Outpatient Commitment: What, Why, and for Whom

Outpatient commitment involves a court order mandating a person to follow a treatment plan or risk sanctions for noncompliance, such as potential involuntary hospitalization and treatment. Because of its role in enhancing compliance, outpatient commitment is regarded by some treatment advocates as a form of assisted treatment and, therefore, as one possible treatment approach for persons with severe psychiatric illnesses such as schizophrenia and bipolar disorder who refuse or neglect to take the medications needed to control the symptoms of their illnesses.

Outpatient commitment has been shown to be highly effective in improving compliance with medication regimens. Studies in Arizona (1), North Carolina (2), Ohio (3), and Iowa (4) showed that outpatient commitment at least doubled rates of treatment compliance. In the Iowa study, for example, it was reported that "outpatient commitment promotes treatment compliance in about 80 percent of patients while they are on outpatient commitment."

Because outpatient commitment improves treatment compliance, it has also been shown to reduce the need for readmission to a psychiatric hospital by 50 to 80 percent (3,4,5,6). In a recent controlled study of outpatient commitment in North Carolina (7), "subjects who underwent sustained periods of outpatient commitment beyond that of the initial court order had approximately 57 percent fewer readmissions and 20 fewer hospital days than control subjects." It was also found that "the predicted probability of any violent behavior was cut in half, from 48 percent to 24 percent" among persons who underwent extended outpatient commitment and also had regular outpatient visits (8). In these studies commitment alone was not sufficient but had to be combined with available and adequate outpatient services.

Why is it needed?

We argue that outpatient commitment is needed because many individuals with severe psychiatric illnesses lack awareness of their illness. This deficit is biologically based (9,10) and is not the same thing as psychological denial. Both schizophrenia and bipolar disorder affect the prefrontal cortex, which is used for insight and for understanding one's needs. When this area of the brain is damaged by disease, the person loses self-awareness. This loss is seen in some neurological disorders, such as Alzheimer's disease, and in some individuals who have had cerebrovascular accidents (strokes). In the most extreme form of such loss, a person who has suffered a stroke may lack awareness that his or her leg is paralyzed, despite obvious evidence to the contrary.

More than 100 studies of awareness of illness and insight in schizophrenia and bipolar disorder have been conducted in recent years. The studies have shown that 40 to 50 percent of individuals with severe psychiatric illnesses have moderately or severely impaired awareness of illness (11,12; personal communication, David A, 1993). For some individuals, awareness may fluctuate over time. For others, it may improve when the individual is taking medication. For many others, however, the lack of awareness of the illness neither fluctuates nor improves with medication.

Understanding this lack of awareness of illness is crucial to understanding why assisted treatment is needed. Individuals with heart disease, rheumatoid arthritis, and cancer occasionally refuse treatment, but in such cases it is assumed that their cognitive functioning and awareness of their illness are intact. One cannot make this assumption about an individual who has a severe psychiatric disorder and impaired awareness of illness.

Failure to take medication may have many unfortunate consequences for those with severe psychiatric disorders, including homelessness, incarceration, violence, and suicide. At least a third of the homeless population, 150,000 persons, have severe psychiatric disorders (13). In one follow-up study of patients discharged from a state psychiatric hospital, 82 percent of those who continued to live in stable housing took their medication, whereas only 33 percent of those who became homeless took their medication (14). A study in Boston found that only 11 percent of homeless individuals with severe psychiatric illnesses were taking medications (15). A similar study in Columbus reported that only 6 percent of such individuals were taking medication and that most "were resistant to traditional methods of psychiatric intervention that relied on voluntary compliance" (16,17).

Incarceration is another apparent consequence of the failure to take needed medication. A recent Department of Justice study reported that 16 percent of inmates in local jails and state prisons—275,900 individuals— were mentally ill, and many were presumed to have been noncompliant with treatment (18). One follow-up study of individuals released from state hospitals reported that 32 percent were arrested and jailed within six months; "psychotropic medication had been prescribed upon their discharges from state hospitals, but the respondents failed to take their medications" (19).

Violent behavior is another potential consequence of the failure to take medication among individuals with severe psychiatric illnesses. A Department of Justice study indicated that almost 1,000 homicides each year are committed by persons with a history of mental illness (20). A significant correlation between the failure to take medication and violent behavior has been reported in several studies (21,22), including one in which "71 percent of the violent patients…had problems with medication compliance, compared with only 17 percent of those without hostile behaviors" (23).

Suicide is still another potential consequence of inadequate medication. In one study of patients who committed suicide, 71 percent "who were depressed in their last episode were not receiving adequate antidepressant or lithium carbonate medication at the time of suicide" (24). In another study that compared 63 individuals with schizophrenia who committed suicide and 63 individuals with schizophrenia who did not, "there were seven times as many patients who did not comply with treatment in the suicide group as in the control group" (25).

For whom is it needed?

