Evidence-Based Reviews

Outpatient commitment: When it improves patient outcomes

Current Psychiatry. 2008 April;7(4):25-35

1 year after Virginia Tech, many states’ statutes remain ambiguous and ineffective.

References

1. Swartz M. Taking issue: can mandated outpatient treatment prevent tragedies? Psychiatr Serv 2007;58(6):737.-

2. Swartz MS, Burns BJ, Hiday VA, et al. New directions in research on involuntary outpatient commitment. Psychiatr Serv 1995;46:381-5.

3. Torrey EF, Kaplan R. A national survey of the use of outpatient commitment. Psychiatr Serv 1995;46:778-84.

4. Swartz MS, Swanson JW. Involuntary outpatient commitment, community treatment orders, and assisted outpatient treatment: what’s in the data? Can J Psychiatry 2004;49(9):585-91.

5. Monahan J, Swartz M, Bonnie R. Mandated treatment in the community for people with mental disorders. Health Aff 2003;22:28-38.

6. Munetz MR, Grande T, Kleist J, Peterson GA. The effectiveness of outpatient civil commitment. Psychiatr Serv 1996;47:1251-3.

7. Rohland BM, Rohrer JE, Richard C. The long-term effects of outpatient commitment on service use. Adm Policy Ment Health 2000;27:383-94.

8. Keilitz I. Empirical studies of involuntary outpatient civil commitment: is it working? Ment Phys Disabil Law Rep 1990;14:368-79.

9. Hiday VA, Scheid-Cook TL. Outpatient commitment for revolving door patients: compliance and treatment. J Nerv Ment Dis 1991;179:83-8.

10. Moloy KA. Analysis: critiquing the empirical evidence. Does involuntary outpatient commitment work?. Washington, DC: Mental Health Policy Resource Center; 1992.

11. Ridgely MS, Borum J, Petrilla J. The effectiveness of outpatient commitment: empirical evidence and experience of eight states. Santa Monica, CA: RAND Corporation; 2001.

12. Kendra’s Law: final report on the status of assisted outpatient treatment. Albany, NY: New York State Office of Mental Health; 2005. Available at: http://www.omh.state.ny.us/omhweb/Kendra_web/finalreport. Accessed February 19, 2008.

13. Swartz MS, Swanson JW, Hiday VA, et al. A randomized controlled trial of outpatient commitment in North Carolina. Psychiatr Serv 2001;52:330-6.

14. Swartz MS, Swanson JW, Wagner RR, et al. Can involuntary outpatient commitment reduce hospital recidivism? Findings from a randomized trial in severely mentally ill individuals. Am J Psychiatry 1999;156:1968-75.

15. Compton SN, Swanson JW, Wagner HR, et al. Involuntary outpatient commitment and homelessness in persons with severe mental illness. J Ment Health Serv Res 2003;5:27-38.

16. Hiday VA, Swartz MS, Swanson JW, et al. Impact of outpatient commitment on victimization of people with severe mental illness. Am J Psychiatry 2002;159:1403-11.

17. Swanson JW, Borum R, Swartz MS, et al. Can involuntary outpatient commitment reduce arrests among persons with severe mental illness? Criminal Justice & Human Behavior 2001 28;156-89.

18. Swanson JW, Swartz MS, Borum R, et al. Involuntary outpatient commitment and reduction of violent behaviour in persons with severe mental illness. Br J Psychiatry 2000;176:324-31.

19. Swartz MS, Swanson JW, Wagner HR, et al. Effects of involuntary outpatient commitment and depot antipsychotics on treatment adherence in persons with severe mental illness. J Nerv Ment Dis 2001;189:583-92.

20. Steadman HJ, Gounis K, Dennis D, et al. Assessing the New York City outpatient commitment pilot program. Psychiatr Serv 2001;52:330-6.

