APA Board Approves Position Statement on Involuntary Outpatient Commitment

Involuntary outpatient commitment can be a “useful tool to promote recovery”—when it’s done right, according to a position statement approved by APA’s Board of Trustees in December 2015.

A successful involuntary outpatient commitment (IOC) plan combines “access to intensive services and a team of mental health professionals working together to help the patient,” said APA President Renée Binder, M.D., a professor of psychiatry at the University of California, San Francisco. (See “From the President”.)

Steven Kenny Hoge, M.D.

“Severely mentally ill people are not getting treatment, and there are not enough inpatient beds; thus, many mentally ill people end up in jails or prisons,” said forensic psychiatrist Steven Kenny Hoge, M.D., of New York, chair of APA’s Committee on Psychiatry and the Law, which drafted the statement. “IOC is not the solution but it is part of a solution to these problems.”

The document effectively sets out the ideal standards for such court-mandated treatment programs (often referred to as “assisted outpatient treatment,” or AOT). Programs are aimed at a very narrow segment of the patient population—patients who, as a result of their mental illness, are unlikely to seek or voluntarily adhere to needed treatment” but must be “systematically implemented, linked to intensive outpatient services, and prescribed for extended periods of time,” said the statement. Services should be equal to those available in other intensive programs and should last at least 180 days, with extensions possible after judicial review.

“I think it’s terrific that APA has taken a thoughtful position on such a potentially contentious issue,” noted Mark Munetz, M.D., a professor and chair of psychiatry at the Northeast Ohio Medical University in Rootstown, in an interview. Munetz spent 20 years as medical director of the Summit County, Ohio, behavioral health authority and helped develop its outpatient commitment program.

“IOC is not an answer by itself,” said Munetz, who was not involved in crafting the APA statement. “But a combination of a court order, over a sufficient period of time, in a system that’s able to provide the necessary treatment and support is likely to get us to where we need to go.”

APA produced a research document on the topic in the 1980s and revised it in 1999. “There have been a lot of new developments and research since,” said Hoge. “So our committee thought that the document should be updated again and that it was time for a position statement, as well.”

IOC is not without controversy.

Opponents say the process wouldn’t be needed if enough accessible, effective services were available. Others are concerned about individuals’ autonomy to make their own treatment decisions. For example, the Judge David L. Bazelon Center for Mental Health Law in Washington, D.C., says that it “opposes all involuntary outpatient commitment as an infringement of an individual’s constitutional rights. … Such coercion undermines consumer confidence and causes many consumers to avoid contact with the mental health system altogether.”

However, some consumer organizations like the National Alliance on Mental Illness (NAMI) do not fully rule out use of IOC, stating that “involuntary inpatient and outpatient commitment and court-ordered treatment should be used only as a last resort. ...”

One thing that concerns Ron Honberg, J.D., NAMI’s national director for policy and legal affairs, is the use of the word “adherence.”

“Consumers think the term connotes paternalism, not necessarily engaging people in shared decision making,” Honberg said in an interview. “We have to think more about what strategies can be used to get people to engage—ideally, voluntarily. The greatest value may be that IOC fosters a collaborative approach and holds the treatment system accountable.”

Yet other critics say that IOC is disproportionately applied to minority groups. One of the few detailed studies of an IOC program is that of New York’s, which concluded that recipients experienced “reduced hospitalization and length of stay, increased receipt of psychotropic medication and intensive care management services, and greater engagements in outpatient services.”

But the study also noted that 34 percent of the patients were African Americans, who make up just 17 percent of the state’s population—data that might suggest discrimination. A follow-up study adjusted both for the higher black population of New York City (where most cases were concentrated) and for a subpopulation of patients who were repeatedly hospitalized in public facilities, the rates of usage came close to parity (Psychiatric News, November 6, 2015).

“The APA position statement and resource document conclude that the use of AOT is not racially discriminatory and that there is no current evidence that AOT is applied disproportionally to minority populations,” said APA President Binder. AOT programs should be independently evaluated to document and correct any disproportionate use among minority groups or inadequate due process protections, she said.

The statement also notes the need for adequate resources to support IOC programs, important in light of recent Congressional proposals to encourage or require states to pass AOT laws.

“Some people think that AOT is magic, but it is not,” said Hoge. “It takes time, work, and money. New York’s law is amply resourced.”

Overall, any involuntary outpatient treatment system needs to be a two-way street, say proponents.

“We’re not only committing individuals to treatment but also committing the treatment system to individuals,” said Munetz. ■