual. Broadly speaking, there are three main types of outpatient programmes, each with varying levels of structure, to consider. Further, while one individual may be able to manage their symptoms with an hour or two of mental health treatment per month, another individual may need more support and structure.

Standard Outpatient Treatment (SOT)1. This involves regular visits to the outpatient clinic, treatment centre, or hospital, as outlined by the individual’s personalised care plan.
2. Therapy sessions are scheduled around the individual’s work, school, and other responsibilities.
3. Treatment may be weekly or more frequent, and may continue for a year or more.
Intensive Outpatient Programme (IOP)1. At least six hours per week for adolescents and nine hour per week for adults, and this typically involves 3 to 4 hours of treatment for up to 5 days per week [1].
2. IOPs are designed to provide more structure and support than SOT while still allowing individuals the time and flexibility to tend to outside responsibilities.
3. The length of an IOP can be anywhere from a few weeks to a year – 90 days is usually the recommended minimum.
Partial Hospitalisation Programme (PHP)1. At least 20 hours per week, and this typically involves 6 or more hours of treatment per day, for up to 7 days per week [1].
2. Highly structured and supervised, PHPs provide the most intensive level of non-residential care, and are often beneficial for individuals reintegrating into their lives after an inpatient stay.
3. PHPs typically last around 30 days before the individual transitions to a more flexible level of care.


  1. The number of hours and days of treatment will vary between providers and clinics/facilities.

While traditional outpatient sessions may take place once a week and last around an hour, structured outpatient lasts anywhere from 6 to 35 hours per week. Individuals will often attend structured outpatient programmes three to five days per week.

Multidisciplinary Teams

Various professionals will make up a multidisciplinary team who will be involved in an individual’s outpatient treatment, and can include:

  • General practitioner (GP)/primary care physician.
  • District/mental health nurse.
  • Psychologist.
  • Psychiatrist.
  • Social worker.
  • Counsellor.

What are the Benefits of Outpatient Treatment?

For individuals with mild to moderate symptoms, (and preferably) strong support systems at home, and the ability to function independently, outpatient treatment is usually a good choice. With this in mind, individuals can benefit because they can:

  • Receive an intense level of programming (much like inpatient treatment) without entirely disrupting their current situation in life, such as work, school or family responsibilities;
  • Turn to outpatient treatment after completing an inpatient programme as part of their continued recovery journey;
  • Return home each night (the home environment can be beneficial for recovery provided that it is a healthy, stable environment);
  • Stay connected with family and friends ones while still receiving the treatment they need;
  • Maintain commitments and responsibilities, such as work and school;
  • Receive extra support from healthcare professionals and fellow participants;
  • Spend more time at the treatment centre, which enables them to focus their attention on recovery;
  • Apply the skills and strategies they learn in treatment to real life situations;
  • Stay connected with their treatment team and remain accountable to their personalised care plan; and
  • Transition slowly back into everyday situations, equipped with tools to help optimise their independence and live a meaningful life.

Outpatient treatment can also be conducted via telehealth, so individuals (for example) living in rural areas or with transport issues do not (always) have to travel to receive services (although telehealth provision varies between countries and providers).

Depending on the country the individual resides in, most outpatient treatment programmes also have the added benefit of being less expensive than inpatient programmes. The on-hand medical care and psychotherapy available as an inpatient increases treatment costs, however, the price difference should not encourage or discourage an individual from choosing the most appropriate treatment for them.


Mental health treatment can be thought of as a continuum, with individuals moving up or down in levels of care as needed. However, it is important that both the individual (with a mental health issue) and their family/friends understand the differences before selecting a treatment programme. Exploring all options prior to making a decision can put you or a loved one on their journey to better long-term mental health.

No matter which treatment option an individual may choose, mental health treatment programmes can help change their life for the better. Mental health issues can be chronic and recovery a lifelong process.

What is Outpatient Commitment?


Outpatient commitment – also termed assisted outpatient treatment (AOT) or community treatment orders (CTO) – refers to a civil court procedure wherein a legal process orders an individual diagnosed with a severe mental disorder to adhere to an outpatient treatment plan designed to prevent further deterioration or recurrence that is harmful to themselves or others.

This form of involuntary treatment is distinct from involuntary commitment in that the individual subject to the order continues to live in their home community rather than being detained in hospital or incarcerated. The individual may be subject to rapid recall to hospital, including medication over objections, if the conditions of the order are broken, and the person’s mental health deteriorates. This generally means taking psychiatric medication as directed and may also include attending appointments with a mental health professional, and sometimes even not to take non-prescribed illicit drugs and not associate with certain people or in certain places deemed to have been linked to a deterioration in mental health in that individual.

