Is forced treatment in our outpatients’ best interests?

Maryland, where we live, is one of only five states that does not have forced outpatient care for psychiatric patients. The more familiar euphemism is "assisted outpatient treatment" or AOT, but it’s a term that sugarcoats what happens, and even if it’s the right thing to legislate, we might as well call it what it is, since psychiatry has long been accused of being overly coercive. This week, the Maryland General Assembly proposed legislation to bring AOT to our state, and the swords are set to be drawn.

Recently, I had the pleasure of hearing Jeffrey Swanson, Ph.D., a medical sociologist at Duke University, speak at the Sheppard and Enoch Pratt Hospital in Baltimore on "Outpatient Commitment as Crisis-Driven Law: Evaluating Policy Options and Effectiveness Through the Lens of Gun Violence." I don’t know what that title means, but I do know it’s a good one for driving up the blood pressure of many people, my own included. If Dr. Swanson could have somehow added abortion, Obamacare, and Woody Allen to his title, the entire country could have chimed in. I’m going to summarize some of the key points of Dr. Swanson’s lecture below.

He started by discussing the controversial topic of mandated community treatment, a practice that inspires "strident disagreement." "Should we have outpatient commitment? And what does it mean to ask if it works?"

Starting with the tragic massacre in Newtown on Dec. 14, 2012, Dr. Swanson noted that in addition to the Sandy Hook victims, 85 other people died from gun fatalities that same day. But Newtown stimulated the conversation. Is it the guns? Our violent culture? The failure of the mental health system? "It’s not in our repertoire," he noted, "to limit access to guns as other nations have done, so instead, we’ve looked to limiting the right to own those guns."

A national opinion poll in 2013 shows that 60% of the U.S. public believes that people with schizophrenia are likely to be violent, and 45% believe that people with mental illness are "far more dangerous" than the general public. In fact, 1 in 70,000 people with schizophrenia kills a stranger and this, said Dr. Swanson, "is what people are really about." He went on to say that curing major mental illness would reduce serious violence by 4%. Meanwhile, 3.5 million people with serious psychiatric disorders go without treatment. "You could tell that story several different ways; it doesn’t have a lot to do with violence."

In New York, legislation to Secure Ammunition and Firearms Enforcement (the NY SAFE Act of 2013), included an expansion of that state’s outpatient forced treatment; it now lasts longer, is required for released prisoners with mental illness, and follows patients when they move to other counties. As I’ve noted in a past column, it also requires mental health professionals to report patients who are believed likely to be violent.

"It’s interesting," Dr. Swanson noted, "that they are connected as part of a gun control package."

Last month, Dr. Swanson said, the White House issued two executive actions aimed at reducing gun violence. Among the executive actions was one that seeks to strengthen gun background checks for gun permits to include people who were on AOT, in addition to people committed to hospitals involuntarily. The executive actions further remove barriers (including Health Insurance Portability and Accountability Act, or HIPAA requirements) that make it difficult to submit information about these patients.

Dr. Swanson then discussed the basic facts about outpatient commitment. It extends the state’s authority from the institution to community-based care and includes a civil court order that requires the patient to comply with recommended treatment and receive services. "It emerged from the ashes of deinstitutionalization as a way to get the treatment to people that they needed." Dr. Swanson noted that there is no requirement for forced medication in the outpatient setting.

There are three types of outpatient commitment. It can be used as a conditional release from the hospital (40 states), as an alternative to hospitalization for people meeting inpatient commitment criteria (33 states, but infrequently used), and as a preventive court-ordered treatment authorized at a lower threshold to prevent further deterioration in a patient’s condition (10 states). Of the states that have outpatient commitment statutes, there is little use of it outside New York. Dr. Swanson noted that this entails "nested prediction in the law" with regard to how likely patients are to comply with treatment and how likely they are to become dangerous.

He was careful to note that one of the major issues with AOT is that not only does it obligate the patient to obtain treatment, but it obligates the state to provide care. Those in the system in New York and North Carolina, where follow-up studies have been conducted, receive case management services, housing, and access to treatment and medications, accommodations that many patients with severe psychiatric disorders are unable to access.

Outpatient commitment’s efficacy

So does AOT work? And what does it mean to even ask that? A pilot study done at Bellevue did not show efficacy. "The treatments they were getting weren’t working very well, and overall the evidence is mixed," Dr. Swanson said. The so-called Duke study (Am. J. Psychiatry 1999;156:1968-75) and the New York AOT studies (Psychiatr. Serv. 2010;61967-9 and Am. J. Psychiatry 2013;170:1423-32), revealed that the successes of forced outpatient treatment are dependent on an investment in effective implementation, the availability of intensive community services, and the duration of treatment – with a notable decrease in hospital readmission rates for those treated for more than 180 days.

