An update about the controversies and possible alternatives.
Involuntary outpatient commitment statutes are now on the books in 42 states and the District of Columbia. Although they vary in detail, the intent of such statutes is to force people with mental illness to accept outpatient treatment, in an effort to reduce relapse, hospitalization, and violent behavior.
However, a review by two researchers at Duke University Medical Center concluded that most outpatient commitment laws are ambiguous and ineffective. One glaring example is the Virginia Tech tragedy in 2007, when student Seung-Hui Cho killed 32 people before committing suicide. Cho had an involuntary outpatient commitment order that wasn't being enforced, possibly because the local mental health clinic didn't understand its obligations or lacked the resources and power to implement the order.
The Duke researchers offered recommendations about when outpatient commitment laws might work and how to implement them — supplementing guidance previously offered by the American Psychiatric Association (APA) and researchers at the RAND Corporation, a leading policy think tank. Meanwhile, the Research Network on Mandated Community Treatment, funded by the John D. and Catherine T. MacArthur Foundation, has published a series of papers evaluating the effectiveness of involuntary outpatient commitment, as well as alternative strategies to encourage treatment, such as subsidized housing, money, criminal sanctions, and psychiatric advance directives.
Outpatient commitment laws
Laws for involuntary outpatient commitment, sometimes also called assisted or mandated outpatient treatment, empower a judge to order a patient to comply with prescribed treatment.
Most outpatient commitment laws require the same criteria as inpatient commitment, such as being a danger to oneself or others. Some states also allow outpatient commitment of patients who are at risk for relapse and hospitalization because of noncompliance with treatment. The commitment period varies, depending on the state.
It also is not clear how often the laws are actually used. Some researchers and advocates believe that outpatient commitment is rarely ordered. However, one study that drew upon interviews with psychiatric outpatients in five different states found that as many as one in five patients said they had received an outpatient commitment order, or a similar court-ordered treatment, at some point in their lives.
But even when an outpatient commitment order is issued, the steps required for implementation are not always clearly defined, and enforcement is weak. In Virginia, for example, outpatient commitment laws were rarely enforced. (In the aftermath of the Virginia Tech shooting, the state's commitment laws are undergoing review.) Some states, such as New York, have better implementation policies.
Do the laws work?
Advocates of outpatient commitment argue that the laws help increase treatment compliance, reduce hospitalization, and decrease violence and homelessness. Critics disagree. Both sides cite research to support their conclusions, but to date the only two controlled studies on the issue have produced conflicting results.
A Duke study, which RAND researchers considered the better of the two, randomly assigned 264 patients discharged from inpatient commitment between 1993 and 1996 to one of two study arms. One group was ordered to outpatient commitment for up to 90 days (with the option of renewal for up to 180 days) combined with consistent community mental health services, while a control group received the same services without an outpatient commitment order.
The Duke researchers concluded that outpatient commitment produced benefits — such as greater treatment adherence, fewer days in the hospital, and fewer violent incidents — only when it was maintained for at least six months and combined with consistent community mental health benefits. When it was mandated for less than six months (even when it was combined with such services), or offered without consistent services, outpatient commitment produced no benefits.
In the other randomized controlled study, New York researchers compared 78 patients ordered to outpatient commitment with 64 patients who were not for one year after discharge from a hospital. Both groups of patients received psychiatric appointments, intensive case management, and, if necessary, treatment for substance abuse. In this study, researchers found no statistically significant difference in rates of hospitalization or arrest, quality of life, symptoms, homelessness, or other outcomes. These researchers concluded that the availability of intensive mental health services was the key factor contributing to any benefit.
Although analyses of various state laws have been published since, no additional randomized controlled studies are currently being conducted. However, the MacArthur Research Network on Mandated Community Treatment and the New York State Office of Mental Health are evaluating the long-term outcomes of patients who received outpatient commitment under the New York statute.