The criteria and process for outpatient commitment are established by law, which vary among nations and, in the US and Canada, among states or provinces. Some jurisdictions require court hearings, where a judge will make a court order, and others require that treating psychiatrists comply with a set of requirements before compulsory treatment is instituted. When a court process is not required, there is usually a form of appeal to the courts or appeal to or scrutiny by tribunals set up for that purpose. Community treatment laws have generally followed the worldwide trend of community treatment. See mental health law for details of countries which do not have laws that regulate compulsory treatment.


In the United States the term “assisted outpatient treatment” (AOT) is often used and refers to a process whereby a judge orders a qualifying person with symptoms of severe untreated mental illness to adhere to a mental health treatment plan while living in the community. The plan typically includes medication and may include other forms of treatment as well. Patients are often monitored and assigned to case managers or a community dedicated to treating mental health known as assertive community treatment (ACT).

Australia, Canada, England, and New Zealand use the term “community treatment order” (CTO).

Comparison to Inpatient Commitment

The terminology, “outpatient commitment”, and legal construction often equate outpatient commitment with inpatient commitment but providing the patient more freedom. In practice, outpatient commitment may be used in situations where commitment would not be used because it is cheaper than inpatient commitment; seen as less draconian; and protects mental health professionals from moral, civil or criminal liability.

Preventive Use

Outpatient commitment is used in some countries to prevent relapse of mental disorders, as many mental disorders are episodic in natural (for example bipolar disorder or schizophrenia) and it can be difficult to predict whether a mental disorder with reoccur.

Some countries use outpatient commitment for first episode psychosis (FEP).


Discussions of “outpatient commitment” began in the psychiatry community in the 1980s following deinstitutionalisation, a trend that led to the widespread closure of public psychiatric hospitals and resulted in the discharge of large numbers of people with mental illness to the community.



Denmark introduced outpatient commitment in 2010 with the Mental Health Act (Danish: Lov om anvendelse af tvang i psykiatrien).


In Germany, as of 2014, only former forensic psychiatry patients may be placed under community treatment orders. Legislation to allow for wider use of CTOs was considered in 2003-2004, but it was ultimately rejected by the Bundestag.

The Netherlands

As of 2014, Dutch law provides for community treatment orders, and an individual who does not comply with the terms of their CTO may be subject to immediate involuntary commitment.


When Norway introduced outpatient commitment in the 1961 Mental Health Act, it could only be mandated for individuals who had previously been admitted for inpatient treatment. Revisions in 1999 and 2006 provided for outpatient commitment without previous inpatient treatment, but this provision is seldom used.


In Sweden, the Compulsory Psychiatric Care Act (Swedish: Lag om psykiatrisk tvångsvård) provides for an administrative court to mandate psychiatric treatment to prevent harm to the individual or others. The law was created in 1991 and revised in 2008.

England and Wales

Changes in service provision and amendments to the Mental Health Act in England and Wales have increased the scope for compulsion in the community. The Mental Health Act 2007 introduced community treatment orders (CTOs). CTOs are legally defined as a form of outpatient leave for individuals detained under section 3 of the Mental Health Act. As such, only members of the medical community are involved in issuing a CTO, though both the section 3 detention underlying the CTO and the CTO itself can be appealed to the Mental Health Tribunal where a panel consisting of medical doctors and a judge will make a decision.

A review of patient data in London found that the average duration of a CTO in the UK was 3 years. Black people in the UK are more than ten times as likely to be under a CTO as white people. 

The legislation in the UK specifically allows CTOs to be issued after a single admission to hospital for treatment. However, the Royal College of Psychiatrists suggested limiting CTOs to patients with a history of noncompliance and hospitalization, when it reviewed the current mental health legislation.

John Mayer Chamberlain argues that this legislation was triggered by the Killing of Jonathan Zito by an individual who had interactions with mental health services prior this event, which led the then conservative government to argue for CTOs.

In a 2021 paper reviewing the mental health act, the UK government proposed a new form of indefinite outpatient commitment allowing for deprivation of liberties an continuous supervision termed supervised discharge. This discharge would be reviewed yearly, and only apply to individuals who would not benefit from treatment in a hospital setting and would be based on risk.  Further, this legislation would only apply to restricted patients who have been diverted to the mental health care system from courts.