The Duke study showed that the control group had a 48% rehospitalization rate, with an average of 27.9 days hospitalized; those assigned to AOT for less than 180 days had a 50% rehospitalization rate, with an average of 37.7 days; and those assigned to AOT for more than 180 days had a 32% rehospitalization rate, with an average of 7.51 days. In fact, those assigned to AOT for less than 6 months appeared to do worse than the controls. The study did show that people receiving AOT were less likely to have violent behaviors and were less likely to be the victims of violence; however, the study included all aggressive behaviors, including shoving and acts that resulted in no injury. Obviously, these studies said nothing about the likelihood that AOT would decrease the probability that someone with a major mental illness would murder a stranger.

And what about the patients: Did they feel helped by forced treatment? This is an issue of key concern to me, because I remain perplexed at the idea that people are not grateful to be returned to a state of mental well-being, and I don’t believe that their concerns about their treatment should be dismissed with the idea that they simply lack insight. Of the patients, only 27% endorsed forced treatment after the fact, while the rest did not. On a measure of "quality of life," there were improvements for those in AOT for more than 12 months but not for those treated for 6 months.

Dr. Swanson concluded his talk by saying that the added benefits of housing and intensive services may have been instrumental in causing some of the positive change that is captured with ongoing AOT. He showed a final slide:

Outpatient commitment is neither a cure-all nor a catastrophe. It brings neither an end to violence nor an end to civil rights. It does not affect the majority of people with some form of psychiatric illness. It cannot fix a fiscal crisis of the state in which resources for mental health services continue to shrink. But it may be a reasonable and measured policy that can make effective treatment much more consistently available to those few among us who are in most need of treatment in the community, who at times may actually want it, but in the real word may not get it any other way.

My conclusion

I’ll leave Dr. Swanson out of it from here, but it’s funny that we started with Newtown, and not one of the many laws that have been passed since that tragic day have done anything to address the spiral that led to that senseless massacre. Today, the shooter’s mother would still be able to purchase guns for his use, and nothing about his story as publicized leads us to believe that he would now be entered into a public database or forced to go to a treatment program.

We’ve started with a problem, and created what we hope might be answers to a whole different set of issues. Perhaps those answers are benign or beneficial, but perhaps they will further antagonize those who most need our help. If the issue is finances and decreasing hospital stays, it’s unclear why we target the mentally ill while leaving those with diabetes and heart disease to drink soda, and those with lung disease to smoke cigarettes. What, no discussion of tobacco and sugar registries?

Until we have shown that it is the "forced" part of AOT that leads to better outcomes, we need to more vigorously address the issue of patient satisfaction, and figure why our treatments – ones that don’t always work and sometimes are toxic – are not palatable to the patients they are intended to help. Until we go there, perhaps we should tread carefully when it comes to curtailing the civil rights of those with any type of illness.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

Maryland, where we live, is one of only five states that does not have forced outpatient care for psychiatric patients. The more familiar euphemism is "assisted outpatient treatment" or AOT, but it’s a term that sugarcoats what happens, and even if it’s the right thing to legislate, we might as well call it what it is, since psychiatry has long been accused of being overly coercive. This week, the Maryland General Assembly proposed legislation to bring AOT to our state, and the swords are set to be drawn.

Recently, I had the pleasure of hearing Jeffrey Swanson, Ph.D., a medical sociologist at Duke University, speak at the Sheppard and Enoch Pratt Hospital in Baltimore on "Outpatient Commitment as Crisis-Driven Law: Evaluating Policy Options and Effectiveness Through the Lens of Gun Violence." I don’t know what that title means, but I do know it’s a good one for driving up the blood pressure of many people, my own included. If Dr. Swanson could have somehow added abortion, Obamacare, and Woody Allen to his title, the entire country could have chimed in. I’m going to summarize some of the key points of Dr. Swanson’s lecture below.

He started by discussing the controversial topic of mandated community treatment, a practice that inspires "strident disagreement." "Should we have outpatient commitment? And what does it mean to ask if it works?"

Starting with the tragic massacre in Newtown on Dec. 14, 2012, Dr. Swanson noted that in addition to the Sandy Hook victims, 85 other people died from gun fatalities that same day. But Newtown stimulated the conversation. Is it the guns? Our violent culture? The failure of the mental health system? "It’s not in our repertoire," he noted, "to limit access to guns as other nations have done, so instead, we’ve looked to limiting the right to own those guns."

