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NEWS
Bellevue Program Successfully
Reduces Hospitalization
for Individuals With Severe Psychiatric Disorders
Arlington, VA – A pilot outpatient commitment
(OPC) program at Bellevue Hospital again demonstrates that intensive outpatient services
coupled with court ordered treatment work to reduce hospital stays for individuals with
severe mental illnesses, such as schizophrenia and manic depressive disorder. In OPC, a
court mandates treatment (usually including medication) for individuals who suffer from
severe mental illnesses who have a history of medication non-compliance in the community.
A new study of the Bellevue OPC program revealed that individuals who received court
orders for treatment in addition to enhanced community services spent 57 percent less time
in psychiatric hospitals than individuals who had enhanced services alone without a court
order. That is, those who did not have court ordered treatment spent 14 weeks in the
hospital, compared to six weeks for those who did have a court order.
Mel Silverman, a member of Rockland County’s
NAMI-FAMILYA, whose 43-year-old son is in the Bellevue program, said, "My son is
doing better now than he ever has during the last 23 years of his illness."
Silverman’s son graduated magna sum laude from Cornell University before being
diagnosed with manic-depressive disorder. According to Mr. Silverman, "You name the
hospital in the New York City Metro area and he has been in it. My son is now on an
even-keel for the first time in a long time thanks to this program."
Silverman’s son has benefited from a court order for treatment, coupled with
services provided by his assertive community treatment (ACT) team, which is an intensive
clinical outreach team. The combination of the court order and the ACT team is an
effective means of ensuring that he continues the treatment that keep him well.
New York is one of the last states to implement OPC even though it has been shown
repeatedly to be effective in other states. In Washington, D.C., admissions
decreased from 1.81 per year to 0.95 per year before and after outpatient commitment; in
Ohio the decrease was from 1.5 to 0.4; and in Iowa from 1.3 to 0.3. In North Carolina,
admissions for patients on outpatient commitment decreased from 3.7 to 0.7 per 1,000 days.
Another study in North Carolina demonstrated fewer psychiatric admissions and shorter
lengths of stay for patients who received case management services enhanced by a court
order (admissions - 0.34 per patient and length of stay 6.9 days) than for individuals who
received case management without a court order.
An equally important finding from the study of the Bellevue OPC program is that the
enhanced community services that all participants received were effective in reducing
rehospitalization rates overall (for individuals with court orders the rate dropped from
87.1 percent to 51.4 percent; for those who did not have orders the rate dropped from 80.1
percent to 41.6 percent).
Another important, yet unexpected finding is that there was no reported difference in
the perception of coercion between the court ordered and non-court ordered participants in
the program. This is significant because it dispels critics’ concerns that the
clinical benefits of treatment will be compromised in OPC programs because patients view
OPC as coercive.
The program could be improved further and the results enhanced by streamlining the
procedures available for enforcing the court orders. Until the end of October 1998, there
was no mechanism available to enforce compliance with treatment orders. The procedure that
was finally put in place is too cumbersome to be effective. The enforcement provisions of
the statute (NY Mental Hygiene Law �9.61) must be re-examined to ensure that the process
is streamlined while still protecting the individual’s rights.
The law that created the Bellevue OPC program is scheduled to expire on June 30, 1999.
Public hearings will be held on Wednesday, December 16, 1998 at New York University
Medical Center from 4:00 p.m. to 8:00 p.m. on the effectiveness of the Bellevue OPC
program and whether to extend the program.
The overall success of the program in reducing the rates of rehospitalization and
length of hospital stays warrants extending the pilot program and expanding it throughout
the state of New York.
###
The Treatment Advocacy Center (www.treatmentadvocacycenter.org) is a national nonprofit organization dedicated to eliminating barriers to the timely and effective treatment of severe mental illnesses. TAC promotes laws, policies, and practices for the delivery of psychiatric care and supports the development of innovative treatments for and research into the causes of severe and persistent psychiatric illnesses, such as schizophrenia and bipolar disorder.
(Editor’s Note: See backgrounder for citations on outpatient commitment research.
To get more information on the report or to obtain a copy, media should call the
NYC Department of Mental Health’s Public Information Office at 212 219 5566).
---------------------------------------------------------------------------------------------------------------
Background: Outpatient Commitment
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 (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 (Swartz 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):
-
OPC patients fewer psychiatric admissions (.34 per OPC patient vs. 1.23 per controls).
-
OPC patients spent fewer mean days in the hospital (6.9 days for OPC patient vs. 20.1
days for controls).
-
OPC patients had "lower odds of violence in the community."
-
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 nonadherence
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 17:113–132, 1991.
Bursten B. Posthospital mandatory outpatient treatment. American Journal of
Psychiatry 143:1255–1258, 1986.
Fernandez GA and Nygard S. Impact of involuntary outpatient commitment on the
revolving-door syndrome in North Carolina. Hospital and Community Psychiatry
41:1001–1004, 1990.
Hiday VA and Scheid-Cook TL. The North Carolina experience with outpatient commitment:
a critical appraisal. International Journal of Law and Psychiatry 10:215–232,
1987.
Munetz MR, Grande T, Kleist J, Peterson GA. The effectiveness of outpatient civil
commitment. Psychiatric Services 47:1251–1253, 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
50:85–94, 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 46:778–784, 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 39:953–958, 1988.
Zanni G and deVeau L. Inpatient stays before and after outpatient commitment. Hospital
and Community Psychiatry 37:941–942, 1986.
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