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Fact Sheet:
ASSISTED OUTPATIENT TREATMENT

Assisted Outpatient Treatment (a.k.a. outpatient commitment) is proposed in Assemblywoman HelenThomson’s 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.

• "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)

• "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 Carolina’s 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)

• "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)

• "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 )

• "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

• "Patients who benefit most {from outpatient commitment} appear to be those who meet Geller’s 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)

• "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." (O’Keefe, 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)

• "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)

• "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)

• "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)

• "As part of our work with the Oregon Task Force on Civil Commitment, we survey the judges and commitment investigators involved in the state’s 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

• "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 Bellevue’s 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)

• "The effectiveness of Israel’s 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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