Modernizing New Jersey’s Civil Commitment Law

New Jersey needs assisted outpatient treatment

Assisted outpatient treatment (AOT), also known as involuntary outpatient commitment (IOC), allows a judge to issue a court order mandating that a person who meets specific criteria adhere to a prescribed community treatment plan, using the possibility of hospitalization as leverage. The main goal of AOT is to foster more consistent adherence to treatment for people whose severe mental illnesses impair their ability to seek and voluntarily comply with treatment.¹ Non-compliance with treatment, specifically non-adherence to medication, is strongly associated with hospitalization,² arrest,³ and violence⁴ among people with severe mental illnesses.

Based on New York’s experience with Kendra’s Law, AOT would be used to help a relatively small number of people in New Jersey – an estimated average of 337 individuals per year.⁵ As the Mental Health Association of New Jersey explains, “a majority of [the mentally ill] can make their own decisions about care.”⁶ AOT would not apply to the majority of people with severe mental illnesses, and would in no way adversely affect the rights of those who are able to make their own decisions regarding treatment.

New Jersey is one of only eight states that does not provide for AOT as an alternative to involuntary hospitalization for people with severe mental illnesses. The practical result of New Jersey’s failure to do so is that community mental health services are only available to people who are able to accept services voluntarily. The rest are left untreated until their condition deteriorates to the point where they are “in need of involuntary commitment” because their mental illness causes them to “be dangerous to self or dangerous to others or property.”⁷ New Jersey essentially forces people who lack insight into their illness to hit rock bottom before they can be helped – and then the only option is one of the state’s scarce remaining hospitals beds.

AOT addresses the most common reason for refusing treatment - lack of insight (anosognosia)

Extensive research since the early 1990s has revealed that some people with schizophrenia and bipolar disorder experience a neurological deficit called “anosognosia,” a condition also commonly found in people suffering other brain disorders such as Alzheimer’s or stroke.⁸ Anosognosia impairs a person’s ability to recognize that their symptoms are caused by a brain disorder.⁹ A leading researcher detailed the severe consequences of this condition:

[P]oor insight in schizophrenia is associated with poorer medication compliance, poorer psychosocial functioning, poorer prognosis, increased relapses and hospitalization and poorer treatment outcomes.¹⁰

The most common reason that people with severe mental illnesses are not being treated is that they do not believe that they need treatment.¹¹ A severe lack of insight into illness can “seriously interfere with [a patient’s] ability to weigh meaningfully the consequences of various treatment options.”¹²

New York has seen dramatic success in its first five years using AOT

Among individuals in first five years of New York’s assisted outpatient treatment program (Kendra’s Law), far fewer experienced hospitalizations (77 percent), episodes of homelessness (74 percent), arrests (83 percent), and incarceration (87 percent) and significantly more individuals had improved medication compliance (50 percent) and participation in substance abuse treatment (65 percent).¹³ Participants also had marked reductions in harmful behavior; and individuals who were in AOT for longer periods had greater reductions in violent behavior. Hospital days were reduced dramatically from an average of 50 days over a six-month period before starting AOT, to an average of 22 days during the six months of AOT, to an average of only 13 days in the six-month period after AOT. That is a full 74 percent reduction in hospital days six months after termination of the court order when compared with the six months prior to AOT.

In July of 2005, the New York Legislature recognized the success of Kendra’s Law and voted (204-1) to extend the benefits it provides. As Governor Pataki explained, "The results are clear. Kendra's Law works."¹⁴

People with severe mental illnesses report improved quality of life with AOT

More than 75 face-to-face interviews have been conducted with participants in New York’s AOT program to assess their opinions about AOT including their perceptions of coercion or stigma associated with the court order and their quality of life as a result of AOT. When asked about the impact of the pressures and other measures that people took to get them to stay in treatment:

• 75 percent of interviewed recipients reported that AOT helped them gain control over their lives,
• 81 percent said that AOT helped them to get well and stay well, and
• 90 percent said AOT made them more likely to keep appointments and take medication.

