Assisted Outpatient Treatment

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Assisted Outpatient Treatment Reduces Hospital Stays, Violence

And Improves Odds of Recovery for People with Severe Mental Illnesses

Approximately 40 percent of all individuals with severe mental illnesses (i.e. schizophrenia and manic-depressive illness) are not receiving treatment at any given time.¹ Many of these individuals are homeless, in jail on misdemeanor charges, and responsible for increasing episodes of violence.²A 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 schizophrenia³ and mania⁴ 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.

Forty-one states use a form of assisted treatment commonly referred to as outpatient commitment, also called assisted outpatient treatment.⁵ Assisted outpatient treatment involves court ordered treatment (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.

Long-term assisted outpatient treatment (LT-AOT) combined with routine outpatient services (3 or more outpatient visits per month) has been shown to be significantly more effective in reducing violence and improving outcomes for severely mentally ill individuals than routine outpatient care without LT-AOT. Results from a North Carolina study ⁶ showed a 36% reduction in violence among severely mentally ill individuals in long-term assisted outpatient treatment (LT-AOT - 180 days or more) compared to individuals receiving less than LT-AOT (0 to 179 days). Among a group of individuals characterized as seriously violent (i.e. committed violent acts within the 4 month period prior to the study), 63.3% of those not in LT-AOT repeated violent acts while only 37.5% of those in LT-AOT did so. LT-AOT combined with routine outpatient services reduced the predicted probability of violence by 50%.

In another report from the North Carolina study,⁷ LT-AOT reduced hospital admissions by 57% and length of hospital stay by 20 days compared to individuals without court ordered treatment. The results were even more dramatic for individuals with schizophrenia and other psychotic disorders for whom LT-AOT reduced hospital admissions by 72% and length of hospital stay by 28 days compared to individuals without court ordered treatment.

The effectiveness of assisted outpatient treatment 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.⁸ Similarly, in Ohio the decrease was from 1.5 to 0.4⁹ and in Iowa from 1.3 to 0.3.¹⁰ In North Carolina, admissions for patients on outpatient commitment decreased from 3.7 to 0.7 per 1,000 days.¹¹ Only two studies have failed to definitively find assisted outpatient treatment effective in reducing admissions. One was a Tennessee study in which it was evident that "outpatient clinics are not vigorously enforcing the law" and thus non-adherence had no consequences.¹²

The second was a study in New York in which the authors acknowledged that a "limit on [the study’s] ability to draw wide-ranging conclusions is the modest size of [the] study group."¹³ Additionally, during the period of the study, there was no procedure in place to transport individuals who did not comply with treatment orders to the hospital for evaluation. As in the Tennessee study, non-adherence to a treatment order had no consequences. Although not statistically significant, the New York study suggests that the court orders did in fact help reduce the need for hospitalization. Patients in the court-ordered group spent a median of 43 days in the hospital during the study year, while patients in the control group spent a median of 101 days in the hospital. The difference in fact just misses statistical significance at the level of p = 0.05.

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.¹⁴ 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.¹⁵ 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.¹⁶ 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."¹⁷

Endnotes:

1Regier, D.A., Narrow, W.E., Rae, D.S., Manderscheid, R.W., Locke, B.Z., Goodwin, F.K. 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, 50:85–94 (1993).

^{2Torrey, E.F. Out of the Shadows: Confronting
America’s Mental Illness Crisis, (John Wiley and Sons, 1997).
^{3Amador, X.F., Strauss, D.H., Yale, S.A., and Gorman, J.M.
Awareness of illness in schizophrenia. Schizophrenia Bulletin, 17:113–132
(1991).
^{4Ghaemi, S.N. Insight and psychiatric disorders: a review of
the literature, with a focus on its clinical relevance for bipolar disorder. Psychiatric
Annals, 27:782–790 (1997).
^{5Torrey, E.F. and Kaplan, R.J. A national survey of the use of
outpatient commitment. Psychiatric Services, 46:778–784 (1995).}}}}

6Swanson, J.W., Swartz, M.S., Borum, R. et al. Involuntary out-patient commitment and reduction of violent behaviour in persons with severe mental illness. British Journal of Psychiatry,176: 224–231 (2000).

^{7Swartz, M.S., Swanson, J.W., Wagner, R.H., et al. Can
involuntary Outpatient commitment reduce Hospital Recidivism? American Journal of
Psychiatry, 156:1968-1975 (1999).
^{8Zanni, G. and deVeau, L. Inpatient stays before and after
outpatient commitment. Hospital and Community Psychiatry 37:941–942 (1986).
^{9Munetz, M.R., Grande, T., Kleist, J., and Peterson, G.A. The
effectiveness of outpatient civil commitment. Psychiatric Services,
47:1251–1253 (1996).
^{10Rohland, B.M. The role of outpatient commitment in the
management of persons with schizophrenia. Iowa Consortium for Mental Health, Services,
Training, and Research (May 1998).
^{11Fernandez, G.A. and Nygard, S. Impact of involuntary
outpatient commitment on the revolving-door syndrome in North Carolina. Hospital and
Community Psychiatry 41:1001–1004 (1990).
^{12Bursten B. Posthospital mandatory outpatient treatment. American
Journal of Psychiatry 143:1255–1258 (1986).
^{13Research study of the New York City involuntary outpatient
commitment pilot program. Policy Research Associates, Inc. (December 1998).
^{14Hiday, V.A. and Scheid-Cook, T.L. The North Carolina
experience with outpatient commitment: a critical appraisal. International Journal of
Law and Psychiatry, 10:215–232 (1987).
^{15Munetz, supra note 8.
^{16Van Putten, R.A., Santiago, J.M., Berren, M.R. Involuntary
outpatient commitment in Arizona: a retrospective study. Hospital and Community
Psychiatry 39:953–958 (1988).}}}}}}}}}}

17Rohland, supra note 9.

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