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Fact Sheet:
ASSISTED OUTPATIENT TREATMENT
Assisted Outpatient Treatment (a.k.a. outpatient commitment) is proposed in
Assemblywoman HelenThomsons bill (AB1800). This effective treatment mechamism can
help stem homelessness, criminalization, and revolving door hospitalizations by requiring
at risk patients to maintain treatment while in the community. The following are excerpts
of some of the many studies that have shown the effectiveness of Assisted Outpatient
Treatment.
What is Assisted Outpatient Treatment?
"Involuntary outpatient care is an innovative
answer to the deinstitutionalization of the severely mentally ill who cannot or will not
care for themselves. We believe that if it is done with clarity and compassion, it can
fulfill the promise of effective treatment and avoid the peril of unnecessary state
control of those individuals who live in the shadows of our society." (Meloy, Reid
J., et al, Clinical Guidelines for Involuntary Outpatient Treatment, Professional Resource
Exchange, Inc. 1990, pg. 64)
Assisted Outpatient Treatment Reduces Revolving Door Hospitalizations
"Involuntary outpatient commitment has been used
as a means of treating so-called revolving door patients in the community and allowing
them to experience the positive aspects of social and community life that stability can
bring. To study the impact of North Carolinas revised outpatient commitment law on
institutionalization rates, the authors measured state hospital admissions and days of
hospitalization within a three-year period for all patients committed to outpatient
treatment during that period. Statistically significant degreases occurred in both
measures: the biggest percent reduction occurred in admission rates." (Fernandez,
G., Nygard, Sylvia, Impact of Involuntary Outpatient Commitment on the Revolving-Door
Syndrome in North Carolina, Hospital and Community Psychiatry, Sept, 1990, Vol. 41, No. 9,
pg. 1001-1004)
- "Involuntary outpatient commitment (OPC) is a civil
justice procedure intended to enhance compliance with community mental health treatment,
to improve functioning, and to reduce recurrent dangerousness and hospital recidivism. The
research literature on OPC indicates that it appears to improve outcomes in rates of
rehospitalization and length of stay." (Swartz, MS et al, The ethical challenges
of a randomized controlled trial of involuntary outpatient commitment, Journal of Mental
Health Adm., 24 (1):35-43, 1997 Winter)
- "These data clearly indicate that the {Massachusetts}
Involuntary Outpatient Treatment group experienced a marked decrease in inpatient use
during the two years following their commitment orders. The number of inpatient days
continued to decrease over the four post-treatment periods, while for admissions the drop
was more immediate and was maintained over time..." (Geller, JL et al, A
competency-based approach to court-ordered outpatient treatment, New Directions Mental
Health Services, (75):81-95, 1997, Fall)
- "The total number of days hospitalized during the 11
month follow-up by the two groups (101 days for controls and 43 days for experimentals) is
a big difference, but one that does not attain statistical significant
However, if we
had had twice as many subjects in the study, this difference in hospital days would have
attained the 5% level of statistical significance." (Policy Research Associates,
Inc., Final Report, Research Study of the New York City Involuntary Outpatient Commitment
Pilot Program, Dec. 4, 1998)
Assisted Outpatient Treatment Increases Medication Compliance
- "Data collected in a statewide study of
psychiatric patients involved in civil commitment hearings in North Carolina were used to
evaluate the effectiveness of outpatient commitment as a less restrictive commitment to
involuntary hospitalization. Six months after the commitment hearings, outcome data for
patients who were committed to outpatient treatment were compared with outcome data for
patients who were released and patients who were involuntarily hospitalized. All three
groups comprised patients who were chronically mentally ill, had previously been
hospitalized and had histories of medication refusal and dangerousness. Patients who were
committed to outpatient treatment were significantly more likely than patients with the
other two dispositions to utilize aftercare services and to continue in treatment." (Hiday,
Virginia; Scheid-Cook, Teresa, A Follow-up of Chronic Patients Committed to Outpatient
Treatment, Hospital and Community Psychiatry, January 1989, Vol. 40, No. 1)
- "Outpatient commitment {in Iowa} appears to improve
compliance with treatment in about 80% of patients. From the data provided in this study,
outpatient commitment appears to be successful in reducing hospital and emergency room use
by persons, who as a group, are characterized by having a history of medication
non-compliance, a history of substance abuse, use of more than two different types of
antipsychotic medications during a five year period, and use of a depot form of
antipsychotic medications. Persons with schizophrenia and other psychotic disorders have
an increased number of outpatient visits compared to the twelve month period preceding
commitment, suggesting that outpatient commitment measures medication compliance." (Rohland,
Barbara, The Role of Outpatient Commitment in the Management of Persons with
Schizophrenia, Report, Iowa Consortium for Mental Health Services, Training, and Research,
May 1998)
Assisted Outpatient Treatment Increases Treatment Compliance even after court order
expires
- "This paper describes the use and effectiveness
of outpatient commitment in inducing compliance with treatment among chronically mentally
ill "revolving door" patients, those who recurrently become dangerous and
revolve through civil commitment courts as well as state mental hospitals
Comparison
of those patients ordered to outpatient commitment with those having other court
dispositions (involuntary hospitalization and release) indicates that outpatient
commitment induces compliance and leads to treatment maintenance even after the court
order terminates." (Hiday, Scheid-Cook, "Outpatient Commitment for
"Revolving Door" Patients: Compliance and Treatment, The Journal of Nervous and
Mental Disease, 1991, Vol. 179, No. 2)
- "In July 1983 Arizona's commitment statutes were
revised to allow the courts to order involuntary outpatient treatment for the mentally
ill. Using retrospective data from medical and court records, patients at a county
hospital in Tucson for whom involuntary commitment was sought before outpatient commitment
was available were compared with similar groups of patients after outpatient commitment
was instituted. Patients ordered to receive outpatient treatment did not differ
significantly in diagnosis or reason for commitment from patients committed to inpatient
treatment before the change in the law. However, shorter inpatient stays were reported
after outpatient commitment became available. In addition, the percentage of patients who
voluntarily maintained an active relationship with community treatment centers six months
after commitment increased significantly after outpatient commitment was instituted."
