Arlington, VA – Attorney General
Eliot Spitzer’s bold and compassionate proposal to implement outpatient commitment
(OPC) statewide for individuals with severe mental illnesses would substantially improve
the quality of life for all New Yorkers, if implemented into law. We commend him on this
landmark step and appreciate his soliciting our input when crafting this long-overdue and
much needed legislation.
The Attorney General’s proposal would help ensure those individuals like Andrew
Goldstein, Michael Laudor, and Larry Hoag would have taken the medications needed to
control the symptoms of their disease, thereby lowering the likelihood of exhibiting
violent behavior. Each of these men suffers from schizophrenia and none was taking
medication when he committed tragic, fatal violent acts. New York State legislators must
stop the deadly pattern of untreated severe mental illness and enact OPC statewide.
At least 39 states now use some form of outpatient assisted treatment to substantially
improve the lives of those suffering from severe mental illness and enhance the
communities in which they live. Long-term OPC has shown repeatedly to be more effective in
improving outcomes for severely mentally ill individuals than routine outpatient care. For
example, among patients who had been outpatient committed in Arizona, 71 percent
voluntarily maintained treatment contacts six months after their court orders expired
compared to almost none of the patients who had not been put on outpatient commitment. A
study in Iowa showed that 80 percent of patients in outpatient commitment complied with
their treatment programs. After their outpatient commitment term expired, some
three-quarters of that group remained in treatment on a voluntary basis.
A recent study of New York’s Bellevue Hospital OPC pilot program revealed that
individuals who received court ordered treatment in addition to enhanced community
services spent 57 percent less time in psychiatric hospitals than individuals who received
only enhanced services. During the 11 months of the study, individuals who had both court
ordered treatment and enhanced services spent only six weeks in the hospital, compared to
14 weeks for those who did not receive court orders.
Nearly half of those individuals who have schizophrenia or manic-depressive illness,
the two severest forms of psychiatric illness, have no awareness of their disease. They do
not recognize that the symptoms of their illness – hallucinations, delusions,
paranoia and withdrawal – are, in fact, symptoms. These individuals consistently
refuse to take medication because they do not believe they are sick, and commonly will
only take it under some form of assisted treatment.
Untreated, the symptoms of these brain diseases can be extraordinarily disabling. For
example, schizophrenia interferes with a person’s ability to think clearly, manage
emotions, make decisions, and relate to others. An individual with schizophrenia
experiences delusions and hallucinations; alterations of the senses; an inability to sort
and interpret incoming sensations, and therefore to respond appropriately; an altered
sense of self; and changes in emotions, movements and behavior. Individuals diagnosed with
manic-depressive illness, or bipolar disorder, also can experience delusions and
hallucinations, coupled with mood swings that alternate from periods of severe highs, or
mania, to extreme lows, or depression. These mood swings are out of proportion or totally
unrelated to events in a person’s life and affect thoughts, feelings, physical
health, behavior, and functioning.
The consequences of failing to treat these illnesses are devastating. For example,
individuals with untreated severe mental illness commit almost 1,000 of the 20,000 annual
homicides in the United States. At least one-third of the estimated 450,000 homeless
individuals suffer from schizophrenia or manic-depressive illness, and 28 percent of these
people forage for some of their food in garbage cans. At least 10 percent, or 170,000
individuals, of our jail and prison populations suffer from these illnesses, costing
American taxpayers a staggering $8.5 billion per year. Moreover, studies suggest that
delaying treatment results in permanent harm, including increased treatment resistance,
worsening severity of symptoms, increased hospitalizations and delayed remission of
symptoms. In addition, persons suffering from severe psychiatric illnesses are frequently
victimized. Studies have shown that 22 percent of women with untreated schizophrenia have
been raped. Suicide rates for both males and females suffering from schizophrenia and
manic-depressive illness are much higher than for the general population.
It’s time to reverse course. Mandatory treatment for those too ill to recognize
their need for treatment is a much more humane intervention than what we have now:
mandatory non-treatment. The legal standard for assisted treatment should be the need for
medical care, not dangerousness. Society has an obligation to save people from
degradation, not just death.
This does not mean that we will have to reopen all the psychiatric hospitals that have
closed as a result of deinstitutionalization. Most individuals with severe mental
illnesses who have experienced severe deterioration in rational thought can live in the
community. But, their living in the community should be conditioned on continued
medication compliance. OPC, conditional hospital releases, and conservatorships must be
widely used to ensure that discharged patients continue to take their medication.
In addition to the Attorney General’s proposal, the Center recommends the state of
New York undertake the following five initiatives:
- Utilize New York’s rarely used conditional discharge statute.
On the
books since 1919, New York’s conditional discharge law allows directors of
psychiatric facilities to put reasonable conditions on the early discharge of patients,
such as taking prescribed medication, refraining from using illicit drugs, and reporting
for appropriate services periodically. If patients do not comply with the discharge
orders, they can be involuntarily returned to the hospital. Patients are presently
released into our communities under no obligation to continue treatment.
- Institute conservatorships statewide.
Conservatorships, also known as
guardianships, have proven to be highly effective in helping people who are mentally
incapacitated with other brain disorders such as Alzheimer’s disease or mental
retardation. Courts appoint someone – a family member, friend, case worker – to
make treatment decisions for the individual suffering from a brain disability. The
conservator can insist that the ill individual take prescribed medication and order that
the person be involuntarily hospitalized if he or she refuses to comply.
- Build a statewide network of community-based outreach services.
When
used in combination with outpatient commitment or conditional discharge, Assertive
Community Treatment (ACT) programs have proven to be one of the most effective tools in
treating people with severe mental illness. Serving as a hospital without walls, ACT
professionals are available around the clock and meet their clients where they live,
providing at-home support at whatever level is needed. Professionals can make sure that
clients are taking their medication and help them meet the challenges of daily life –
every day tasks ranging from grocery shopping and keeping doctor appointments to managing
money and getting along with others.
- Increased police training.
Police officers are increasingly the first
at the scene of calls involving individuals with severe mental illness. While police
contact with the mentally ill has grown substantially, their training in dealing with
psychotic individuals has not, resulting in far too many violent, and in many instances
fatal, encounters. Proper training would enable the police to defuse more situations
successfully without resorting to physical force.
- Repeal the Medicaid Institutions for Mental Diseases (IMD) exclusion.
The state level, as a general rule, is the most logical level of government to take
responsibility for public psychiatric services. As it stands now, the Federal government
controls how a state is allocated funds for its mentally ill citizens. As a result, the
question driving a state’s mental health system is not "what does a patient
need?" but rather "what will federal programs pay for?" When the Federal
government established Medicaid and other federal programs for the mentally ill, it
excluded most payments to state psychiatric hospitals and other "institutions for the
treatment of mental diseases" or IMDs. Because the federal government did not want to
take on what had been a state responsibility, hundreds of thousand of patients have been
discharged from state psychiatric hospitals – where they can receive the best care
– and transferred to nursing homes and similar institutions. More than 90 percent of
state hospital beds have been eliminated over the last 45 years, resulting in disjointed
and substandard care and follow-up for the sickest and most vulnerable in society. New
York must tell Washington to repeal the Medicaid IMD exclusion.