A national opinion poll in 2013 shows that 60% of the U.S. public believes that people with schizophrenia are likely to be violent, and 45% believe that people with mental illness are "far more dangerous" than the general public. In fact, 1 in 70,000 people with schizophrenia kills a stranger and this, said Dr. Swanson, "is what people are really about." He went on to say that curing major mental illness would reduce serious violence by 4%. Meanwhile, 3.5 million people with serious psychiatric disorders go without treatment. "You could tell that story several different ways; it doesn’t have a lot to do with violence."

In New York, legislation to Secure Ammunition and Firearms Enforcement (the NY SAFE Act of 2013), included an expansion of that state’s outpatient forced treatment; it now lasts longer, is required for released prisoners with mental illness, and follows patients when they move to other counties. As I’ve noted in a past column, it also requires mental health professionals to report patients who are believed likely to be violent.

"It’s interesting," Dr. Swanson noted, "that they are connected as part of a gun control package."

Last month, Dr. Swanson said, the White House issued two executive actions aimed at reducing gun violence. Among the executive actions was one that seeks to strengthen gun background checks for gun permits to include people who were on AOT, in addition to people committed to hospitals involuntarily. The executive actions further remove barriers (including Health Insurance Portability and Accountability Act, or HIPAA requirements) that make it difficult to submit information about these patients.

Dr. Swanson then discussed the basic facts about outpatient commitment. It extends the state’s authority from the institution to community-based care and includes a civil court order that requires the patient to comply with recommended treatment and receive services. "It emerged from the ashes of deinstitutionalization as a way to get the treatment to people that they needed." Dr. Swanson noted that there is no requirement for forced medication in the outpatient setting.

There are three types of outpatient commitment. It can be used as a conditional release from the hospital (40 states), as an alternative to hospitalization for people meeting inpatient commitment criteria (33 states, but infrequently used), and as a preventive court-ordered treatment authorized at a lower threshold to prevent further deterioration in a patient’s condition (10 states). Of the states that have outpatient commitment statutes, there is little use of it outside New York. Dr. Swanson noted that this entails "nested prediction in the law" with regard to how likely patients are to comply with treatment and how likely they are to become dangerous.

He was careful to note that one of the major issues with AOT is that not only does it obligate the patient to obtain treatment, but it obligates the state to provide care. Those in the system in New York and North Carolina, where follow-up studies have been conducted, receive case management services, housing, and access to treatment and medications, accommodations that many patients with severe psychiatric disorders are unable to access.

Outpatient commitment’s efficacy

So does AOT work? And what does it mean to even ask that? A pilot study done at Bellevue did not show efficacy. "The treatments they were getting weren’t working very well, and overall the evidence is mixed," Dr. Swanson said. The so-called Duke study (Am. J. Psychiatry 1999;156:1968-75) and the New York AOT studies (Psychiatr. Serv. 2010;61967-9 and Am. J. Psychiatry 2013;170:1423-32), revealed that the successes of forced outpatient treatment are dependent on an investment in effective implementation, the availability of intensive community services, and the duration of treatment – with a notable decrease in hospital readmission rates for those treated for more than 180 days.

The Duke study showed that the control group had a 48% rehospitalization rate, with an average of 27.9 days hospitalized; those assigned to AOT for less than 180 days had a 50% rehospitalization rate, with an average of 37.7 days; and those assigned to AOT for more than 180 days had a 32% rehospitalization rate, with an average of 7.51 days. In fact, those assigned to AOT for less than 6 months appeared to do worse than the controls. The study did show that people receiving AOT were less likely to have violent behaviors and were less likely to be the victims of violence; however, the study included all aggressive behaviors, including shoving and acts that resulted in no injury. Obviously, these studies said nothing about the likelihood that AOT would decrease the probability that someone with a major mental illness would murder a stranger.

And what about the patients: Did they feel helped by forced treatment? This is an issue of key concern to me, because I remain perplexed at the idea that people are not grateful to be returned to a state of mental well-being, and I don’t believe that their concerns about their treatment should be dismissed with the idea that they simply lack insight. Of the patients, only 27% endorsed forced treatment after the fact, while the rest did not. On a measure of "quality of life," there were improvements for those in AOT for more than 12 months but not for those treated for 6 months.