( Robert A. Van Putten, M.D.; Jose M. Santiago, M.D.; and Michael R. Berren, Ph.D.,
Hospital and Community Psychiatry (vol. 39, no. 9, pp. 953-958), September, 1988 )
Assisted Outpatient Treatment reduces violence
- "Individuals in the OPC group who got longer and
sustained periods of OPC {Outpatient Commitment} (e.g. 180 days or more) did significantly
better on the following outcomes: Lower odds of any psychiatric admission, fewer
psychiatric admissions, longer time to readmission, shorter total days of hospitalization,
lower odds of violence in the community. These improved outcomes in the "high
dose" group were particularly strong among individuals with psychotic diagnosis
(non-affective disorders) and among individuals with SMI/SA and histories of violence
(aggressive dually diagnosed individuals {mentally ill and substance abusing}." (Swartz,
Marvin, et al, "Can Involuntary Outpatient Commitment Reduce Hospital Readmissions
among Severely Mentally Ill Individuals?, presented at International Congress on Law &
Mental Health, July 1998, Paris.)
- OPC works in terms of keeping patients in treatment and on
medication, increasing compliance, permitting residence outside an institution and social
interaction outside the home, and maintaining patients in the community with few dangerous
episodes." (Hiday, V, Scheid-Cook, T, The North Carolina Experience with
Outpatient Commitment: A critical Appraisal, International Journal of Law and Psychiatry,
Vol. 10, 215-231, 1987
Assisted Outpatient Treatment is more effective than Assertive Case Management Alone
- "Patients who benefit most {from outpatient
commitment} appear to be those who meet Gellers guidelines, that is those who have
demonstrated repeated cycles of psychotic decompensation, involuntary hospitalization and
treatment, good response, discharge, noncompliance with treatment and psychotic
decompensation
That aggressive case management alone was not adequate to maintain
these patients in the community is evidenced by the considerable amount of case management
services provided to them in the period before outpatient commitment. " (Munetz,
Mark, The Effectiveness of Outpatient Civil Commitment, Psychiatric Services, Nov. 1996,
Vol. 47, No. 11, pg. 1251-53)
Assisted Outpatient Treatment Reduces Substance Abuse
- "We examined outcomes of patients with severe
mental illness who were involuntarily committed for up to five years to the state
psychiatric hospital {New Hampshire} and who were conditionally discharged to outpatient
treatment
Outcomes measured were hospital days, violence, medications compliance,
residential moves, substance abuse and employment. Positive improvements were found in all
areas of functioning with the most consistent effects for medication compliance, substance
abuse, and violence." (OKeefe, et al, Treatment Outcomes for Severely
Mentally Ill Patients Conditionally Discharged to Community Based Treatment, Journal of
Nervous and Mental Diseases, 185:409-411, 1997)
Assisted Outpatient Treatment Increases Quality of Life for the Person
- "The data indicate that OPC {at St. Elizabeth
Hospital, D.C.} is successful
OPC works in terms of keeping people in treatment and
on medication, increasing compliance, permitting residence outside an institution and
social interaction outside the home, and maintaining patients in the community with few
dangerous episodes." (Zanni, G, deVear, L, Inpatient Stays Before and After
Outpatient Commitment, Hospital and Community Psychiatry, September 1986, Vol. 37, No. 9)
- "Even though the law {in Tennessee} does not
demonstrably reduce readmissions, it might have other beneficial effects such as improving
the quality of life of patients while they are out of the hospital, reducing the severity
of illness at the time of readmission, or shortening the time spent in the hospital."
