THE ETHICAL CHALLENGES OF A RANDOMIZED CONTROLLED TRIAL OF INVOLUNTARY OUTPATIENT COMMITMENT

Involuntary outpatient commitment (OPC) is a civil justice procedure i ntended to enhance compliance with community mental health treatment t o improve functioning and to reduce recurrent dangerousness and hospit al recidivism. The research literature on OPC indicates that it appear s to improve outcomes in rates of rehospitalization and length of stay However all studies to date have serious methodological limitations b ecause of selection bias; lack of specification of target populations; unclear operationalization of OPC; unmeasured variability in type, fr equency, and intensity of treatment; as well as other confounding fact ors. To address limitations in these studies, the authors designed a r andomized controlled trial (RCT) of OPC, combined with community-based case management, which is now under way in North Carolina. This artic le describes ethical dilemmas in designing and implementing an RCT of a legally coercive intervention in community-based settings. These eth ical dilemmas challenge the experimental validity of an RCT but can be successfully addressed with careful planning and negotiation.