Scotland has a different community commitment regime from England and Wales introduced in the 2003 Mental Health Act. There is ongoing debate in the UK on the place of coercion and compulsion in community mental health care.

North America

In the last decade of the 20th century and the first of the 21st, “outpatient commitment” laws were passed in a number of US states and jurisdictions in Canada.


In the mid-1990s, Saskatchewan became the first Canadian province to implement community treatment orders, and Ontario followed in 2000. As of January 2016, New Brunswick was the only province without legislation that provided for either CTOs or extended leave.

United States

By the end of 2010, 44 US states had enacted some version of an outpatient commitment law. In some cases, passage of the laws followed widely publicised tragedies, such as the murders of Laura Wilcox and Kendra Webdale.


Australia and New Zealand introduced community treatment orders in the 1980s and 1990s.


In Australia, community treatment orders last for a maximum of twelve months but can be renewed after review by a tribunal.


A systematic review in 2016 that looked at around 200 papers investigating effectiveness of CTOs for patient outcomes. It found that non-randomised trials had dramatically varying results and found that no randomised controlled trials showed any benefits to the patient for outpatient commitment apart from a reduction in the risk of being the victim of crime.

The same interventions can have different effects in different countries due to legal, bureaucratic and social factors.


Research published in 2013 showed that Kendra’s Law in New York, which served about 2,500 patients at a cost of $32 million, had positive results in terms of net cost, reduced arrests. About $125 million is also spent annually on improved outpatient treatment for patients who are not subject to the law. In contrast to New York, despite wide adoption of outpatient commitment, the programs were generally not adequately funded.

“Although numerous AOT programs currently operate across the United States, it is clear that the intervention is vastly underutilized.”

Arrests, Danger, and Violence

The National Institute of Justice considers assisted outpatient treatment an effective crime prevention programme. Some studies in the US have found that AOT programmes have reduced the chances of arrest. Kendra’s Law has lowered risk of violent behaviours, reduced thoughts about suicide.

Outcomes and hospital admissions

AOT “programs improve adherence with outpatient treatment and have been shown to lead to significantly fewer emergency commitments, hospital admissions, and hospital days as well as a reduction in arrests and violent behavior.”

“The likelihood of psychiatric hospital admission was significantly reduced by approximately 25% during the initial six-month court order…and by over one-third during a subsequent six-month renewal of the order…. Similar significant reductions in days of hospitalization were evident during initial court orders and subsequent renewals…. Improvements were also evident in receipt of psychotropic medications and intensive case management services. Analysis of data from case manager reports showed similar reductions in hospital admissions and improved engagement in services.”

74% fewer participants experienced homelessness. 77% fewer experienced psychiatric hospitalization. 56% reduction in length of hospitalisation. 83% fewer experienced arrest. 87% fewer experienced incarceration. 49% fewer abused alcohol. 48% fewer abused drugs. Consumer participation and medication compliance improved. The number of individuals exhibiting good adherence to meds increased 51%. The number of individuals exhibiting good service engagement increased 103%. Consumer perceptions were positive. 75% reported that AOT helped them gain control over their lives. 81% said AOT helped them get and stay well. 90% said AOT made them more likely to keep appointments and take meds. 87% of participants said they were confident in their case manager’s ability. 88% said they and their case manager agreed on what was important to work on.

In Nevada County, CA, AOT (“Laura’s Law“) decreased the number of psychiatric hospital days 46.7%, the number of incarceration days 65.1%, the number of homeless days 61.9%, and the number of emergency interventions 44.1%. Laura’s Law implementation saved $1.81-$2.52 for every dollar spent, and receiving services under Laura’s Law caused a “reduction in actual hospital costs of $213,300” and a “reduction in actual incarceration costs of $75,600.”

In New Jersey, Kim Veith, director of clinical services at Ocean Mental Health Services, noted the AOT pilot programme performed “beyond wildest dreams.” AOT reduced hospitalisations, shortened inpatient stays, reduced crime and incarceration, stabilised housing, and reduced homelessness. Of clients who were homeless, 20% are now in supportive housing, 40% are in boarding homes, and 20% are living successfully with family members.

Writing in the British Journal of Psychiatry in 2013, Jorun Rugkåsa and John Dawson stated:

“The current evidence from RCTs suggests that CTOs do not reduce readmission rates over 12 months.”

“We find that New York State’s AOT Program improves a range of important outcomes for its recipients, apparently without feared negative consequences to recipients.”

