To the Editor: In the Law & Psychiatry column in the January 2008 issue—"Florida's Outpatient Commitment Law: A Lesson in Failed Reform?"—Petrila and Christy (1) questioned the success of outpatient commitment by speculating about reasons that it is underused. Although outpatient commitment is used relatively infrequently, the more accurate measure of the effectiveness of a treatment mechanism is how well it works to improve patient outcomes.
Outpatient commitment—sometimes called assisted outpatient treatment—is a court order combined with outpatient treatment for individuals with severe psychiatric disorders. It is available in 42 states. Research on outpatient commitment has shown it to be effective in dramatically decreasing rates of both hospitalization and incarceration. For example, in North Carolina over one year, outpatient commitment decreased average hospital days per patient by 36% (2) and arrest rates by 73% (3). In New York, assisted outpatient treatment decreased average hospital days per patient by 56%, and the number of patients who experienced incarceration was reduced by 87% (4).
Since Florida passed its first outpatient commitment law in 2004, about half of the orders issued under the law have been in Seminole County. In June 2005 a pilot outpatient commitment program was implemented in Seminole County organized by the Seminole Community Mental Health Center and the Seminole County Sheriff's Office. A program coordinator was hired, but otherwise the program used existing services and resources and took advantage of an excellent relationship between the mental health center and local law enforcement.
During the 18-month pilot program, 51 patients were referred for consideration, 45 petitions were filed, and 36 petitions were approved, which meant that 36 patients were ordered into the program by the court. At the end of 18 months, complete data were available for 21 patients, all of whom had been in the program for six months or longer. Total psychiatric hospital days and jail days were compiled for each patient for two periods—the patient's time in the program and an identical length of time before the patient entered the program.
The average number of hospital days per patient decreased from 64.0 to 36.8, a 43% decrease. The savings in hospital costs averaged $14,463 per patient or a total of $303,728 for the 21 patients. The average number of days incarcerated per patient decreased from 16.1 to 4.5, a 72% decrease. The cost per day for an inmate with medical costs in the Seminole County Jail is $59. Thus the total cost avoided for the 21 patients was $14,455.
These results, like those of previous studies, demonstrate that outpatient commitment, when used for selected individuals with serious psychiatric disorders, significantly reduces the time spent hospitalized and incarcerated. For mental health administrators looking for ways to improve psychiatric treatment and reduce costs, outpatient commitment should be used more often.
Ms. Esposito is affiliated with the Treatment Advocacy Center, Arlington, Virginia. Dr. Westhead and Mr. Berko are with Seminole Community Mental Health Center, Fern Park, Florida.
Petrila J, Christy A: Florida's Outpatient Commitment Law: A Lesson in Failed Reform? Psychiatric Services 59:21—23, 2008
Fernandez GA, Nygard S: Impact of involuntary outpatient commitment on the revolving-door syndrome in North Carolina. Hospital and Community Psychiatry 41:1001—1004, 1990
Swanson JW, Borum R, Swartz MS, et al: Can involuntary outpatient commitment reduce arrests among persons with severe mental illness? Criminal Justice and Behavior 28:156—189, 2001
Kendra's Law: Final Report on the Status of Assisted Outpatient Treatment. Albany, New York State Office of Mental Health, Mar 2005