Psychiatric Readmissions Rose After Court-Ordered Treatment Expired in Arizona Cohort

A small retrospective cohort study from Arizona’s public behavioral health system has found that psychiatric hospital admissions rose sharply after court-ordered treatment expired, while adherence to appointments and long-acting injectable medication also slipped, though not significantly. The research, published in Community Mental Health Journal, followed patients placed on Court-Ordered Treatment, or COT, between 2020 and 2021 and compared each person’s outcomes during the mandated treatment period with outcomes during the first year after the court order expired. Because every participant served as their own control, the design offers an unusually direct look at what happens when the legal requirement to attend treatment is lifted while the underlying psychiatric illness persists.

The study was conducted at a public safety net hospital whose behavioral health programs—the Behavioral Health Specialty Center, the First Episode Center, and the Assertive Community Treatment team—serve roughly 500 patients with serious mental illness annually, covering both urban and rural populations in Arizona. Researchers retrospectively reviewed electronic medical records and court documentation for all adults placed on outpatient COT by the Arizona Mental Health Court between January 1, 2020, and December 31, 2021. Ninety-four patients were initially identified, but 65 were excluded because their court orders were actively renewed, they had not transitioned to voluntary care before the study endpoint, or they lacked a full 12-month post-expiration follow-up window. That left 29 patients, about 30.9 percent of the original group, for the paired analyses.

The cohort was young and predominantly male, with a mean age of 32 years; 24 patients, or 82.8 percent, were male and five, or 17.2 percent, were female. Most participants identified as White, and the most common primary psychiatric diagnosis was schizophrenia. Patients were followed across three outpatient clinics: 13 at the First Episode Center, 10 in the Assertive Community Treatment program, and six at the Specialty Clinic. Two investigators independently extracted data using a standardized abstraction form, and a third reviewer checked all abstracted data, with discrepancies resolved by consensus.

The headline finding concerned psychiatric readmission. During the COT period, three of the 29 patients, or 10.3 percent, experienced at least one psychiatric readmission. During the year after the court order expired, that figure rose to 10 of 29 patients, or 34.5 percent. Using the exact McNemar test, appropriate for paired binary outcomes with few discordant observations, the researchers reported a McNemar chi-square of 5.4 with one degree of freedom, p equal to .039, a statistically significant within-subject difference. Most patients who remained free of hospitalization during COT also stayed stable afterward, but several who had not required hospitalization during the mandated period were readmitted during the follow-up year.

The two secondary outcomes moved in the same direction but did not reach statistical significance. Missed outpatient psychiatric appointments increased from seven of 29 patients, or 24.1 percent, during COT to 11 of 29, or 37.9 percent, after expiration, with a McNemar chi-square of 2.7 and p equal to .219. Patients who missed appointments before expiration tended to miss them afterward as well, while those with no missed appointments generally continued attending without gaps. For long-acting injectable antipsychotic medication, complete administration records were unavailable for ten patients, leaving 19 for the paired analysis. One patient missed at least one scheduled LAI dose during COT compared with four after expiration, a difference that was not statistically significant at p equal to .250. The authors stress that these adherence findings should be interpreted cautiously because of the limited sample size and the small number of missed-dose events.

Court-ordered outpatient treatment, also known as community treatment orders or assisted outpatient treatment, exists to provide treatment in the least restrictive setting for people with serious mental illness who meet statutory criteria for involuntary treatment. The legal framework for civil commitment in the United States was shaped in part by the Supreme Court’s 1975 decision in O’Connor v. Donaldson, which emphasized that mental illness alone does not justify involuntary hospitalization if a person is not dangerous and can live safely in the community alone or with the help of willing, responsible family or friends. States have since developed varying commitment statutes, generally requiring evidence of dangerousness, grave disability, or similar criteria.