“The increased services available under AOT clearly improve recipient outcomes, however, the AOT court order, itself, and its monitoring do appear to offer additional benefits in improving outcomes.”

Effect on Mental Illness System

Access to Services

“AOT has been instrumental in increasing accountability at all system levels regarding delivery of services to high need individuals. Community awareness of AOT has resulted in increased outreach to individuals who had previously presented engagement challenges to mental health service providers.”

“Improved treatment plan development, discharge planning, and coordination of service planning. Processes and structures developed for AOT have resulted in improvements to treatment plans that more appropriately match the needs of individuals who have had difficulties using mental health services in the past.”

“Improved collaboration between mental health and court systems. As AOT processes have matured, professionals from the two systems have improved their working relationships, resulting in greater efficiencies, and ultimately, the conservation of judicial, clinical, and administrative resources. There is now an organized process to prioritize and monitor individuals with the greatest need; AOT ensures greater access to services for individuals whom providers have previously been reluctant to serve; There is now increased collaboration between inpatient and community-based providers.”

In New York City net costs declined 50% in the first year after assisted outpatient treatment began and an additional 13% in the second year. In non-NYC counties, costs declined 62% in the first year and an additional 27% in the second year. This was in spite of the fact that psychotropic drug costs increased during the first year after initiation of assisted outpatient treatment, by 40% and 44% in the city and five-county samples, respectively. The increased community-based mental health costs were more than offset by the reduction in inpatient and incarceration costs. Cost declines associated with assisted outpatient treatment were about twice as large as those seen for voluntary services.

“In all three regions, for all three groups, the predicted probability of an MPR ≥80% improved over time (AOT improved by 31–40 percentage points, followed by enhanced services, which improved by 15–22 points, and ‘neither treatment,’ improving 8–19 points). Some regional differences in MPR trajectories were observed.”

“In tandem with New York’s AOT program, enhanced services increased among involuntary recipients, whereas no corresponding increase was initially seen for voluntary recipients. In the long run, however, overall service capacity was increased, and the focus on enhanced services for AOT participants appears to have led to greater access to enhanced services for both voluntary and involuntary recipients.”

“It is also important to recognize that the AOT order exerts a critical effect on service providers stimulating their efforts to prioritize care for AOT recipients.”


“We find no evidence that the AOT Program is disproportionately selecting African Americans for court orders, nor is there evidence of a disproportionate effect on other minority populations. Our interviews with key stakeholders across the state corroborate these findings.”

“We found no evidence of racial bias. Defining the target population as public-system clients with multiple hospitalizations, the rate of application to white and black clients approaches parity.”

Service Engagement

“After 12 months or more on AOT, service engagement increased such that AOT recipients were judged to be more engaged than voluntary patients. This suggests that after 12 months or more, when combined with intensive services, AOT increases service engagement compared to voluntary treatment alone.”

Consumers approve. Despite being under a court order to participate in treatment, current AOT recipients feel neither more positive nor more negative about their treatment experiences than comparable individuals who are not under AOT.

“When the court order was for seven months or more, improved medication possession rates and reduced hospitalization outcomes were sustained even when the former AOT recipients were no longer receiving intensive case coordination services.”

In Los Angeles, CA, the AOT pilot programme reduced incarceration 78%, hospitalisation 86%, hospitalisation after discharge from the programme 77%, and cut taxpayer costs 40%.

In North Carolina, AOT reduced the percentage of persons refusing medications to 30%, compared to 66% of patients not under AOT.

In Ohio, AOT increased attendance at outpatient psychiatric appointments from 5.7 to 13.0 per year. It increased attendance at day treatment sessions from 23 to 60 per year. “During the first 12 months of outpatient commitment, patients experienced significant reductions in visits to the psychiatric emergency service, hospital admissions, and lengths of stay compared with the 12 months before commitment.”

In Arizona, “71% [of AOT patients] … voluntarily maintained treatment contacts six months after their orders expired” compared with “almost no patients” who were not court-ordered to outpatient treatment.

In Iowa, “it appears as though outpatient commitment promotes treatment compliance in about 80% of patients… After commitment is terminated, about ¾ of that group remain in treatment on a voluntary basis.”


Proponents have argued that outpatient commitment improves mental health, increases the effectiveness of treatment, lowers incidence of homelessness, arrest, incarceration and hospitalisation and reduces costs. Opponents of outpatient commitment laws argue that they unnecessarily limit freedom, force people to ingest dangerous medications, or are applied with racial and socioeconomic biases.


