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			Does Assisted Outpatient Treatment Work

			Scientific studies prove Assisted Outpatient Treatment Works. Approximately 40 percent of all individuals with neurobiological disorders (i.e. schizophrenia and manic-depressive illness) are not receiving treatment at any given time (Regier et al., 1993). Many of these individuals are homeless, in jail on misdemeanor charges, and responsible for increasing episodes of violence (Torrey 1997). A major reason why so many severely psychiatrically ill individuals are not being treated is that, because of the effects of the illness on their brain, they lack awareness of their illness. Studies have shown that approximately half of all patients with schizophrenia (Amador et al. 1991) and mania (Ghaemi 1997) have markedly impaired awareness of their illness as measured by tests of insight; thus they are similar to some patients with cerebrovascular accidents (strokes) and with Alzheimer’s disease. Such individuals consistently refuse to take medication because they do not believe they are sick. In most cases they will take medication only under some form of assisted treatment. At least 37 states use a form of assisted treatment commonly referred to as outpatient commitment (OPC) (Torrey and Kaplan 1995). OPC involves a court ordered treatment (usually including medication) as a condition of remaining in the community for individuals who have a history of medication non-compliance. Typically, violation of the court ordered conditions can result in the individual being hospitalized for further treatment. New York is one of the few states that does not have an OPC statute. Long term OPC has been shown to be significantly more effective in improving outcomes for severely mentally ill individuals than routine outpatient care according to a recent study ((Schwartz et al.). In a study from North Carolina, severely mentally ill individuals in long-term OPC (greater than 180 days) in contrast to individuals receiving routine outpatient care (controls): 1) OPC patients fewer psychiatric admissions (.34 per OPC patient vs. 1.23 per controls). 2) OPC patients spent fewer mean days in the hospital (6.9 days for OPC patient vs. 20.1 days for controls). 3) OPC patients had “lower odds of violence in the community.” 4) Improved outcomes were particularly strong among individuals with SMI/SA and histories of violence. The effectiveness of outpatient commitment in decreasing hospital admissions has been clearly established in several studies. In Washington, D.C., admissions decreased from 1.81 per year to 0.95 per year before and after outpatient commitment (Zanni and deVeau 1986). Similarly, in Ohio the decrease was from 1.5 to 0.4 (Munetz et al. 1996), and in Iowa from 1.3 to 0.3 (Rohland 1998). In North Carolina, admissions for patients on outpatient commitment decreased from 3.7 to 0.7 per 1,000 days (Fernandez and Nygard 1990). The only study that failed to find outpatient commitment effective in significantly reducing admissions was a Tennessee study; however, in that study it was evident that “outpatient clinics are not vigorously enforcing the law” and thus non adherence had no consequences (Bursten 1986). Outpatient commitment has also been shown to be effective as a form of assisted treatment in increasing treatment compliance. In North Carolina only 30 percent of patients on outpatient commitment refused medication during a six-month period compared to 66 percent of patients not on outpatient commitment (Hiday and Scheid-Cook 1987). In Ohio, outpatient commitment increased patients’ compliance with outpatient psychiatric appointments from 5.7 to 13.0 per year and with attendance at day treatment sessions from 23 to 60 per year (Munetz et al., 1996). In Arizona, among patients who had been outpatient committed “71 percent of the patients voluntarily maintained treatment contacts six months after their orders expired” compared to “almost no patients” who had not been put on outpatient commitment (Van Putten et al. 1988). And in Iowa “it appears as though outpatient commitment promotes treatment compliance in about 80 percent of patients while they are on outpatient commitment. After commitment is terminated about three-quarters of that group remain in treatment on a voluntary basis” (Rohland 1998). References Amador XF, Strauss DH, Yale SA, Gorman JM. Awareness of illness in schizophrenia. Schizophrenia Bulletin 17:113132, 1991. Bursten B. Post hospital mandatory outpatient treatment. American Journal of Psychiatry 143:12551258, 1986. Fernandez GA and Nygard S. Impact of involuntary outpatient commitment on the revolving-door syndrome in North Carolina. Hospital and Community Psychiatry 41:10011004, 1990. Hiday VA and Scheid-Cook TL. The North Carolina experience with outpatient commitment: a critical appraisal. International Journal of Law and Psychiatry 10:215232, 1987. Munetz MR, Grande T, Kleist J, Peterson GA. The effectiveness of outpatient civil commitment. Psychiatric Services 47:12511253, 1996. Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. The de facto US Mental and Addictive Disorders Service System: Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Archives of General Psychiatry 50:8594, 1993. Rohland BM. The role of outpatient commitment in the management of persons with schizophrenia. Iowa Consortium for Mental Health, Services, Training, and Research, May 1998. Swartz M, Swanson J, Hiday V, Borum R, Burns B and Wagner, R. Can Involuntary Outpatient Commitment Reduce Hospital Readmissions Among Severely Mentally Ill Individuals? Presented at the International Congress on Law & Mental Health. Paris, France. July 1998. Torrey EF and Kaplan RJ. A national survey of the use of outpatient commitment. Psychiatric Services 46:778784, 1995. Torrey EF. Out of the Shadows: Confronting America’s Mental Illness Crisis. New York: John Wiley and Sons, 1997. Van Putten RA, Santiago JM, Berren MR. Involuntary outpatient commitment in Arizona: a retrospective study. Hospital and Community Psychiatry 39:953958, 1988. Zanni G and deVeau L. Inpatient stays before and after outpatient commitment. Hospital and Community Psychiatry 37:941942, 1986. [ To top of page ] [ To index ] Scientific Proof Positive: Outpatient Commitment Works The following are scientific studies that prove Outpatient Commitment Laws in other states have helped people