Advice about implementation
Some guidelines exist regarding when to order outpatient commitment and how to implement these orders to increase the likelihood of success.
Patients. The APA recommends that outpatient commitment be considered not only for patients who meet a state's criteria for inpatient commitment, but also for those who are unlikely to comply with needed treatment, and those who are likely to deteriorate so much without treatment that they become a danger to themselves or someone else. However, the APA also recommends that patients being considered for outpatient commitment have both an acceptable treatment plan and access to a community provider who supports the plan.
Based on their findings, the Duke reviewers think that people with schizophrenia are most likely to benefit from outpatient commitment. No evidence exists that outpatient commitment will benefit patients with personality disorders or those suffering from substance abuse alone (without a coexisting mental illness).
Mental health services. For outpatient commitment to be successful, a community must be able to offer comprehensive mental health services such as assertive community treatment, intensive case management, appropriate medications, and supported housing. Unfortunately, these services may not be available everywhere. And in the public mental health system, patients may need to wait months or even years to receive some of these services.
Duration. The APA and the Duke reviewers both state that outpatient commitment should last six months or longer to be effective.
Team plan. The APA and Duke reviewers also recommend that the clinicians carrying out the outpatient commitment order be involved in treatment planning ahead of time. The Duke researchers note that most outpatient commitments are ordered during discharge planning from an inpatient unit. Therefore, once the inpatient team makes the judgment that outpatient commitment would be helpful, they must coordinate with outpatient providers and law enforcement to make the plan work.
Alternatives to outpatient commitment
About half of patients in the public mental health system have experienced some type of pressure to adhere to treatment. One study interviewed patients in five U.S. locations to determine how frequently four types of leverage were used to promote treatment adherence. The most common means of leverage was subsidized housing, reported by 23% to 40% of patients. Criminal sanctions ranked second, reported as leverage by 15% to 30% of patients. Involuntary outpatient commitment was third, reported by 12% to 20% of patients. Use of money as leverage ranked last, reported by 7% to 19% of patients.
Unfortunately, few studies have yet evaluated how well any of these strategies improve treatment adherence.
Subsidized housing. The U.S. Department of Housing and Urban Development offers subsidized housing programs to people with mental illness. These programs are managed at the local level through community mental health centers and other agencies. Because subsidized housing slots are limited, they are often formally or informally used as an enticement to getting treatment. For example, a patient may have to sign a lease agreeing to continued mental health treatment or face eviction.
Criminal sanctions. When a patient with a mental illness is convicted of a crime, a judge may be able to mandate treatment as part of probation and as an alternative to jail time.
Money. The U.S. Social Security Administration (SSA) allows the appointment of a representative payee — a family member, mental health worker, or other designee — to manage money for patients unable to do so on their own. Access to SSA disability payments is sometimes used to coax recipients to comply with treatment.
Psychiatric advance directives. These legal documents provide a mechanism for patients to specify, in advance, what types of psychiatric treatments they prefer or to appoint a health care agent to make such decisions for them, should they become incapacitated.
American Psychiatric Association. "Mandatory Outpatient Treatment Resource Document," December 1999. APA Document Reference No. 990007.
Bonnie RJ, et al. "From Coercion to Contract: Reframing the Debate on Mandated Community Treatment for People with Mental Disorders," Law and Human Behavior (Aug. 2005): Vol. 29, No. 4, pp. 485–503.
Monahan J, et al. "Use of Leverage to Improve Adherence to Psychiatric Treatment in the Community," Psychiatric Services (Jan. 2005): Vol. 56, No. 1, pp. 37–44.
RAND Law & Health Research Brief. "Does Involuntary Outpatient Treatment Work?" www.rand.org/pubs/research_briefs/RB4537/index1.html.
Swartz MS, et al. "Outpatient Commitment: When It Improves Patient Outcomes," Current Psychiatry (April 2008): Vol. 7, No. 4, pp. 25–35.
For more references, please see www.health.harvard.edu/mentalextra.