We propose that outpatient commitment, as a form of assisted treatment, should be considered for any individual with a severe psychiatric disorder who has impaired awareness of his or her illness and is at risk of becoming homeless, incarcerated, or violent or of committing suicide.

One example is the case of Phyllis Iannotta, who supported her parents for 22 years before developing schizophrenia (26). Although she responded to medication, she had no awareness of her illness and so neglected to take it. She became homeless in New York City and in 1981 was found raped and murdered in an alley. At that time there was no provision for outpatient commitment in New York state. Among her few possessions when she was found were a can of cat food and a plastic spoon.

George Wooten developed schizophrenia during high school (27). He responded to medications when hospitalized but neglected to take them when released. He abused alcohol and glue and was incarcerated in the Denver County Jail more than 100 times before he died on the streets. No outpatient commitment was ever instituted.

Russell Weston developed paranoid schizophrenia in his early twenties. His symptoms improved when he was on medication, but because he had no awareness of his illness, he rarely took it. Even though he assaulted a hospital worker and threatened to kill the President and others, he was never put on any form of assisted treatment. He traveled to Washington, D.C., and has been charged with killing two police officers at the Capitol.

Thomas McGuire was a college graduate who had worked steadily for 15 years. Mr. McGuire became acutely manic. During an early episode, he was successfully treated with medication. However, he exhibited no awareness of being ill and refused to continue to take medication or to be hospitalized. Despite his family's pleas that he be placed on some form of mandated treatment, the hospital released him untreated. Six hours later, he hanged himself (13).

Phyllis Iannotta, George Wooten, Russell Weston, Thomas McGuire, and other individuals like them are candidates for outpatient commitment. Overall in the United States, about 3.5 million people have active symptoms of schizophrenia or bipolar disorder at any given time (28). As noted above, 40 to 50 percent of them, 1.4 to 1.75 million people, have significantly impaired awareness of their illness or their need for treatment (11,12). Other studies have shown that 36 to 50 percent of individuals with schizophrenia and bipolar disorder are not being treated at any given time (29,30). For a small subset of them—probably around 100,000 individuals—outpatient commitment could be the most effective form of assisted treatment.

Outpatient commitment is only one possible form of assisted treatment. The number of patients who might need outpatient commitment partly depends on the relative availability of other forms of assisted treatment. All forms of what we refer to as assisted treatment include some form of explicit or implicit coercion. Other forms of assisted treatment to outpatient commitment are described below.

Advance directives. Psychiatric advance directives are legal documents that permit mentally ill persons to authorize and specify treatment in anticipation of future periods of mental incapacity. These directives may be effective for mentally ill persons who have regained awareness of their illnesses and seek to authorize treatment when help is needed in the future. Advance directives will not help those who are unable to recognize that they will need assistance with treatment in the future.

Assertive case management. Many studies have shown that the Program for Assertive Community Treatment (PACT) and similar programs, in which teams actively assist with treatment in the home, improve treatment compliance. However, for at least a third of patients, assertive case management is not effective, which suggests that additional assisted interventions are needed (31).

Representative payees. Appointing a representative payee for Supplemental Security Income, Social Security Disability Insurance (SSDI), and Veterans Affairs benefits is another approach. Studies have shown that this form of assisted treatment, in which a mentally ill person permits a trusted individual to help him or her use funds wisely, reduces hospitalization (32) and homelessness (33). However, no published study has shown its effectiveness in improving treatment compliance. The U.S. Third Circuit Court of Appeals ruled that a man with epilepsy was not entitled to SSDI unless he complied with his prescribed antiseizure medication regimen (34). Thus a legal precedent has been set for use of this mechanism to enforce compliance.

Conditional release. In many states, patients involuntarily committed to a state psychiatric hospital can be released on the condition that they follow their treatment plan, including taking medication (35). A study in New Hampshire, a state in which conditional release is widely used, showed that it was very effective in increasing medication compliance and reducing episodes of violence by mentally ill persons (36).

Conservatorship or guardianship.In conservatorship or guardianship, a court appoints an individual to make decisions for a legally incompetent individual. This legal tool is widely used for individuals with mental retardation but is used only sporadically for individuals with severe psychiatric illnesses. Studies of conservatorship showed it to be highly effective in improving treatment compliance (37,38).

Mental health courts. A growing number of mentally ill persons face incarceration, even for "nuisance crimes" like vagrancy. Mental health courts, although still uncommon, have been developed to offer mentally ill persons an alternative to incarceration through supervised treatment. In 2000 Congress passed legislation establishing a series of mental health courts to be models for others to follow.

Objections to outpatient commitment

Objections to outpatient commitment have been voiced by some consumers, by a few mental health professionals, and most prominently by civil liberties groups and the Bazelon Center for Mental Health Law. The major objections to outpatient commitment include the following.

