Does Involuntary Outpatient Treatment Work?

In most mental health systems there are people with severe mental illness who are prone to relapse, have repeated hospitalizations and criminal justice contacts, and disproportionately use the most costly services. Many also have alcohol or drug abuse problems. Such individuals often fail to take their prescribed medications, worsening their condition.

Many states use some form of civil commitment—a statutorily created and court-ordered form of compulsory treatment—to compel patients to undergo treatment, including taking medication. The goal is to ensure public safety and to make sure that those who need treatment receive it. Despite its wide use, involuntary treatment has been the most consistently debated issue in mental health law for the last 30 years.

California may be considering a proposal to expand existing statutes to include involuntary outpatient treatment, in which a court orders an individual to comply with a specific outpatient treatment regimen. To inform the decision, the Senate Committee on Rules asked RAND to answer three questions:

• Does involuntary outpatient treatment work?
• How has it been implemented in states that currently use it?
• How would such a law affect people with severe mental illness in California?

A RAND team led by Susan Ridgely reviewed the available studies, interviewed stakeholders in eight states, and analyzed administrative data on services provided by California's county mental health contract agencies. Their conclusions:

• There is no evidence that a court order is necessary to achieve compliance and good outcomes, or that a court order, in and of itself, has any independent effect on outcomes.
• The attorneys, behavioral health officials, and psychiatrists who were interviewed support involuntary outpatient treatment as a way to make sure people get needed services, but many feel the services offered in their communities are inadequate for making involuntary outpatient treatment work.
• Available data make it very difficult to estimate the law's potential effect in California.
• The data suggest that a significant percentage of people with mental illness who need services aren't getting them, and those who do get very few.

Approach

RAND conducted an evidence-based review of the empirical literature on involuntary outpatient treatment—the first such review ever conducted. An evidence-based review is a scientific investigation that critically analyzes studies rather than simply reporting their findings.

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Ohio
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• North Carolina

The team reviewed statutory and case law on involuntary treatment in eight states (see map), chosen because they have involuntary outpatient treatment systems, some of which had been rigorously studied. Priority was placed on reviewing states with outpatient treatment systems similar to California's. To gather information about how the laws had been implemented, the researchers also conducted interviews with prosecuting and defense attorneys, county behavioral health officials, and psychiatrists in these states. The interviews allowed the researchers to juxtapose actual experience with an analysis of statutory and case law in each state.

To take a snapshot of involuntary treatment in California, RAND analyzed data from the California Department of Mental Health's Client Data System (CDS), which contains service records for all persons served by California's county mental health contract agencies.

How Effective Is Involuntary Outpatient Treatment?

Empirical evidence on effectiveness of involuntary outpatient treatment is slim. Significant design flaws in early studies of involuntary outpatient treatment reduce the confidence that can be placed in their findings. Among more recent studies, there have been only two randomized clinical trials—the gold standard for empirical investigations. One was conducted in New York City, the other in North Carolina by Duke University investigators. The studies came to conflicting conclusions.

The investigators in New York compared outcomes such as rates of rehospitalization, arrests, quality of life, psychiatric symptoms, and homelessness for two groups: mentally ill individuals subject to involuntary treatment and individuals receiving intensive services but without a commitment order. They found no significant differences between these groups. However, some features of the study—for instance, the small number of people studied, non-equivalent comparison groups, lack of enforcement of court orders—make it difficult to draw definitive conclusions from these results.

The Duke study, the better of the two, suggests that a sustained outpatient commitment order (180+ days), when combined with intensive mental health services, may increase the number of individuals who receive mental health treatment, including prescribed medications, and reduce negative outcomes such as relapse, violent behavior, victimization, and arrest. Only people under court order who also received intensive mental health services had these improved outcomes. Thus this study does not tell us whether court orders without intensive treatment have any effect.

In contrast, the literature provides clear evidence that alternative community-based health treatment programs can produce good outcomes for people with severe mental illness. In one such program—Assertive Community Treatment (ACT)—community-based care is delivered by a team of highly trained mental health professionals. Because ACT is staff-intensive, it is more expensive than traditional mental health services.

No randomized clinical trials have examined the relative efficacy of involuntary outpatient treatment and assertive community treatment. Thus the empirical literature does not tell us whether a court order is necessary to achieve good outcomes.

What Is the Experience of Other States That Use Involuntary Outpatient Treatment?