with neurobiological disorders (i.e., schizophrenia, bipolar disorder, etc.) in their recovery, while simultaneously cutting down on hospital use and deterring dangerous behavior that often results from untreated brain disorders. New York is faced with a ludicrous and cruel situation. If someone needs medical care but fails to recognize it, current law only allows a judge to order the most expensive and most restrictive form of treatment: inpatient hospitalization. Judges, psychiatrists, consumers and family members should have available a less restrictive, less expensive, and often more beneficial option: outpatient commitment. All of these scientific studies have been published in peer-review publications. Experts, not advocates, performed them. You are encouraged to read them in detail. For your convenience, relevant sections of each study's conclusions are quoted below. The Effectiveness of Outpatient Civil Commitment Mark R. Munetz, M.D.; Thomas Grande, M.A.; Jeffrey Kleist, Ph.D.; and Gregory A. Peterson, M.D. Psychiatric Services (vol. 47, no. 11, pp. 1251-1253), November, 1996“The effects of outpatient civil commitment on community tenure and functioning were studied in a group of 20 patients with a history of recurrent hospitalizations, noncompliance with outpatient treatment, and good response to treatment. 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. They significantly increased the number of appointments kept with their psychiatrist. It appears that when used judiciously, outpatient civil commitment is a helpful tool in maintaining hospital recidivists in the community.” (p.1251) (emphasis added) Involuntary Outpatient Commitment in Arizona: A retrospective study Robert A. Van Putten, M.D.; Jose M. Santiago, M.D.; and Michael R. Berren, Ph.D. Hospital and Community Psychiatry (vol. 39, no. 9, pp. 953-958), September, 1988 “In July 1983 Arizona's commitment statutes were revised to allow the courts to order involuntary outpatient treatment for the mentally ill. Using retrospective data from medical and court records, patients at a county hospital in Tucson for whom involuntary commitment was sought before outpatient commitment was available were compared with similar groups of patients after outpatient commitment was instituted. Patients ordered to receive outpatient treatment did not differ significantly in diagnosis or reason for commitment from patients committed to inpatient treatment before the change in the law. However, shorter inpatient stays were reported after outpatient commitment became available. In addition, the percentage of patients who voluntarily maintained an active relationship with community treatment centers six months after commitment increased significantly after outpatient commitment was instituted.” (p. 953) (emphasis added) The North Carolina Experience with Involuntary Commitment: A Critical Appraisal Virginia Aldige Hiday, Ph.D., and Teresa L. Scheid-Cook, Ph.D. International Journal of Law and Psychiatry (vol. 10, pp. 215-232), 1987 “This study is the first to evaluate OPC [outpatient commitment] with a six month follow-up and to compare its effects with those of release and involuntary [inpatient] hospitalization. The data indicate that [outpatient commitment] is successful. When respondents show up and begin treatment, [outpatient commitment] works in terms of keeping patients in treatment and on medication, increasing compliance, permitting residence outside an institution and social interaction outside the home, and maintaining patients in the community with few dangerous episodes.” (p. 229) (emphasis added) Involuntary Administration of Medication in the Community: The Judicial Opportunity Marilyn J. Schmidt, J.D., and Jeffrey L. Geller, M.D., M.P.H. Bulletin of the American Academy of Psychiatry and Law (vol. 17, no. 3, pp. 283-292), 1989 “For the previously long-term institutionalized patient, a court order for outpatient treatment, with its coercive component, can be crucial to medication maintenance in the community until insight is achieved. For the rapid recidivist, such an order can procure the compliance with medication necessary to stay out of the hospital. And, for the outpatient, a court order can obviate the need for hospitalization altogether.” (p. 291) (emphasis added) Violent Behavior By Individuals With Serious Mental Illness E. Fuller Torrey, M.D. Hospital and Community Psychiatry (vol. 45, no. 7, pp. 653-662), 1994“…[T]he vast majority of individuals with serious mental illness are not violent and are not more dangerous than individuals in the general population. A subgroup of such individuals [almost all untreated], however, are more dangerous, and the data suggest that this problem is increasing.” (p. 658) (emphasis added) “...Recommendations...Outpatient commitment, in which an individual with serious mental illness can remain in the community only as long as he or she takes medication and otherwise complies with specific treatment, should be used much more widely.” (p.660) (emphasis added) “In some states [including New York], an individual with tuberculosis and schizophrenia may be treated involuntarily for the tuberculosis but not for the schizophrenia.” (p.660) (emphasis added). Mental Disorder and Violent Behavior John Monahan, Ph.D. American Psychologist (vol. 47, no.4, pp. 511-521), 1992."The data that have recently become available, fairly read, suggest the one conclusion I did not want to reach: Whether the measure is the prevalence of violence among the disordered, or the prevalence of disorder among the violent, whether the sample is people who are selected for treatment as inmates or patients in institutions or people randomly chosen from the open community, and no matter how many social and demographic factors are statistically taken into account, there appears to be a relationship between mental disorder and violent behavior. Mental disorder may be a robust and significant risk factor for the occurrence of violence as an increasing number of clinical researchers in recent years have averred." (p. 519) (citations omitted) (emphasis added) The scientific evidence is clear: Outpatient commitment works. Our judges must have the option to use it. New York needs outpatient commitment. [ To top of page ] This document was compiled by the New York Treatment Advocacy Coalition. (Posted 2/1999)

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