Arizona offers a distinctive setting for this kind of research because a single court order can authorize both inpatient and outpatient treatment under Title 36, Chapter 5 of the Arizona Revised Statutes. When statutory criteria are met, a court may order treatment for someone who, because of mental illness, is a danger to self or others, persistently or acutely disabled, or gravely disabled and unwilling or unable to accept voluntary treatment. Inpatient treatment can be ordered for up to 180 days and outpatient treatment for up to 365 days in total, with orders renewable when clinically indicated. During outpatient COT, patients are expected to participate in an individualized treatment plan that may include psychiatric appointments, prescribed medications, and community-based services.

The authors are careful about what the results do and do not show. Because the study was retrospective and observational, lacked a comparison group of similar patients not receiving COT, and analyzed a small, selected sample, the association between active COT and fewer readmissions cannot be interpreted as evidence that COT caused the difference. Other factors, including changes in illness severity, social support, access to community services, and clinician decision-making, may have influenced outcomes. The researchers also note that mirror-image designs like this one are susceptible to regression to the mean: patients typically enter mandated treatment during periods of greater clinical instability, so some of the apparent improvement during COT may reflect the natural course of illness rather than the effect of the order itself.

Selection bias is a further concern. Only patients whose court orders expired before the study endpoint were included; those whose orders were renewed may have differed in illness severity, treatment adherence, housing stability, substance use, or clinical risk. The retrospective record review also meant that several potentially important variables—substance use disorders, housing status, illness severity, duration of illness, and prior hospitalization history—were not consistently available for analysis. The cohort’s composition, predominantly White non-Hispanic male patients, may further limit generalizability to more diverse populations. The study was also underpowered to draw meaningful conclusions about missed appointments or LAI adherence, and continued engagement with community mental health services after expiration may itself have helped many patients maintain adherence.

The findings align with a body of earlier observational work. Previous studies have reported reductions in psychiatric admissions and inpatient days among patients on involuntary outpatient commitment in North Carolina, fewer inpatient admissions following outpatient commitment in Washington, D.C., and shorter hospital stays and greater voluntary engagement with community services in Arizona. Mirror-image studies by other groups have likewise reported reduced hospital utilization during periods of outpatient commitment. Yet those investigations differed substantially in sample size, design, populations, legal frameworks, and outcome measures, and most compared outcomes before and after commitment rather than examining the transition from active order to expiration within the same individuals. Reviews of the broader literature have found mixed evidence and substantial heterogeneity, including limited evidence on medication adherence after community treatment orders end.

Beyond the statistics, the study touches on enduring ethical tensions. COT is intended as the least restrictive option and may promote continuity of care for people at high risk of treatment disengagement, but it remains a coercive legal intervention whose potential benefits must be weighed against patient autonomy, the therapeutic alliance, and equitable implementation—particularly given that initiation and renewal decisions vary across jurisdictions and health systems. The authors call for larger, prospective, multicenter studies with more diverse populations, comparison groups, standardized measures of illness severity and treatment engagement, patient-reported outcomes, and attention to social determinants of health, to identify which patients are most likely to benefit from court-ordered treatment while minimizing unnecessary restrictions on personal liberty.

Subject of Research: Psychiatric readmission and treatment adherence during and after court-ordered outpatient treatment

Article Title: Readmission and Treatment Adherence During and After Court-Ordered Treatment in Arizona: A Retrospective Cohort Study

Article References: Sood, S., Mannekote, S., Filippelli, J., Dudeja, N., Ayoub, A., Ramos, G., & Mathieson, K. (2026). Readmission and Treatment Adherence During and After Court-Ordered Treatment in Arizona: A Retrospective Cohort Study. Community Mental Health Journal. https://doi.org/10.1007/s10597-026-01741-3

Image Credits: AI Generated

DOI: 10.1007/s10597-026-01741-3

Keywords: court-ordered treatment, serious mental illness, psychiatric readmission, treatment adherence, long-acting injectable antipsychotics, community treatment orders, assisted outpatient treatment, retrospective cohort study, Arizona, involuntary outpatient commitment, public behavioral health system, civil commitment