A randomized control study of AOT showed similar results. Researchers assessed the impact of AOT on quality of life of people with severe mental illnesses, covering a range of areas including social relationships, daily activities, finances, residential living situation, and global life satisfaction. They found remarkable evidence that subjects who underwent sustained periods of AOT had measurably greater subjective quality of life at the end of the study year. It appears that AOT exerts its effect largely by improving treatment adherence and decreasing symptomatology.¹⁵

A randomized control study shows that AOT significantly reduces the consequences of nontreatment

The most comprehensive, randomized control study of AOT, referred to as the Duke Study, involved people who “generally did not view themselves as mentally ill or in need of treatment.”¹⁶ The study compared people who were offered community mental health services with people who were offered the same services combined with a court order requiring participation in those services (i.e., the difference was the court order). The Duke Study showed that combining a court order with services for a long term (at least six months) reduced hospitalization (up to 74 percent), reduced arrests (74 percent), reduced violence (up to 50 percent), reduced victimization (43 percent) and improved treatment compliance (58 percent).¹⁷

Studies in other states also demonstrate that AOT works

• In Washington, D.C., hospital admissions decreased from 1.81 per year before to 0.95 per year after outpatient commitment.¹⁸
• In Ohio, the number of hospital admissions decreased from 1.5 to 0.4 per year. Outpatient commitment increased patients’ compliance with outpatient psychiatric appointments from 5.7 to 13.0 per year and attendance at day treatment sessions from 23 to 60 per year.¹⁹
• In Iowa, the number of hospital admissions were reduced from 1.3 to 0.3, total number of hospital days from 33.3 to 4.6, and length of stay from 26.7 to 18.6.²⁰
• In North Carolina, admissions for patients on outpatient commitment decreased from 3.7 to 0.7 per 1,000 days.²¹
• 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.²²
• 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.²³

Caregivers and people with severe mental illnesses report improved quality of life after sustained AOT

Families and friends who are caregivers for people with severe mental illnesses experience significant strain, particularly when their loved ones refuse treatment. In a study of the effect of AOT on caregivers, extended outpatient commitment contributed significantly to reduced caregiver strain.²⁴

Consumers believe the benefits of AOT outweigh the potential disadvantage of perceived coercion

In a survey of people with schizophrenia concerning preferences related to AOT, “being free to participate in treatment or not” was the least important outcome. When asked to rank their preferences, they answered that reducing symptoms, avoiding interpersonal conflict, and avoiding re-hospitalization outranked avoidance of outpatient commitment.²⁵ Studies show that a majority of people with severe mental illnesses who received mandatory treatment later agreed with the decision.²⁶ An informal survey of cons umers of services for people with severe mental illnesses by a fellow consumer revealed that a majority supported outpatient commitment.²⁷ A formal survey published in July 2004 found that a majority of consumers regard mandated treatment as effective and fair.²⁸ One prominent consumer advocate who has schizophrenia explained that those “who have been primarily interested in consumer rights and liberties … focus … on opposing the use of forced treatment. … On the other hand, consumer advocates who place a high value on the need for psychiatrically disabled persons to receive treatment tend to support [AOT].”²⁹

New Jersey cannot afford not to have AOT

New Jersey’s state psychiatric hospitals are severely overcrowded, with a readmission rate estimated to be as high as 35 percent at one of the state hospitals.³⁰ In its analysis of the FY 2005 state budget, the New Jersey Office of Legislative Services (OLS) warned that, “the actual census at Ancora, Greystone, and Trenton [New Jersey’s psychiatric hospitals] has historically exceeded the estimates included in the recommended budget” and“[t]he actual census of the three facilities has been between 5.3 percent and 14.1 percent greater than the estimates included in the recommended budgets between FY 2000 to FY 2004.”³¹ Two hundred and fifty-three individuals, almost ten percent of individuals between the ages of 18-64 admitted to a state hospital, are readmitted within 30 days of discharge. The readmission rate jumps to 22 percent in the six-month period following discharge.³²

County budgets are being adversely impacted by high hospital readmission rates as well, because counties are responsible for 50 percent of the cost of care that their residents receive in state psychiatric hospitals.³³ AOT reduces hospital readmissions significantly and is needed to reduce overcrowding and budget shortfalls.

