What can New York learn about assisted treatment for schizophrenia from assisted treatment for tuberculosis?
Because individuals with tuberculosis who resist treatment risk infecting others, in 1993, New York City passed a law that allows the Commissioner of Health to issue orders compelling a person
- to be examined for tuberculosis;
- to complete treatment;
- to receive treatment under direct observation; or
- to be detained for treatment. (NYC Health Code 11.47(d) (1994).
A similar law has been proposed for the treatment of individuals with neurobiological disorders like schizophrenia who as a result of non-compliance are likely to become ‘danger to self or others’. Like with the tuberculosis law, the Outpatient Assisted Treatment Law allows someone to be ordered into treatment. While outpatient assisted treatment legislation only allows a court to order treatment (as opposed to the Commissioner of Health), and includes many other patient due-process protections, there are many similarities in the legislation being proposed to treat neurobiological (NBD) disorders to that currently used to treat individuals with TB who resist treatment.
Both pieces of legislation were designed to protect the public. The tuberculosis legislation was proposed to protect the public from the spread of tuberculosis caused by individuals with TB not complying with treatment. Outpatient Assisted Treatment is being proposed to help protect the public from incidents of violence caused by individuals with NBD who do not comply with treatment.
While Assisted Outpatient Treatment has proven successful at protecting both the public and individuals with NBD in the many states that have tried it, it has not been used in New York except in a small pilot program at Bellevue Hospital in NYC. While that project showed a dramatic decrease in hospital usage associated with treatment orders, the study was seriously flawed. Individuals who were non-compliant, psychotic, and/or violent were all excluded from the study. Since these individuals are the very ones this program was intended to help, results from this study are inconclusive at best.
Since the tuberculosis legislation has been in effect since 1993, the question is asked, which findings from that legislation could be applied to the treatment of individuals with TB? Following are some of them.
1. Outpatient Treatment Orders increase compliance
The question has been asked, does outpatient assisted treatment increase compliance? The learning from the TB program indicates it does. Since the TB program was implemented in April 1993, new cases decreased by 54.6% and cases of multidrug-resistant TB decreased by 87.3%. 96% of those placed under treatment orders successfully completed treatment.
2. There will be no need to involuntarily medicate or hospitalize significant numbers of people on outpatient treatment orders as the mere existence of treatment orders enhances compliance.
Some have questioned how the state will enforce compliance with outpatient treatment orders. The TB experience shows that the mere existence of the TB law was enough to increase compliance and few needed the most restrictive interventions. Of the 17 patients in a study who received warning letters because of their noncompliance with mandatory directly observed therapy, 13 completed treatment without being detained. For 76% of patients non compliant with mandatory treatment, warning letters were sufficient to induce recompliance. This finding is fully consistent with the Bellevue Study of Outpatient Assisted Treatment. In that study, providers reported that reminding non compliant consumers of the existence of treatment orders was an important tool in ensuring treatment compliance. In fact, in the Bellevue study, not a single patient was medicated over objection.
3. Detention increased compliance even after detention ended.
Some have suggested that non-compliance with Assisted Outpatient Treatment Orders will lead to individuals being involuntarily inpatient hospitalized for indeterminate periods. Experience with the treatment of TB shows this is not likely to be the case. Detention for individuals with TB was rarely used, but when used it was extremely effective at increasing compliance. Among 35 patients who had been detained, but discharged prior to treatment completion, 31 completed treatment.
4. Treatment Orders worked for those who are hardest to treat: those who abuse substances, are homeless, and/or have been incarcerated.
TB and NBD are similar in that the diseases are disproportionately represented among the homeless, substance abusers, and those who have been incarcerated. Among those ordered into treatment for TB, 50% were homeless, 42% used injection drugs, 63% had a history of alcohol abuse, and 48% had a history of incarceration. These figures are directionally consistent with those who have serious NBD.