(Bursen, Ben, Posthospital Mandatory Outpatient Treatment, American Journal Psychiatry,
142:10, October, 1986)
Assisted Outpatient Treatment Reduces Criticism of Mental Health System
- "One criticism remained. The law was letting a
needy group slip through its cracks. The chronic mentally ill who failed to obtain
treatment on their own, who then decompensated and exhibited bizarre behavior, could not
be civilly committed until they did something dangerous even though they had a history of
becoming dangerous in the later states of decompensation following bizarre behavior.
Family, friends, mental health professionals, and courts had to sit by and wait for these
persons to threaten, attempt, or complete acts which could result in harm before civil
commitment could be used to restrain and force treatment on them. This group of chronic
mentally ill revolved regularly in and out of the state hospitals. Once involuntarily
hospitalized and stabilized on medication, they no longer met the dangerousness criterion
for commitment. Soon after release, however, they quit taking their medication and quit
going for treatment which predictively led to decompensation, bizarre behavior, and
eventual dangerousness. Ten years after the initial reform statute, the state legislature
designed the outpatient commitment law (OPC) to fill the cracks in the statute through
which this needy group had fallen
The data indicate that OPC is successful." (Hiday,
V, Scheid-Cook, T, The North Carolina Experience with Outpatient Commitment: A critical
Appraisal, International Journal of Law and Psychiatry, Vol. 10, 215-231, 1987)
Patients Believe Assisted Outpatient Treatment Works
- "This study examined beliefs about the provision
of outpatient commitment and their effects among 306 people with severe and persistent
mental illness who were awaiting a period of outpatient commitment
About 82 percent
believed that when people are under outpatient commitment, they are more likely to keep
their appointment at the mental health center. Seventy-seven percent thought that people
on outpatient commitment are more likely to stay out of the hospital. Eighty-three percent
of respondents thought people on outpatient commitment are more likely to take their
medication." (Borum et al, Consumer Perceptions of Involuntary Outpatient
Commitment, Psychiatric Services, Nov. 199, Vol. 50, No. 11, pg 1489-1491)
Judges Opinion of Assisted Outpatient Treatment
- "As part of our work with the Oregon Task Force
on Civil Commitment, we survey the judges and commitment investigators involved in the
states involuntary treatment program
Regarding changes in the system, the
investigators and judges indicated that outpatient treatment (including compliance with
medications) should be required of committed patients. These professionals noted that
involuntary outpatient treatment could only be enforced if the system included a mechanism
for hospitalizing patients who were noncompliant." (McFarland, B.H. et al,
Investigators and judges opinions about civil commitment. Bulletin of the American
Academy of Psychiatry and the Law, 1989, 17(1):15-24
Assisted Outpatient Treatment commits the System to the Patient
- "PRA found that the court orders provided a
structure around which providers and patients constantly negotiated the terms of
treatment. This is also consistent with Bellevues observation that outpatient
commitment orders often engage severely mentally ill individuals with histories of
noncompliance in a dialogue about the need for treatment when they are still outpatients,
and therefore assist in soliciting patient compliance in the community and preventing
relapse.", (Telson, H., et al, Report of the Bellevue Hospital Center Outpatient
Commitment Pilot Program, March 1, 1999)
- "According to this model, court-mandated outpatient
treatment may improve long-term outcomes both directly and indirectly in several ways: by
stimulating case management efforts, mobilizing supportive resources, improving individual
compliance with treatment in the community, reducing clients psychiatric symptoms
and dangerous behavior, improving clients social functioning, and finally be
reducing the chance of illness relapse and rehospitalization." (Swanson, et al,
Interpreting the effectiveness of involuntary outpatient commitment, a conceptual model,
Journal of American Academy of Psychiatry and the Law, 25 (1):5-16, 1997)
Assisted Outpatient Treatment is effective cross international borders
- "The effectiveness of Israels compulsory
ambulatory treatment orders was evaluated based on a one year follow up of the 326 orders
served during the first four years of implementation
Success was defined as
continuous treatment for the entire six-month period of compulsory ambulatory treatment,
or as voluntary hospitalization during or after the compulsory ambulatory period. The
compulsory ambulatory treatment order was found to be efficacious in 43.4 percent of the
cases, in 32.5 percent it did not succeed in preventing compulsory hospitalization, and in
the remaining cases (22.1 percent) success was partial...Our results indicate that
compulsory ambulatory treatment is an effective tool for the prevention of compulsory
hospitalization." (Durst, et al, E, Evaluation of Compulsory Ambulatory Treatment
in Israel, Psychiatric Services, May 1999, Vol. 50, No. 5)
***This document was compiled by the
California Treatment Advocacy Coalition***
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