While many outpatient commitment laws have been passed in response to violent acts committed by people with mental illness, most proponents involved in the outpatient commitment debate also make arguments based on the quality of life and cost associated with untreated mental illness and “revolving door patients” who experience a cycle of hospitalisation, treatment and stabilisation, release, and decompensation. While the cost of repeated hospitalisations is indisputable, quality-of-life arguments rest on an understanding of mental illness as an undesirable and dangerous state of being. Outpatient commitment proponents point to studies performed in North Carolina and New York that have found some positive impact of court-ordered outpatient treatment. Proponents include: Substance Abuse and Mental Health Services Administration (SAMHSA), US Department of Justice, Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services, American Psychiatric Association, National Alliance on Mental Illness, International Association of Chiefs of Police. SAMHSA included Assisted Outpatient Treatment in their National Registry of Evidence Based Program and Practices. Crime Solutions: Management Strategies to Reduce Psychiatric Readmissions. The Treatment Advocacy Centre are an advocacy group that campaign for the use of outpatient commitment.


Outpatient commitment opponents make several varied arguments. Some dispute the positive effects of compulsory treatment, questioning the methodology of studies that show effectiveness. Others highlight negative effects of treatment. Still others point to disparities in the way these laws are applied.

The opponents claim they are giving medication to the patient, but there are no brain chemical imbalances to correct in “mental illness”. Our ability to control ourselves and reason comes from the mind, and the brain is being reduced in size from the psychiatric medications.

The slippery slope argument of “If government bodies are given power, they will use it in excess.” was proven when 350–450 CTOs were expected to be issued in 2008 and more than five times that number were issued in the first few months. Every year there are increasing numbers of people subject to CTO’s.

The psychiatric survivors movement opposes compulsory treatment on the basis that the ordered drugs often have serious or unpleasant side-effects such as tardive dyskinesia, neuroleptic malignant syndrome, excessive weight gain leading to diabetes, addiction, sexual side effects, and increased risk of suicide. The New York Civil Liberties Union has denounced what they see as racial and socioeconomic biases in the issuing of outpatient commitment orders. The main opponents to any kind of coercion, including the outpatient commitment and any other form of involuntary commitment, are Giorgio Antonucci and Thomas Szasz.

Linking Opioid Use Disorder & High Levels of Out-patient Care Prior to Diagnosis

Research Paper Title

The cascade of care for opioid use disorder: a retrospective study in British Columbia, Canada.


The ‘cascade of care’ framework, measuring attrition at various stages of care engagement, has been proposed to guide the public health response to the opioid overdose public health emergency in British Columbia, Canada.

The researchers estimated the cascade of care for opioid use disorder and identified factors associated with care engagement for people with opioid use disorder (PWOUD) provincially.


Retrospective study using a provincial-level linkage of four health administrative databases.

All PWOUD in BC from 01 January 1996 to 30 November 2017.

The eight-stage cascade of care included diagnosed PWOUD, ever on opioid agonist treatment (OAT), recently on OAT, currently on OAT and retained on OAT: ≥ 1, ≥ 3, ≥ 12 and ≥ 24 months).

Health-care use, homelessness and other demographics were obtained from physician billing records, hospitalisations, and drug dispensation records. Receipt of income assistance was indicated by enrolment in Pharmacare Plan C.


A total of 55 470 diagnosed PWOUD were alive at end of follow-up. As of 2017, a majority of the population (n = 39 456; 71%) received OAT during follow-up; however, only 33% (n = 18 519) were currently engaged in treatment and 16% (n = 8960) had been retained for at least 1 year.

Compared with those never on OAT, those currently engaged in OAT were more likely to be aged under 45 years [adjusted odds ratio (aOR) = 1.75, 95% confidence interval (CI) = 1.64, 1.89], male (aOR = 1.72, 95% CI = 1.64, 1.82), with concurrent substance use disorders (aOR = 2.56, 95% CI = 2.44, 2.70), hepatitis C virus (HCV) (aOR = 1.22, 95% CI = 1.14, 1.33) and either homeless or receiving income-assistance (aOR = 4.35, 95% CI = 4.17, 4.55).

Regular contact with the health-care system-either in out-patient or acute care settings-was common among PWOUD not engaged in OAT, regardless of time since diagnosis or treatment discontinuation.


People with opioid use disorder in British Columbia, Canada show high levels of out-patient care prior to diagnosis.