5. Treatment orders are race and wealth neutral.
In their efforts to oppose outpatient assisted treatment some have suggested that minorities, the poor and others will be disproportionately ‘targeted’. The same arguments were expressed when tuberculosis legislation was developed. Those fears proved unfounded. A study of the TB program in the February 1999 New England Journal of Medicine reported, “Among the patients who received any regulatory order, the data indicate that there was no racial or social basis with regard to detention.” “The majority of patients with TB who had severe social problems never required any regulatory intervention, and very few required detention…The concern that the power to detain patients who were homeless or who were substance abusers was not realized.”
6. The availability of outpatient assisted treatment does not mean large numbers of people will be affected
In their efforts to oppose outpatient assisted treatment legislation, some have suggested that the state will use outpatient assisted treatment to order individuals into treatment who would readily accept voluntary treatment. The same fears were expressed when the tuberculosis legislation was developed. Those fears proved unfounded. Only 2% of the estimated 8,000 individuals with TB were ever treated under regulatory orders.
7. The power to detain individuals was not abused.
Patients in the Assisted Outpatient Treatment pilot project at Bellevue were provided extensive due process protections, including the right to counsel and a court hearing. Yet some have suggested that authorities will use their power to engage in massive lock ups of individuals with NBD. The experience with the TB program suggests this fear is unfounded. The New England Journal of Medicine reported, “Detention was only used when it was judged necessary to protect the public health. Patients who were detained posed a serious risk to the public health….These were the patients the law was intended to reach--those with a history of repeated hospitalizations who did not accept directly observed therapy voluntarily, were not able to complete treatment without detention, and were likely to spread disease”
Conclusion
Court ordered treatment has been proven to be effective at protecting patients in the large number of states that have utilized it. The small outpatient pilot project at Bellevue suggests a similar utility for the intervention in New York. Yet many have raised concerns about the program. Those concerns appear unwarranted when examined in light of New York’s successful use of court ordered treatment for individuals with Tuberculosis.
This article was written in February 1999 by D.J. Jaffe (under the massive tutelage of Dr. E. Fuller Torrey). An original article by Dr. E. Fuller Torrey, which formed the basis of this paper, appears in the Spring 1999 issue of City Journal published by the Manhattan Institute, NYC. Source information for this paper is from “The use of legal action in New York City to ensure treatment of Tuberculosis” by M. Rose Gasner, J.D., Khin Lay Maw, M.D., Gabriel Feldman, M.D., Paula Fujiwara, M.D., and Thomas Frieden, M.D. in New England Journal of Medicine, Vol 340 Number 5, February 4, 1999.
[ Back to NY-TAC Index ] [ Op-eds ] [ NY Laws ] [ Issues ] [ Join NY-TAC ]
The information on /newyork is provided as a public service by the NY Treatment Advocacy Coalition. For more information, to join, or to make a donation, write to NY Treatment Advocacy Coalition, Suite 4B, 250 West 27th St., New York, NY 10001 or call (212) 366-0527. To support our efforts, make checks payable to Treatment Advocacy Center. To become a free member and receive updates, please send your name, (organization's name, if any) address, phone, fax, and e-mail address to the above address, along with the following signed statement: "I HAVE RECEIVED INFORMATION ABOUT THE NY TREATMENT ADVOCACY COALITION, SUPPORT IT'S MISSION, WANT TO RECEIVE UPDATES AND BE LISTED AS A MEMBER AND SUPPORTER." Unfortunately, requests for free memberships without this information and statement can not be honored. Contents of all material on the Coalition's web site is copyrighted and rights are reserved by the NY Treatment Advocacy Coalition unless otherwise indicated. However content may be reproduced, downloaded, disseminated, or transferred by nonprofit organizations that support our mission for educational purposes if correct attribution is made to the NY Treatment Advocacy Coalition. Please feel free to call with questions on neurobiological disorders, treatment laws or the benefits of medication compliance at 703.294.6001 or 212.366.0527. Send questions via e-mail to stanleyj@psychlaws.org. Media inquiries to press@treatmentadvocacycenter.org. Technical comments on the web site (www.psychlaws.org) can be sent to Webmaster@psychlaws.org.