Dr. Swanson concluded his talk by saying that the added benefits of housing and intensive services may have been instrumental in causing some of the positive change that is captured with ongoing AOT. He showed a final slide:

Outpatient commitment is neither a cure-all nor a catastrophe. It brings neither an end to violence nor an end to civil rights. It does not affect the majority of people with some form of psychiatric illness. It cannot fix a fiscal crisis of the state in which resources for mental health services continue to shrink. But it may be a reasonable and measured policy that can make effective treatment much more consistently available to those few among us who are in most need of treatment in the community, who at times may actually want it, but in the real word may not get it any other way.

My conclusion

I’ll leave Dr. Swanson out of it from here, but it’s funny that we started with Newtown, and not one of the many laws that have been passed since that tragic day have done anything to address the spiral that led to that senseless massacre. Today, the shooter’s mother would still be able to purchase guns for his use, and nothing about his story as publicized leads us to believe that he would now be entered into a public database or forced to go to a treatment program.

We’ve started with a problem, and created what we hope might be answers to a whole different set of issues. Perhaps those answers are benign or beneficial, but perhaps they will further antagonize those who most need our help. If the issue is finances and decreasing hospital stays, it’s unclear why we target the mentally ill while leaving those with diabetes and heart disease to drink soda, and those with lung disease to smoke cigarettes. What, no discussion of tobacco and sugar registries?

Until we have shown that it is the "forced" part of AOT that leads to better outcomes, we need to more vigorously address the issue of patient satisfaction, and figure why our treatments – ones that don’t always work and sometimes are toxic – are not palatable to the patients they are intended to help. Until we go there, perhaps we should tread carefully when it comes to curtailing the civil rights of those with any type of illness.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

Maryland, where we live, is one of only five states that does not have forced outpatient care for psychiatric patients. The more familiar euphemism is "assisted outpatient treatment" or AOT, but it’s a term that sugarcoats what happens, and even if it’s the right thing to legislate, we might as well call it what it is, since psychiatry has long been accused of being overly coercive. This week, the Maryland General Assembly proposed legislation to bring AOT to our state, and the swords are set to be drawn.

Recently, I had the pleasure of hearing Jeffrey Swanson, Ph.D., a medical sociologist at Duke University, speak at the Sheppard and Enoch Pratt Hospital in Baltimore on "Outpatient Commitment as Crisis-Driven Law: Evaluating Policy Options and Effectiveness Through the Lens of Gun Violence." I don’t know what that title means, but I do know it’s a good one for driving up the blood pressure of many people, my own included. If Dr. Swanson could have somehow added abortion, Obamacare, and Woody Allen to his title, the entire country could have chimed in. I’m going to summarize some of the key points of Dr. Swanson’s lecture below.

He started by discussing the controversial topic of mandated community treatment, a practice that inspires "strident disagreement." "Should we have outpatient commitment? And what does it mean to ask if it works?"

Starting with the tragic massacre in Newtown on Dec. 14, 2012, Dr. Swanson noted that in addition to the Sandy Hook victims, 85 other people died from gun fatalities that same day. But Newtown stimulated the conversation. Is it the guns? Our violent culture? The failure of the mental health system? "It’s not in our repertoire," he noted, "to limit access to guns as other nations have done, so instead, we’ve looked to limiting the right to own those guns."

A national opinion poll in 2013 shows that 60% of the U.S. public believes that people with schizophrenia are likely to be violent, and 45% believe that people with mental illness are "far more dangerous" than the general public. In fact, 1 in 70,000 people with schizophrenia kills a stranger and this, said Dr. Swanson, "is what people are really about." He went on to say that curing major mental illness would reduce serious violence by 4%. Meanwhile, 3.5 million people with serious psychiatric disorders go without treatment. "You could tell that story several different ways; it doesn’t have a lot to do with violence."

In New York, legislation to Secure Ammunition and Firearms Enforcement (the NY SAFE Act of 2013), included an expansion of that state’s outpatient forced treatment; it now lasts longer, is required for released prisoners with mental illness, and follows patients when they move to other counties. As I’ve noted in a past column, it also requires mental health professionals to report patients who are believed likely to be violent.

"It’s interesting," Dr. Swanson noted, "that they are connected as part of a gun control package."

Last month, Dr. Swanson said, the White House issued two executive actions aimed at reducing gun violence. Among the executive actions was one that seeks to strengthen gun background checks for gun permits to include people who were on AOT, in addition to people committed to hospitals involuntarily. The executive actions further remove barriers (including Health Insurance Portability and Accountability Act, or HIPAA requirements) that make it difficult to submit information about these patients.

