Can Mandated Outpatient Treatment Prevent Tragedies?

This issue of Psychiatric Services features research that will inform the treatment of people with severe mental illness who are involved with the criminal justice system. Steven Lamberti's contribution, "Understanding and Preventing Criminal Recidivism Among Adults With Psychotic Disorders," draws our attention to treatment nonadherence as a final common pathway in criminal recidivism and highlights the potential use of various types of legal mandates, such as mandated outpatient treatment, to promote treatment adherence. A key point of emphasis is the paucity of research on the effectiveness of interventions specific to individuals with mental illness involved in the criminal justice system. All too often programs have embraced interventions with unknown effectiveness for this population under the largely untested assumption that they should work as well as they do for groups outside the criminal justice system. However, consumers in this population are far more likely to have comorbid substance use disorders, antisocial personality traits, or disorders and fragile social networks that may require new or modified treatments.

Many readers of Lamberti's article will now view it through a far different lens, sifting for clues to avert tragedies such as the recent shootings at Virginia Tech. Here we must be quite circumspect. As Lamberti points out, most states have laws authorizing "mandated outpatient treatment"—requiring that some people get ongoing outpatient mental health treatment—and it appears that the Virginia Tech assailant was at least nominally mandated to outpatient treatment in 2005. However, although Virginia's commitment law permits use of mandated outpatient treatment, it sets a criterion for its use identical to the criterion of imminent dangerousness for inpatient treatment, offers little guidance on enforcement in the event of treatment nonadherence, and provides no administrative infrastructure to make the law work. Virginia, already undergoing an exhaustive review of its commitment laws, will doubtless ask if a well-implemented mandated outpatient treatment statute is warranted.

Violent acts, fortunately rare, have become the focal point for supporters of mandated outpatient treatment in the states that have recently enacted mandated outpatient treatment laws. Kendra's Law in New York, Laura's Law in California, and Kevin's Law in Michigan are all named for victims of individuals with mental illness. Mandated outpatient treatment orders, as conceived, are not so much about preventing violence as they are about improving treatment adherence and reducing relapse. The downstream benefit of preventing rare acts of murderous violence will be exceedingly hard to demonstrate, although at least one study suggests that some kinds of violence can be so prevented. But for mandated outpatient treatment to work, states have to provide committed consumers effective services in the community. And that costs money.