Advocates and opponents of outpatient commitment found evidence to bolster their respective claims in a report published by the RAND Institute for Civil Justice in February.
The $87,000 study sought to determine the impact of involuntary outpatient treatment in California, and while it succeeded in further stirring the debate about outpatient commitment, it came up with no conclusive answers.
In the report, researchers said that there is no evidence suggesting a need for a court order to ensure patient compliance with treatment. Ultimately, they were unable to assess what impact, if any, involuntary outpatient treatment would have in California.
"Should we really be passing a law that is going to affect so many people, when we can’t predict what the effect will be?," asked primary investigator Susan Ridgely, J.D., in an interview with Psychiatric News.
The RAND team conducted a review of empirical literature on involuntary outpatient treatment, analyzed data from the California Department of Mental Health, and interviewed people in eight states with experience in involuntary outpatient treatment systems.
Each method of investigation presented challenges, according to the researchers. During the literature review, RAND researchers discounted scores of studies on involuntary outpatient treatment because of methodological flaws, and decided to focus on two randomized clinical trials.
One, undertaken by researcher Marvin Swartz, M.D., and colleagues at Duke University studied 331 people with mental illness in North Carolina. The study showed no significant differences between two groups—those who received outpatient commitment and those who did not. However, it found that extended court order for outpatient commitment, when combined with intensive treatment, resulted in 57 percent fewer hospital admissions and 28 fewer hospital days than those for the control group, who were not under outpatient commitment.
That study appeared in the December 1999 issue of the American Journal of Psychiatry.
Still, RAND researchers noted limitations with the study. For instance, the length of the outpatient commitment was not randomly assigned. Also, Duke researchers administered an "adherence protocol" to enforce treatment when necessary—something that may or may not be possible in the real world.
Thomson, who introduced the outpatient commitment bill last year, was aware of the limitations but was nonetheless convinced that something needed to be done now.
"The Duke study showed clear evidence that people who had a serious mental illness and a court-ordered outpatient program providing them with intensive community-based mental health treatment had good outcomes," she told Psychiatric News. "This gives me the data I need to go forward with our outpatient commitment program."
The second clinical trial of outpatient commitment was conducted with patients in a pilot program at Bellevue Hospital Center in New York City.
Howard Telson, M.D., and colleagues compared a group of patients who had been court ordered into assisted outpatient treatment with a group of patients receiving intensive services but not under court orders. The study found no statistically significant differences between these groups in terms of rehospitalization, arrests, or homelessness. RAND researchers said that study limitations such as small sample size may have affected the findings, however.
Researchers also examined the California Department of Mental Health’s Client Data System (CDS), which contains information on approximately 380,000 people who had received involuntary inpatient services between 1997 and 1998. RAND researchers mined the data to get a better picture of the use of involuntary treatment in California.
The CDS database contains demographic, clinical, and service information on these patients, as well as a patient’s legal status at the time of admission and discharge—that is, if the patient voluntarily entered the hospital or was committed.
CDS data from 1997-98 revealed that there were 106,314 admissions under a 72-hour hold. But 51,932 people accounted for all of these admissions—characteristic of what some refer to as the "revolving-door" phenomenon.
This finding did not surprise Thomson. "Another interesting piece of this is that 19,528 of these people had no record of outpatient services in the previous 12 months," she said. "I’m glad we had a researcher to point out what we already knew."
The CDS analysis estimated the number of people at highest risk for involuntary commitment by looking at people who had been on a 72-hour hold and were also diagnosed with schizophrenia or another psychotic disorder. Of people with these diagnoses, 7,388 had at least one other episode of involuntary treatment in the prior 12 months, and 3,140 had no outpatient service in this time frame. Researchers also found that almost 7,000 people were involuntarily hospitalized for 14 days or more. These are the people Thomson hopes to help with her new proposal.
The report stated that the respondents felt that outpatient commitment is neither as effective as a solution to the problem of compliance as its advocates claim, nor is it as restrictive a law as people with mental illness fear. Michael Allen, J.D., disagreed with the idea that the law would not be restrictive and said that the report supports his position. Allen is senior staff attorney at the Bazelon Center for Mental Health Law in Washington, D.C., a legal advocacy organization for people with mental illness.
"The report shows that there is no evidence that the addition of a court order [to intensive treatment] has any effect at all on recovery, hospital use, or contacts with the mental health or criminal justice systems," Allen told Psychiatric News.
He said he believes that involuntary outpatient commitment violates a person’s constitutional rights and foils its own objectives. "The most disruptive thing about involuntary outpatient commitment is that it rips the heart out of the therapeutic alliance, which is the premise of community mental health," he said. Allen said that the mental health community needs to find ways to get people engaged and return willingly to the system to give them what they need to survive in the community, and involuntary outpatient commitment does just the opposite.
"If we have a system led by sheriffs and doctors with needles to enforce treatment, we will chase people away from the system."
Allen pointed to alternatives, such as Connecticut’s "Peer Engagement Specialist Program," which uses peer support to engage people with mental illness, many of whom are homeless and resistant to entering treatment. The peers are usually people who have come from the streets themselves, have received treatment in the mental health system, and are on the road to recovery.
Allen also mentioned Senate Bill 931, proposed by Burton in late February. The bill would require the California Department of Mental Health to award and administer grants to counties for the purpose of improving, expanding, and coordinating treatment services for people with mental illness who are about to be involuntarily hospitalized. The bill would provide for such things as vocational rehabilitation, transportation, supported housing, and respite care, for instance. Burton was not available for comment.
Thomson is developing a proposal to amend Assembly Bill 1421.
Introduced in February, it makes no significant changes to current law, but is intended to serve as a place holder that will be updated with Thomson’s recommendations, which are currently under development. The new proposal will include recommendations based on data from the RAND report.
RAND researchers only got half of the picture, however. They learned that the CDS data did not include episodes of involuntary treatment under private insurers or the state-funded Medi-Cal program, which accounted for half of all involuntary admissions, according to the California Department of Mental Health.
The RAND team also spoke with the people who implement outpatient commitment law—including attorneys, behavioral health company officials, and psychiatrists in eight states, including New York, which recently passed the controversial Kendra’s Law.
"I was surprised at the uniformity of responses we received from people," said Ridgely. "Most people supported involuntary outpatient treatment but claimed that their states did not have the resources to enforce the involuntary treatments."
The RAND report, "The Effectiveness of Involuntary Outpatient Treatment," is posted at www.rand.org/publications/MR/MR1340/. The AJP study, "Can Involuntary Outpatient Commitment Reduce Hospital Recidivism?: Findings From a Randomized Trial With Severely Mentally Ill Individuals," is posted at http://ajp.psychiatryonline.org/cgi/content/full/156/12/1968?. Information on the California bill can be accessed at www.leginfo.ca.gov/bilinfo.html by searching on 1421 under "Bill Number." ▪