It is known that there are over 3 million individuals with schizophrenia and manic-depressive illness (bipolar disorder) in the United States. Approximately 800,000 of them are individuals who, before deinstitutionalization began 30 years ago, would have been hospitalized in state psychiatric hospitals (Torrey 1997).

It is also known that approximately 40 percent of all individuals with schizophrenia and manic-depressive illness are not under treatment at any one time (Regier et al. 1993). Many of these 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.

Possible options for assisted treatment are the following:

Under assertive case management, case managers actively seek out at their homes or elsewhere in the community patients who do not follow up with appointments. The Program of Assertive Community Treatment (PACT or ACT teams) is the best known example of this. Multiple studies have demonstrated that PACT teams decrease rehospitalization days. In a Baltimore study of homeless individuals with severe psychiatric disorders, 77 were assigned to a PACT team and compared with 75 others assigned to traditional outpatient treatment. During the following year, those treated by the PACT team had fewer hospital days (35 versus 67), fewer days living on the streets (10 versus 24), and fewer days in jail (9 versus 19) (Lehman et al. 1997). Those treated by the PACT team also had increased medication compliance (either intermittently or fully compliant) from 29 percent at the start to 55 percent after one year; however, "approximately one-third of the subjects were noncompliant at any given time point" (Dixon et al. 1997). Assertive case management would therefore appear to be an effective method of assisted treatment for some patients but not others.

To assist with money management, a patient’s SSI, SSDI, or VA disability check can be assigned to the patient’s family, case manager, or psychiatric clinic as the representative payee. Studies have shown that using a representative payee reduces hospitalization days (Luchins et al. 1998), substance abuse (Rosenheck et al. 1997), and days spent homeless (Stoner 1989). No study has been done on the effect of using representative payees to improve medication compliance. Anecdotal information, however, suggests that this arrangement is not unusual, e.g., the patient must accept a depot antipsychotic injection as a condition for being given his/her monthly check. In a U.S. Third Circuit Court of Appeals ruling, the court ruled that a man with epilepsy and borderline mental retardation was not entitled to SSDI benefits unless he demonstrated compliance with his anti-epileptic medication (Brown v. Bowen, 845 F2d 1211, 3rd Circuit, 1988).

Conservatorships and guardianships occur when a court appoints an individual to make treatment decisions for another individual who is believed to be mentally incompetent. They are used most frequently for individuals with mental retardation and with severe neurological diseases such as Alzheimer’s disease; they are less often used for individuals with severe psychiatric illnesses except in California. In one study done in that state, "of the 35 patients who were placed on conservatorship, 29 (83 percent) remained stable as long as the conservatorship lasted," but for the 21 patients whose conservatorship was terminated, only 9 (43 percent) remained stable after termination" (Lamb and Weinberger 1992).

This is closely related to outpatient commitment and conservatorship. In Massachusetts, which does not have an outpatient commitment statute, patients with severe psychiatric illnesses have the right to refuse medication. A mental health professional can take such an individual to court; if the court finds that the patient is incompetent, it may use a substituted judgment standard, appoint a guardian, and order the patient to take medication. In a six-month study of patients subjected to such a procedure, their admissions decreased from 1.6 to 0.6, and hospital days decreased from 113 to 44 (Geller et al. 1998). Reflecting on substituted judgment, Dr. Jeffrey Geller noted: "In one of the more ironic outcomes of mental health law over the last two decades, the right to refuse treatment court decisions have become the basis in Massachusetts for involuntary community treatment orders" (Geller 1993).

"Benevolent coercion" is Dr. Geller’s term for threatening to institute legal proceedings to compel treatment for patients who do not comply with treatment. Geller reported that he informed his patients that "if the lithium level fell below 0.5 meq/liter, the patient would be involuntarily admitted to a state hospital" (Geller 1986). According to Geller, such "benevolent coercion" is an effective method of assisted treatment. Anecdotal evidence suggests that it is used widely but rarely discussed publicly.

In one mental health center in upstate New York, the staff has an informal working arrangement with the local judge. Patients with severe psychiatric disorders who are noncompliant with medication and who are considered to be potentially dangerous to themselves or others are picked up by the police on misdemeanor charges. On arraignment, the judge refers them to the mental health center and suspends sentence pending their compliance with treatment. If they do not comply, they can be put in jail. There is no published account of such an arrangement, but anecdotal data suggest that it is not rare, especially in rural areas where a single judge may cover the entire population.

Although all forms of assisted treatment appear to be effective for some patients with severe psychiatric illnesses, efficacy for treatment compliance has only been clearly established for outpatient commitment. The paucity of research on assisted treatment is surprising given its importance.

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