Outpatient commitment is not necessary. If you improve mental illness services, severely psychiatrically ill individuals will seek them out. In response, we argue that the target population suffers from impaired awareness of their illness, clouding their judgment about the need for treatment. Even if available mental illness services are excellent, it seems apparent that people who do not believe that they are ill will not use them.

It is wrong to involuntarily commit people to mental illness services when the services are deficient. We agree that public mental illness services are deficient in almost every U.S. state. However, many severely psychiatrically ill persons are at risk or victimized. They live on the streets and eat out of garbage cans. They are periodically jailed. Some are a clear danger to themselves or others. We believe that the public should not have to wait for services to improve while vulnerable persons and the public are at risk.

The threat of outpatient commitment drives away the people who need to be treated. This objection alleges that individuals who have been treated involuntarily or threatened with involuntary treatment will thereafter avoid treatment. Studies have demonstrated that the majority of severely psychiatrically ill patients who have been coerced into taking medications in the past agree in retrospect that it was in their best interests (39,40). In one study (41), 71 percent of the patients agreed with the statement: "If I become ill again and require medication, I believe it should be given to me even if I don't want it at the time."

Outpatient commitment siphons off resources from the mental illness treatment system so that fewer resources are available for patients who want to use the services voluntarily. If one assumes that a fixed amount of total resources are available for treatment, this statement is true. But resources can also be increased, as they were in 1999, when New York State implemented outpatient commitment. In addition, because it appears to lower treatment costs by reducing hospital use, outpatient commitment should make more funds available for all patients. Implicitly, opponents of outpatient commitment are also arguing that individuals who voluntarily seek services and have good awareness of their illness are more entitled to treatment than those who shun treatment and lack awareness of their illness.

Outpatient commitment increases the stigma of mental illness by making mentally ill people targets of coercion. Studies in the United States (42) and Germany (43) have shown that the single largest cause of stigma is episodes of violence perpetrated by severely mentally ill persons. By providing a means by which severely mentally ill persons who lack awareness of their illness can be treated, and thereby decreasing episodes of violence, outpatient commitment and other forms of assisted treatment should ultimately decrease stigma related to mental illness.

Individuals should never be coerced into taking antipsychotic medications, because these medications are very dangerous. According to one authority " antipsychotic agents are among the safest drugs available in medicine" (44). Like all medications, they have side effects, but as a group these side effects are comparable to those of drugs used to treat heart disease or rheumatoid arthritis.

Outpatient commitment will be a dragnet, ensnaring many individuals who do not need it. Because outpatient commitment is usually predicated on a need-for-treatment standard and not just on overt dangerousness, critics fear that it will ensnare many individuals who do not need it. Experience suggests that there is no basis for such fears. For example, in December 1996, Wisconsin adopted a new need-for-treatment standard. In the first 22 months after its adoption, only 35 requests for commitment were made under the new standard (45). Individuals mandated into outpatient treatment should always have legal representation, regularly scheduled reviews of the commitment, and the right to appeal a decision. Also, the legal standards governing commitment decisions should be neither vague nor ambiguous.

Outpatient commitment is an infringement on a person's civil liberties; no one should ever be involuntarily treated. In the United States, individuals with medical illnesses such as active tuberculosis who refuse to take medication are regularly hospitalized involuntarily and treated. In New York City alone, an average of 100 such involuntarily hospitalizations take place each year, and many more such patients agree to take medication only after being threatened with involuntary treatment (46). We do not suggest that severe mental illness is analogous to a communicable disease; however, the rationale is similar: medically needed treatment should be provided in the best interest of both the individual and society.

We argue that the real liberty question regarding individuals with severe psychiatric disorders is whether they are in fact free when ill. If one's thoughts and behavior are driven by delusions and hallucinations because of a disease process of the brain over which the person has no control, is this truly liberty? This point was best expressed by Herschel Hardin, a former member of the board of directors of the British Columbia Civil Liberties Association (47). He wrote, "The opposition to involuntary committal and treatment betrays a profound misunderstanding of the principle of civil liberties. Medication can free victims from their illness—free them from the Bastille of their psychoses—and restore their dignity, their free will, and the meaningful exercise of their liberties."

Conclusions

Outpatient commitment is one form of assisted treatment that we argue is useful for individuals with severe psychiatric illnesses who have limited awareness of their illness. It is not, nor is it claimed to be, a panacea for the problems facing the nation's mental health systems. In the absence of assisted treatment, we have witnessed rising rates of homelessness, incarceration, violence, and suicide among persons with severe mental illness. Common sense and compassion both argue for the use of assisted treatment, including outpatient commitment when needed.

Dr. Torrey is president and Ms. Zdanowicz is executive director of the Treatment Advocacy Center in Arlington, Virginia. Address correspondence to Dr. Torrey at 5430 Grosvenor Lane, Suite 200, Bethesda, Maryland 20814 (e-mail, [email protected]).