Outpatient commitment

Outpatient commitment refers to mental health law that allows the involuntary treatment of individuals diagnosed with mental disorders who are resident in the community rather than detained in hospital. The individual may be subject to rapid recall to hospital, including for forced treatment, if the conditions of the plan/order are broken. This generally means taking psychiatric medication as directed and may also include attending appointments with a mental health professional, and sometimes even not to take non-prescribed illicit drugs and not associate with certain people or in certain places deemed to have been linked to a deterioration in mental health in that individual.

In the United States the term "assisted outpatient treatment" or "AOT" is often used and refers to a process whereby a judge orders a qualifying person with symptoms of severe untreated mental illness to adhere to a mental health treatment plan while living in the community. The plan typically includes medication and may include other forms of treatment as well. In England the Mental Health Act 2007 introduced "Community Treatment Orders (CTOs)".

In Australia they are also called Community Treatment Orders and last for a maximum of twelve months but can be renewed after review by a tribunal. Criteria for outpatient commitment are established by law, which vary among nations and, in the U.S., from state to state. Some require court hearings and others require that treating psychiatrists comply with a set of requirements before compulsory treatment is instituted.

When a court process is not required, there is usually a form of appeal to the courts or appeal to or scrutiny by tribunals set up for that purpose. Community treatment laws have generally followed the worldwide trend of community treatment. See mental health law for details of countries which do not have laws that regulate compulsory treatment.

Implementation

United States

Canada

History

Discussions of "outpatient commitment" began in the psychiatry community in the 1980s following deinstitutionalization, a trend that led to the widespread closure of public psychiatric hospitals and resulted in the discharge of large numbers of people with mental illness to the community. In the last decade of the 20th century and the first of the 21st, "outpatient commitment" laws were passed in a number of U.S. states and jurisdictions in Canada.

By the end of 2010, 44 U.S. states had enacted some version of an outpatient commitment law. In some cases, passage of the laws followed widely publicized tragedies, such as the murders of Laura Wilcox and Kendra Webdale.

Research published in 2013 showed that Kendra's Law in New York, which served about 2,500 patients at a cost of $32 million, had positive results in terms of net cost, reduced hospitalization, reduced arrests, use of outpatient treatment and use of medication. About $125 million is also spend annually on improved outpatient treatment for patients who are not subject to the law. In contrast to New York, despite wide adoption of outpatient commitment, the programs were generally not adequately funded.

Evidence

A 2011 meta-analytical review consisted of two RCTs, one a 1999 study done in New York and the other a 2001 study done in North Carolina, found that outpatient commitment "results in no significant difference in service use, social functioning or quality of life compared with standard care." The authors of this meta-analysis note in their 2012 update on Cochrane Reviews that five recently published studies are currently awaiting classification and may alter their findings.

Controversy

Proponents have argued that outpatient commitment improves mental health, increases the effectiveness of treatment, and reduces costs. Opponents of outpatient commitment laws argue that they unnecessarily limit freedom, force people to ingest dangerous medications, or are applied with racial and socioeconomic biases.

Proponents

While many outpatient commitment laws have been passed in response to violent acts committed by people with mental illness, most proponents involved in the outpatient commitment debate base their arguments on the quality of life and cost associated with untreated mental illness and "revolving door patients" who experience a cycle of hospitalization, treatment and stabilization, release, and decompensation. While the cost of repeated hospitalzations is indisputable, quality-of-life arguments rest on an understanding of mental illness as an undesirable and dangerous state of being. Outpatient commitment proponents point to studies performed in North Carolina and New York that have found some positive impact of court-ordered outpatient treatment.

Opponents

Outpatient commitment opponents make several varied arguments. Some dispute the positive effects of compulsory treatment, questioning the methodology of studies that show effectiveness. Others highlight negative effects of treatment. Still others point to disparities in the way these laws are applied. The psychiatric survivors movement opposes compulsory treatment on the basis that the ordered drugs often have serious or unpleasant side-effects such as tardive dyskinesia, neuroleptic malignant syndrome, excessive weight gain leading to diabetes, addiction, sexual side effects, and increased risk of suicide. The New York Civil Liberties Union has denounced what they see as racial and socioeconomic biases in the issuing of outpatient commitment orders. The main opponents to any kind of coercion, including the outpatient commitment and any other form of involuntary commitment, are Giorgio Antonucci and Thomas Szasz.

See also

US specific:

• Kendra's Law
• Laura's Law
• MindFreedom International
• Treatment Advocacy Center

General:

• Involuntary treatment
• Deinstitutionalisation
• Deinstitutionalisation in Italy
• Psychiatric reform in Italy
• Giorgio Antonucci
• Thomas Szasz

External links

• [1] - Treatment Advocacy Center
• MindFreedom.org - MindFreedom
• National Mental Health Consumers' Self-Help Clearinghouse
• Civil commitment laws and standards by state - Civil commitment laws and standards by state