Medication non-adherence is a significant factor in hospital readmissions. A study of Medicaid recipients with schizophrenia in California revealed that “individuals who were [medication] non-adherent were two and one-half times more likely to be hospitalized than those who were adherent.”³⁴ The same study found that those who are non-adherent incur 43 percent more in service costs than those who adhere to medication. AOT can help reduce such costs by improving medication compliance.

New Jersey has made substantial investments in community mental health services in recent years. Under Phase I of New Jersey’s Redirection Plan, Marlboro Psychiatric Hospital was closed in 1998 and $50 million has been invested annually in community psychiatric services.³⁵ In FY 2005, the state appropriated an additional $30 million for the second phase of the plan (Redirection II) to redirect money from state psychiatric hospitals to community services.³⁶ Redirection I & II created a variety of intensive services, including thirty-one PACT teams, considered the most comprehensive form of community treatment. Unfortunately, the effectiveness of those services is compromised because New Jersey does not have AOT. The PACT Model recognizes that sometimes a court order may be required to ensure that clients benefit from these services.³⁷ New Jersey currently does not have that option. As a consequence, nearly one thousand people who have been enrolled in PACT services are not actively participating.³⁸ New Jersey’s citizens have made a strong investment in PACT services; they deserve to know their programs are benefiting those in need.

ENDNOTES

¹Swanson, J.W., Swartz, M.S., Elbogen. E.B., Wagner, H.R., Burns, B.J. (2003). Effects of involuntary outpatient commitment on subjective quality of life in persons with severe mental illness. Behavioral Science and the Law, 21, 473-91.

²Weiden, P.J., Kozma, C., Grogg, A., Locklear, J. (2004). Partial compliance and risk of hospitalization among California Medicaid patients with schizophrenia. Psychiatric Services, 55, 886-91. Medication gaps as small as one to ten continuous days in a one-year period were associated with a two-fold increase in hospitalization risk.

³Munetz, M.R., Grande, T.P., Chambers, M.R. (2001). The incarceration of individuals with severe mental disorders. Community Mental Health Journal, 37, 361-72. Nearly 90 percent of a sample of individuals with severe mental illness in a local jail were partially or completely non-complaint with medication in the year before they were incarcerated.

⁴Swartz, M.S., Swanson, J.W., Hiday, V.A., Borum, R., Wagner, H.R., Burns, B.J. (1998). Violence and severe mental illness: The effects of substance abuse and nonadherence to medication. American Journal of Psychiatry, 155, 226-31. Substance abuse, medication non-compliance and low insight into illness operate together to increase violence risk.

⁵As of March 2005, 3,908 individuals received treatment orders under Kendra’s Law. This translates to an average of 747 individuals per year. According to the U.S. Census Bureau, New Jersey’s population is approximately 45 percent of New York’s (19,190,115 vs. 8,638,396 persons). Based on the experience in New York, it is estimated that New Jersey will have an average of 337 people receiving court orders per year.

⁶McHugh, Margaret. (2004, October 26). Support wanes for bill to help mentally ill . Star Ledger.

⁷N.J.S.A. 30:4-27.2.m.

⁸Treatment Advocacy Center (2005, June) Impaired awareness of illness (anosognosia): A major problem for individuals with schizophrenia and bipolar disorder. Retrieved July 23, 2005, from /BriefingPapers/BP14.htm; McGlynn, S.M., & Schacter, D.L. (1997). The neuropsychology of insight: Impaired awareness of deficits in a psychiatric context. Psychiatric Annals 27, 806-11; Amador, X. (2000). I Am Not Sick, I Don’t Need Help (1 st ed.) New York: Vida Press.

⁹Amador, X.F., Flaum, M., Andreason, N.C., Strauss, D.H., Yale, S.A., Clark, S.C., et al. (1994). Awareness of illness in schizophrenia and schizoaffective and mood disorders,Archives Gen. Psychiatry , 51, 826-36; Fennig, S., Everett, E., Bromet, E.J., Jandorf, L., Fenning, S.R., Tanenberg-Karant, et al., (1996). Insight in first-admission psychotic patients.Schizophrenia Research, 22, 257-63.

¹⁰Schwartz, R.C. (1998). The relationship between insight, illness, and treatment outcome in schizophrenia. Psychiatric Quarterly, Spring, 1-22.

