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Individual differences |
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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.
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 "preventable tragedies, such as the murders of Laura Wilcox and Kendra Webdale.
A landmark report by the RAND Corporation  was commissioned by the Senate Committee on Rules in 2001 when a bill authorizing court-ordered outpatient treatment was being debated in California (subsequently passed and known as "Laura's Law" for Laura Wilcox). This 176-page report was an evidence-based review that both searched the literature and interviewed key informants for their perceptions of the assisted outpatient treatment system. Among the findings:
- There was widespread support for outpatient commitment among key informants, although quite a few expressed only qualified support for the practice in their own states.
- Three things were deemed critical to the success of outpatient commitment: having the infrastructure to support it; having the services to make it work for patients; and having a service system that can deliver those services rationally.
- Outpatient commitment laws were being used infrequently in most states and were used primarily as a discharge-planning vehicle rather than an alternative to hospitalization.
- As part of their commitment process, at least three states were using mechanisms to involve the patient in development of a consensus plan for compliance with mental health treatment.
- There was disagreement as to whether the outpatient commitment order is "reciprocal"(i.e., commits the provider or mental health system to provide services as well as committing the patient to receive them).
- Provider liability was a concern but not an overwhelming one.
- Not all outpatient commitment orders were specific about which agency will provide services and what the specific treatment will be. Medication was not necessarily a part of the commitment orders.
- In most states, medication over objection was not allowed under outpatient commitment orders.
- The burden of monitoring outpatient commitment orders most often fell to treatment providers, most of whom did not have the resources to provide high levels of supervision.
- States differed widely in the extent to which their outpatient commitment orders had "teeth"(i.e., were enforceable).
In the literature review, Rand noted that the literature in 2001 was not of high methodological quality and that "while there may exist a subgroup of people with severe mental illness for whom a court order acts as leverage to enhance treatment compliance, the best studies suggest that the effectiveness of outpatient commitment is linked to the provision of intensive services. Whether court orders have any effect at all in the absence of intensive treatment is an unanswered question." However, more recent studies such as those from the New York Office of Mental Health (OMH) in 2005 and 2009  showed that outpatient treatment was effective.
These studies were also tended to refute criticissm from opponents of assisted outpatient treatment. The 2005 study found:
Specifically, the OMH study found that among participants in the AOT program:
- 74 percent fewer experienced homelessness;
- 77 percent fewer experienced psychiatric hospitalization;
- 83 percent fewer experienced arrest; and
- 87 percent fewer experienced incarceration.
Comparing the experience of outpatient commitment recipients over the first six months of commitment to the same period immediately prior to commitment, the OMH study found:
- 55 percent fewer recipients engaged in suicide attempts or physical harm to self;
- 49 percent fewer abused alcohol;
- 48 percent fewer abused drugs;
- 47 percent fewer physically harmed others;
- 46 percent fewer damaged or destroyed property; and
- 43 percent fewer threatened physical harm to others.
As a component of the OMH study, researchers with the New York State Psychiatric Institute and Columbia University conducted face-to-face interviews with 76 recipients to assess their opinions about the program and its impact on their quality of life. The interviews showed that after receiving treatment, assisted outpatient treatment recipients overwhelmingly endorsed the program:
- 75 percent reported that AOT helped them gain control over their lives;
- 81 percent said that AOT helped them to get and stay well; and
- 90 percent said AOT made them more likely to keep appointments and take medication.
Additionally, 87 percent of participants said they were confident in their case manager's ability to help them; 88 percent said that they and their case manager agreed on what is important for them to work on, i.e., assisted outpatient treatment exhibited a positive effect on the therapeutic alliance.
In 2009, an independent study by Duke University into alleged racism found "no evidence that the (assisted outpatient treatment) Program is disproportionately selecting African Americans for court orders, nor is there evidence of a disproportionate effect on other minority populations. Our interviews with key stakeholders across the state corroborate these findings."
Subsequent studies have confirmed a positive effect in outcomes, albeit attenuated from the NY OMH 2005 study. A 2010 study on Kendra's Law by Gilbert et al. showed that "the odds of arrest for participants currently receiving assisted outpatient treatment (AOT) were nearly 2/3 lower (OR .39, p<.01) than for individuals who had not yet initiated AOT or signed a voluntary service agreement." Another 2010 study from Swartz et al. tracked Medicaid claims and state reports for 3,576 AOT consumers from 1999-2007. They found that "the likelihood of psychiatric hospital admission was significantly reduced by ~25% during the initial six-month court order (odds ratio [OR]=.77, 95CI=.72-.82) and by over 1/3 during a subsequent six-month renewal of the order (OR=.59, CI=.54-.65) compared with the period before initiation of the court order. Similar significant reductions in days of hospitalization were evident during initial court orders and subsequent renewals (OR=.80, CI=.78-.82, & OR-.84, CI=.81-.86, respectively)."
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.
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.
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.
- Commitment (psychiatric)
- E. Fuller Torrey
- International Center for the Study of Psychiatry and Psychology
- Involuntary treatment
- Kendra's Law
- Laura's Law
- MindFreedom International
- Partial hospitalization
- Treatment Advocacy Center
- Psychlaws.org - 'A Guide to Laura’s Law: California's New Law for Assisted Outpatient Treatment', The California Treatment Advocacy Coalition and The Treatment Advocacy Center (January, 2003)
- Keys to Commitment (A Guide for Family Members) by Robert J. Kaplan, J.D.
- State-by-state chart of U.S. commitment laws
- MindFreedom.org - 'Bill for More Forced Psychiatry Passed by California Legislature, Goes to Governor', California Network of Mental Health Clients (September 3 2002)
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