The research team conducted interviews with 37 prosecuting and defense attorneys, psychiatrists, and local behavioral health officials to learn how involuntary outpatient treatment had been implemented in their states; how consistently it had been implemented across jurisdictions, judges, and providers; and how it had affected patients, providers, treatment resources, and care.

One dominant message emerged from the interviews: It is dangerous to make assumptions about how outpatient commitment is actually implemented just by analyzing the law that permits it.

Respondents also agreed that successful outpatient commitment required a community to have the following:

• The infrastructure to handle petitions, receive court orders, and track people through the system.
• Available treatment services—e.g., assertive community treatment, intensive case management, newer medications, and supported housing.
• A service system that can deliver care rationally—e.g., appropriate caseloads, incentives to modify provider behavior, efforts to improve the quality of routine care, and attention to the needs of patients rather than just the bottom line.

Summing up, respondents felt that outpatient commitment is neither as effective a solution to the problem of compliance as its advocates claim nor, in its practical application, as repressive a law as consumer/survivors fear. In terms of implementation, respondents suggested that a good involuntary outpatient treatment statute would be simple and specific and would include unambiguous criteria and standards. Implementation should be uniform across a state, with a fixed point of accountability in every community and adequate training for all stakeholders.

How Would an Involuntary Outpatient Commitment Law Affect People with Mental Illness in California?

The CDS, the client data system for the California Department of Mental Health, contains service records showing demographic, clinical, and service information for all persons served by California's county mental health contract agencies. The CDS also shows a patient's legal status at the time of admission and discharge—that is, whether a patient was voluntarily seeking treatment or had been involuntarily committed for some specified period. However, admissions under Medi-Cal Inpatient Consolidation are not reported in the CDS. As a consequence, the available data do not provide a complete description of involuntary inpatient treatment in California, making it very difficult to predict how a new law would affect people with mental illness.

However, the CDS data provide some useful information. The team focused on fiscal year 1997-1998 because it is the most recent year for which the data were complete. During that period, less than 1 percent of the more than 58,000 individuals who were involuntarily hospitalized remained in treatment involuntarily after an initial 14-day commitment. Only 12 percent of those committed for a 72-hour hold for evaluation and treatment moved on to a lengthier commitment. Most of these individuals were treated in crisis or emergency settings rather than in a hospital.

These findings suggest that there were many people in California whose illness was severe enough to bring them to the attention of authorities for evaluation and preliminary treatment. But either their illnesses were not severe enough to warrant continuing their treatment involuntarily, or facilities persuaded them to agree to remain in treatment voluntarily. About one-quarter of the 72-hour holds were discharged on voluntary status.

The table to the left focuses on people whose most restrictive commitment in 1997–1998 was a 72-hour hold. This group represents nearly 90 percent of all individuals in the California commitment system. The table shows whether these individuals had received mental health services in the 12 months before the 72-hour hold, and what type of services they received.

About 40 percent of these patients had been hospitalized in the prior year, and the median number of hospital days was six. About two-thirds had received day services such as crisis stabilization or rehabilitation, or outpatient services such as case management, medication support, and crisis intervention, but the median service use was very low.

Within this group were about 16,500 people who had experienced more than one 72-hour hold in 12 months. Of these, 7,400 had a diagnosis of schizophrenia or other psychotic disorders. More than 35 percent of them had received no outpatient services in the prior 12 months. Because the CDS contains only administrative data, the researchers could not tell whether lack of compliance, or problems in accessing community-based services, or both explain this pattern. If lack of compliance is the problem, this group might be an at-risk target population for involuntary outpatient treatment.

What Can We Really Say About Involuntary Outpatient Treatment?

The RAND team's research could not provide an answer to the question of whether an involuntary outpatient treatment system in California is worth the additional costs to mental health treatment systems, the courts, and law enforcement. Nor are there cost effectiveness studies that compare the relative return on investment of developing an involuntary outpatient treatment system or focusing all available resources on developing state-of-the-art community-based mental health treatment systems in every California county. Either approach would require the state's sustained administrative and financial commitment.

This study has important implications for other states considering involuntary outpatient treatment statutes or thinking of revising existing laws. The lack of empirical evidence about the comparative effectiveness of involuntary versus voluntary treatment is troubling—decisions may be influenced more by advocacy than by fact. Also, the experiences of those who have implemented involuntary outpatient treatment systems suggest that both the process of implementation and its practical details are critical to success.

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