¹¹Kessler, R.C., Berglund, P.A., Bruce, M.L., Koch, J.R., Laska, E.M., Leaf, P.J., et al. (2001). The prevalence and correlates of untreated serious mental illness.Health Services Research, 36, 987-1007; Treatment Advocacy Center. What percentage of individuals with severe mental illnesses are untreated and why . Retrieved July 21, 2005 from /BriefingPapers/BP13.pdf.

¹²Grisso, T., & Appelbaum, P.S. (1998). Assessing competence to consent to treatment: A guide for physicians and other health professionals. New York: Oxford University Press.

¹³New York State Office of Mental Health. (2005, March). Kendra’s Law: Final report on the status of assisted outpatient treatment.

¹⁴Gormley, Michael. (2005, March 8). Pataki proposes making Kendra's Law for mentally ill permanent. Newsday.

¹⁵Swanson, J.W., Swartz, M.S., Elbogen. E.B., Wagner, H.R., Burns, B.J. (2003). Effects of involuntary outpatient commitment on subjective quality of life in persons with severe mental illness. Behavioral Science and the Law, 21, 473-91.

¹⁶Swartz, M.S., Swanson, J.W., Wagner, H.R., Burns, B.J., Hiday, V.A., Borum, R. (1999). Can inv oluntary outpatient commitment reduce hospital recidivism? American Journal of Psychiatry, 156, 1968-75.

¹⁷Swartz, M.S., Swanson, J.W., Hiday, V.A., Wagner, H.R., Burns, B.J., Borum, R. (2001). A randomized controlled trial of outpatient commitment in North Carolina. Psychiatric Services, 52, 325-9; Swartz, M.S., Swanson, J.W., Wagner, H.R., Burns, B.J., Hiday, V.A., Borum, R. (1999). Can inv oluntary outpatient commitment reduce hospital recidivism? American Journal of Psychiatry, 156, 1968-75; Swanson, J.W., Borum, R., Swartz, M.S., Hiday, V.A., Wagner, H.R., Burns, B.J. (2001). Can involuntary outpatient commitment reduce arrests among persons with severe mental illness? (2001). Criminal Justice and Behavior, 28, 156- 89; Swanson, J.W., Swartz, M.S., Borum, R., Hiday, V.A., Wagner, H.R., Burns, B.J. (2000). Involuntary outpatient commitment and reduction of violent behaviour in persons with severe mental illness. Brit. J. Psychiatry , 176, 324-31; Hiday, V.A., Swartz, M.S., Swanson, J.W., Borum, R.,Wagner, H.R. (2002). Impact of outpatient commitment on victimization of people with severe mental illness. American Journal of Psychiatry, 159, 1403-11; Swartz, M.S., Swanson, J.W., Wagner, H.R., Burns, B.J., Hiday, V.A. (2001). Effects of involuntary outpatient commitment and depot antipsychotics on treatment adherence in persons with severe mental illness. J. Nerv. and Mental Diseases, 189, 583-92.

¹⁸Zanni, G., & deVeau, L. (1986) Inpatient stays before and after outpatient commitment. Hospital and Community Psychiatry 37, 941–42.

¹⁹Munetz, M.R., Grande, T, Kleist, J, Peterson G.A. (1996). The effectiveness of outpatient civil commitment. Psychiatric Services, 47, 1251–53.

²⁰Rohland, B.M., Rohrer, J.E., Richards, C.R. (2000). The long-term effect of outpatient commitment on service use. Administration and Policy in Mental Health, 27, 383-94.

²¹Fernandez, G.A., & Nygard, S. (1990). Impact of involuntary outpatient commitment on the revolving-door syndrome in North Carolina. Hospital and Community Psychiatry, 41, 1001–04.

²²Hiday, V.A., & Scheid-Cook, T.L. (1987). The North Carolina experience with outpatient commitment: A critical appraisal. International Journal of Law and Psychiatry, 10, 215–32.

²³Van Putten, R.A., Santiago, J.M., Berren, M.R. (1988). Involuntary outpatient commitment in Arizona: A retrospective study. Hospital and Community Psychiatry, 39, 953–58.