Dr. Swanson then discussed the basic facts about outpatient commitment. It extends the state’s authority from the institution to community-based care and includes a civil court order that requires the patient to comply with recommended treatment and receive services. "It emerged from the ashes of deinstitutionalization as a way to get the treatment to people that they needed." Dr. Swanson noted that there is no requirement for forced medication in the outpatient setting.

There are three types of outpatient commitment. It can be used as a conditional release from the hospital (40 states), as an alternative to hospitalization for people meeting inpatient commitment criteria (33 states, but infrequently used), and as a preventive court-ordered treatment authorized at a lower threshold to prevent further deterioration in a patient’s condition (10 states). Of the states that have outpatient commitment statutes, there is little use of it outside New York. Dr. Swanson noted that this entails "nested prediction in the law" with regard to how likely patients are to comply with treatment and how likely they are to become dangerous.

He was careful to note that one of the major issues with AOT is that not only does it obligate the patient to obtain treatment, but it obligates the state to provide care. Those in the system in New York and North Carolina, where follow-up studies have been conducted, receive case management services, housing, and access to treatment and medications, accommodations that many patients with severe psychiatric disorders are unable to access.

Outpatient commitment’s efficacy

So does AOT work? And what does it mean to even ask that? A pilot study done at Bellevue did not show efficacy. "The treatments they were getting weren’t working very well, and overall the evidence is mixed," Dr. Swanson said. The so-called Duke study (Am. J. Psychiatry 1999;156:1968-75) and the New York AOT studies (Psychiatr. Serv. 2010;61967-9 and Am. J. Psychiatry 2013;170:1423-32), revealed that the successes of forced outpatient treatment are dependent on an investment in effective implementation, the availability of intensive community services, and the duration of treatment – with a notable decrease in hospital readmission rates for those treated for more than 180 days.

The Duke study showed that the control group had a 48% rehospitalization rate, with an average of 27.9 days hospitalized; those assigned to AOT for less than 180 days had a 50% rehospitalization rate, with an average of 37.7 days; and those assigned to AOT for more than 180 days had a 32% rehospitalization rate, with an average of 7.51 days. In fact, those assigned to AOT for less than 6 months appeared to do worse than the controls. The study did show that people receiving AOT were less likely to have violent behaviors and were less likely to be the victims of violence; however, the study included all aggressive behaviors, including shoving and acts that resulted in no injury. Obviously, these studies said nothing about the likelihood that AOT would decrease the probability that someone with a major mental illness would murder a stranger.

And what about the patients: Did they feel helped by forced treatment? This is an issue of key concern to me, because I remain perplexed at the idea that people are not grateful to be returned to a state of mental well-being, and I don’t believe that their concerns about their treatment should be dismissed with the idea that they simply lack insight. Of the patients, only 27% endorsed forced treatment after the fact, while the rest did not. On a measure of "quality of life," there were improvements for those in AOT for more than 12 months but not for those treated for 6 months.

Dr. Swanson concluded his talk by saying that the added benefits of housing and intensive services may have been instrumental in causing some of the positive change that is captured with ongoing AOT. He showed a final slide:

Outpatient commitment is neither a cure-all nor a catastrophe. It brings neither an end to violence nor an end to civil rights. It does not affect the majority of people with some form of psychiatric illness. It cannot fix a fiscal crisis of the state in which resources for mental health services continue to shrink. But it may be a reasonable and measured policy that can make effective treatment much more consistently available to those few among us who are in most need of treatment in the community, who at times may actually want it, but in the real word may not get it any other way.

My conclusion

I’ll leave Dr. Swanson out of it from here, but it’s funny that we started with Newtown, and not one of the many laws that have been passed since that tragic day have done anything to address the spiral that led to that senseless massacre. Today, the shooter’s mother would still be able to purchase guns for his use, and nothing about his story as publicized leads us to believe that he would now be entered into a public database or forced to go to a treatment program.

We’ve started with a problem, and created what we hope might be answers to a whole different set of issues. Perhaps those answers are benign or beneficial, but perhaps they will further antagonize those who most need our help. If the issue is finances and decreasing hospital stays, it’s unclear why we target the mentally ill while leaving those with diabetes and heart disease to drink soda, and those with lung disease to smoke cigarettes. What, no discussion of tobacco and sugar registries?

Until we have shown that it is the "forced" part of AOT that leads to better outcomes, we need to more vigorously address the issue of patient satisfaction, and figure why our treatments – ones that don’t always work and sometimes are toxic – are not palatable to the patients they are intended to help. Until we go there, perhaps we should tread carefully when it comes to curtailing the civil rights of those with any type of illness.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).