On April 16, 2007, Seung Hui Cho shot and killed 32 students and faculty on the Virginia Tech campus and wounded 25 others before killing himself. A judge had declared Cho mentally ill in 2005 and placed him on involuntary outpatient commitment (OPC). Cho apparently never sought treatment, and no one made sure that he did (Box 1).¹

Much second-guessing has occurred about whether enforcing Cho’s OPC could have prevented the Virginia Tech tragedy. Most states authorize OPC, but few make much use of OPC statues that require patients to adhere to prescribed treatment in the community. Virginia was typical; an OPC statute was on the books but rarely enforced.

This article discusses the evidence on OPC laws’ effectiveness and offers recommendations on how to use these tools in psychiatric practice.

Mandating needed treatment

OPC—also called “assisted outpatient treatment” or “mandated outpatient treatment”—is a civil court procedure whereby a judge can order a noncompliant mentally ill patient to adhere to needed treatment. OPC statutes exist in 42 states and the District of Columbia, although judges use these powers erratically.^2,3

Most states have set identical thresholds for inpatient and outpatient commitment, such as when the patient is considered dangerous to self or others or (in some statutes) so gravely impaired that he is unable to safely care for himself in the community. These high thresholds have dramatically reduced inpatient commitment eligibility and yet may flag the patient as too dangerous for outpatient commitment.

Box 1

Virginia’s OPC statute: Inpatient criteria for outpatient cases

Virginia’s commitment laws are in review because of the Virginia Tech shootings in April 2007. The state’s existing OPC provisions are embedded in involuntary commitment law, which is mainly directed toward inpatients. As a result, Virginia’s law:

merely permits mandated outpatient treatment
duplicates inpatient criteria for “imminent dangerousness” (although the state legislature is considering relaxing this criterion)
provides no guidance on enforcement in the event of treatment nonadherence
provides no administrative infrastructure to make the law work.

Virginia’s statute is typical. It lacks a separate threshold for outpatient commitment, using the same high threshold of imminent threat to self or others that is required for inpatient commitment.

Clinicians are uncomfortable using inpatient criteria for outpatient commitment. Labeling a patient as “ill enough” to be confined and then recommending that he or she be released to outpatient treatment feels like a liability risk.

Because the legislative intent in most state statutes was to set criteria and procedures for inpatient commitment, steps for implementing outpatient commitment are often ill-defined. An outpatient commitment process requires:

notification to the responsible outpatient local mental health authority, clinicians, and local courts that the order is in place
expectations regarding the order
steps required to renew the order, if indicated.

States such as New York with fully operational outpatient commitment statutes have clear implementation processes.

OPC orders usually cannot force medication. Periods of initial and subsequent commitment vary across states but not dramatically. In North Carolina, for example, initial OPC may be ≤90 days, after which a hearing must be held to renew the order for ≤180 days. Depending on individual states’ statutes, OPC can be used as:

an alternative to hospitalization for patients who meet inpatient commitment criteria
a form of conditional release for patients completing an involuntary inpatient commitment
an alternative to hospitalization for noncompliant patients at risk for relapse and involuntary inpatient commitment.²

Few states have lowered the threshold to the last variant, allowing OPC use to avert relapse and hospitalization. Newer statutes in New York, North Carolina, and elsewhere have incorporated these preventative outpatient commitment criteria.^4,5

Clinical Point

Labeling a patient as ‘ill enough’ to be confined, then recommending his release to outpatient treatment feels like a liability risk

Enforcement. Courts typically can request that law officers transport patients who fail to comply with OPC to a treatment facility. There, patients will be encouraged to comply with treatment or evaluated for inpatient commitment.² This relatively weak enforcement authority has led some to argue that OPC has no teeth.

Without clearly defined steps for implementation, an outpatient commitment order can be likened to a message in a bottle—a cry for help at risk for nondelivery. In the Virginia Tech case, the judge issued an outpatient commitment order for Cho, but how the local clinic understood its responsibilities and what resources and enforcement power it had were unclear.

Noncontrolled studies

Evidence from noncontrolled OPC studies is difficult to interpret because of:

lack of comparable committed and noncommitted groups
difficulty in comparing treatment across comparison groups
selection effects, whereby clinicians and courts select patients for a predicted good outcome.²