²⁴Groff, A., Burns, B.J., Swanson, J.W., Swartz, M.S., Wagner, H.R., Tompson, M. (2004). Caregiving for persons with mental illness: The impact of outpatient commitment on caregiving strain. Journal of Nervous & Mental Disease, 192, 554-62.

²⁵Swartz, M.S., Swanson, J.W., Wagner, H.R., Hannon, M.J., Burns, B.J., Shumway, M. (2003). Assessment of four stakeholder groups’ preferences concerning outpatient commitment for persons with schizophrenia. American Journal of Psychiatry. 160, 1139-46.

²⁶Treatment Advocacy Center . Consumers’ Perceptions of Assisted Treatment . Retrieved July 25, 2005 from/BriefingPapers/BP12.htm.

²⁷Kull, J. Nelson, What do consumers really think about assisted outpatient treatment ? Retrieved July 25, 2005 from /GeneralResources/pa16.htm

²⁸Swartz, M.S., Wagner, H.R., Swanson, J.W., Elbogen. E.B. (2004). Consumers’ perceptions of the fairness and effectiveness of mandated community treatment and related pressure. Psychiatric Services, 55, 780-5.

²⁹Munetz, M.R., Galon, P.A., Frese, F.J. (2003). The ethics of mandatory community treatment. Journal of Amer. Acad. of Psychiatry and the Law, 31, 173-83.

³⁰State of N. J., Office of Mgmt. & Budget. (2004, February 24). Fiscal Year 2004-2005 Budget. D-180. (Trenton State Psychiatric Hospital - 336 readmissions / 972 admissions).

³¹Office of Legislative Services. (2004, April). Analysis of the New Jersey Budget: Dept. of Human Services Fiscal Year 2004-2005. Retrieved from http://www.njleg.state.nj.us/legislativepub/budget/human05.pdf.

³²N. J. Division of Mental Health Services. (2004, September). Community Mental Health Services Block Grant Application for Fiscal Years 2005-2007. NJ-47, Retrieved from http://www.state.nj.us/humanservices/dmhs/BLOCK-GRANT%20YRS%2005-07.pdf.

³³N.J.S.A. 30:4-78

³⁴Gilmer, T.P., Dolder, C.R., Lacro, J.P., Folsom, D.P., Garcia, P., et al. (2004). Adherence to treatment with antipsychotic medication and health care costs among Medicaid beneficiaries with schizophrenia. American Journal of Psychiatry, 161, 692-9.

³⁵N.J. Dept. of Human Services, N.J. Div. of Mental Health Services. (1997, May). Projected implementation plan for the redirection plan: Status report and updated implementation schedule. 66.

³⁶State of N.J., Office of Mgmt. & Budget. (2004, February 24). Fiscal Year 2004-2005 Budget.D-176.

³⁷The PACT Manual recognizes that: some clients who enter PACT treatment voluntarily later refuse treatment and may become candidates for involuntary services if they relapse… In this case the PACT team first tries to stay involved with the client who declines treatment … If the client’s behavior … meets the commitment law criteria, the PACT team participates in the commitment process. Allness, D., Knoedler, W.H. (2003, June). A manual for ACT start-up: Based on the PACT model for community-based treatment for persons with severe and persistent mental illnesses (2003 ed.). Virginia: NAMI. TAB 17

³⁸In fiscal 2005, New Jersey’s budget for PACT services was at least $15.1M for 1,858 people, for an average cost of $8,133 per person per year. Most notably, according to the Community Mental Health Services Block Grant Application, 38 percent of PACT enrollees – almost 1,000 individuals in need – were not actively participating in PACT services. Unfortunately, because New Jersey PACT teams have no means of engaging clients that refuse services, proven programs such as PACT are rendered ineffective. State of N. J., Office of Management and Budget. (2005, March 1). Fiscal Year 2005-2006 Budget. D-172; N. J. Division of Mental Health Services. (2004, September). Community Mental Health Services Block Grant Application for Fiscal Years 2005-2007. NJ-62, Retrieved from http://www.state.nj.us/humanservices/dmhs/BLOCK-GRANT%20YRS%2005-07.pdf; N.J. Dept. of Human Services, N. J. Div. of Mental Health Services. (1997, May). Projected implementation plan for the redirection plan: Status report and updated implementation schedule.

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