Younger age, male sex, urban residence, lower income level and homelessness appear to be independently associated with increased opioid agonist treatment engagement.


Piske, M., Zhou, H., Min, J.E., Hongdilokkul, N., Pearce, L.A., Homayra, F., Socias, M.E., McGowan, G. & Nosyk, B. (2020) The cascade of care for opioid use disorder: a retrospective study in British Columbia, Canada. Addiction (Abingdon, England). doi: 10.1111/add.14947. [Epub ahead of print].

Depression: Obstetric Mental Health Clinics & Outpatient Psychiatric Services

Research Paper Title

Depression Outcomes From a Fully Integrated Obstetric Mental Health Clinic: A 10-Year Examination.


A fully integrated Obstetric Mental Health Clinic (OBMHC) was established in 2007 in the rural northwest United States to address perinatal depression.

The purpose of this mixed methods study was to examine depression outcomes in women receiving outpatient psychiatric services between 2007 and 2017 at a fully integrated OBMHC and to explore patient and obstetric team perceptions of OBMHC experiences.


A retrospective database study was employed; depression was measured at baseline and follow-up visits using the Edinburgh Postnatal Depression Scale.

Descriptive statistics, regression models, and trend analysis were employed to determine effectiveness.

A subset of patients participated in telephone interviews; the obstetric team was surveyed regarding perceptions of the service.


The sample included 192 women (195 pregnancies). Approximately 72% experienced less depression by the first follow-up visit.

Patients taking three or more psychiatric medications attended more OBMHC visits.

Trend analysis indicated that women with the highest levels of depression had the best response to the intervention.

Three qualitative themes emerged:

  • Safe Place;
  • Mental/Emotional Stability; and
  • Integrated Personalised Approach.

Obstetric team members (n = 11) perceived the clinic to be helpful and noted improved access to mental health care.


OBMHCs can be effective when psychiatric nurses are embedded within an outpatient obstetric service.

Improved access, timely services, and patient reassurance can lead to an improved pregnancy experience and reduced depressive symptoms.

The longevity of this clinic’s experience serves as a role model for other centres to replicate this successful integrated model of care.


Goedde, D., Zidack, A., Li, Y.H., Arkava, D., Mullette, E., Mullowney, Y. & Brant, J.M. (2020) Depression Outcomes From a Fully Integrated Obstetric Mental Health Clinic: A 10-Year Examination. Journal of the American Psychiatric Nurses Association. doi: 10.1177/1078390319897311. [Epub ahead of print].

Clinical Characteristics of OCD in Children & Adolescents: Developing vs Developed Countries

Research Paper Title

Clinical profile of obsessive-compulsive disorder in children and adolescents: A multicentric study from India.


Data from the Western countries suggest that obsessive-compulsive disorder (OCD) in children and adolescents is associated with male preponderance, comorbid neurodevelopmental disorders, and high family loading.

However, data are limited from the developing countries with respect to the demographic and clinical characteristics of OCD in children and adolescents.

To study the demographic and clinical characteristics of children and adolescents (age ≤18 years) with OCD.


This was a cross-sectional study, conducted in outpatient treatment setting, across six centres in India.


Participants were assessed using a semi-structured pro forma for sociodemographic information, clinical characteristics, the Children’s Yale Brown Obsessive Compulsive Scale (CYBOCS), Structured Clinical Interview for Diagnostic and Statistical Manual, 5th Edition Research Version, Children’s Depression Rating Scale, and Family Interview for Genetic Studies.


The sample was largely male with a moderate illness severity. Nearly 75% of the sample had illness onset before the age of 14 years.

Aggressive, contamination-related obsessions and washing, checking, and repeating compulsions were the most common symptoms.

CYBOCS assessment revealed that >2/3rd of children and adolescents endorsed avoidance, pathological doubting, overvalued sense of responsibility, pervasive slowness, and indecisiveness.

Family history and comorbidity rates were low. OC-related disorders were present in about 10% of the sample.


This study suggests that the clinical characteristics of OCD in children and adolescents in developing countries differ on certain aspects as reported from developed countries.


Sharma, E., Tripathi, A., Grover, S., Avasthi, A., Dan, A., Srivastava, C., Goyal, N., Manohari, S.M. & Reddy, J. (2019) Clinical profile of obsessive-compulsive disorder in children and adolescents: A multicentric study from India. Indian Journal of Psychiatry. 61(6), pp.564-571. doi: 10.4103/psychiatry.IndianJPsychiatry_128_19.