Harvard Mental Health Letter

Outpatient commitment

The emptying of mental hospitals began a half-century ago with the hope that effective treatment would be available on the outside, and patients would be willing to accept it. But for many neither of those conditions has been met. Many thousands of so-called revolving-door patients consume a disproportionate share of the resources of the health care and criminal justice systems as they move between jails, prisons, emergency rooms, psychiatric hospitals, rented rooms, group homes, and the street.

At any given time, a third to half of people with schizophrenia or bipolar disorder are not receiving treatment, and a third of the homeless are mentally ill. Many are too discouraged or disorganized to take any initiative. Some will not agree to treatment because they are isolated and withdrawn, or paranoid and suspicious. Others refuse help because they wrongly believe they are doing well enough without it. Court-ordered treatment — known as outpatient commitment, mandatory outpatient treatment, or assisted outpatient treatment — has been proposed as a partial solution to this problem.

What are the standards?

The laws of more than 40 states permit outpatient commitment, mainly for patients who are actually or potentially dangerous to themselves or others. The best-known state law is Kendra's Law, passed in New York in 1999 after a woman was pushed under a subway train by a man with schizophrenia. Under the New York law, which is fairly typical, assisted outpatient treatment is authorized for people who, because of failure to comply with treatment, have been in a mental hospital, prison, or jail within the last three years or have committed an act of violence in the last four years. To be committed, they have to be in danger of relapse or deterioration that would result in physical harm to themselves or others.

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