MONTREAL – Outpatient commitment can be a useful tool if it is implemented for a long enough period and combined with more frequent services, Dr. Marvin S. Swartz said at the annual meeting of the American Academy of Psychiatry and the Law.
“We do show that outpatient commitment exerts an effect over and above enhanced services,” said Dr. Swartz, who is head of social and community psychiatry at Duke University Medical Center, Durham, N.C. “But if you give outpatient commitment without enhanced services, it has no effect.”
Forty-one states have outpatient commitment statutes, Dr. Swartz said. These laws allow courts to mandate that outpatient psychiatry patients attend treatment sessions. If patients refuse to go to the sessions, health care providers can enlist the aid of law enforcement authorities to bring the patients in.
In a study Dr. Swartz and his colleagues conducted with 331 patients who had recently been hospitalized for a mental illness, patients who had more than 6 months of outpatient commitment were less likely to be readmitted to the hospital compared with those who had less than 6 months' worth. In addition, those who had 6 months or more of outpatient commitment had a lower mean number of hospital stays and a much lower number of average days in the hospital–8 days versus 30 days–compared with those either in the control group or with less than 6 months of outpatient commitment.
“This is a significant effect of outpatient commitment,” Dr. Swartz said. “Most of the effect was among folks with psychotic disorders such as schizoaffective disorder and schizophrenia, as opposed to mood disorders or bipolar disorders.”
Those who were violent in the past and had 6 months or more of outpatient commitment were also less likely to be violent, he added.
Overall, “treatment adherence improved with outpatient commitment, and outpatient commitment can reduce violence, victimization, and family strain, and can improve medication adherence and quality of life,” he said.
But outpatient commitment is just a single point on the spectrum of leverage psychiatrists can use to get patients to come for treatment, noted Dr. Paul Appelbaum, chair of psychiatry at Columbia University, New York. Other leverage points include housing, money, and, in some cases, control over parole, he said.
Child custody is another example; a provider might say: “'We'll support your regaining custody of your child, or having more unsupervised visits, but we really can't do that in good conscience … unless you're coming to treatment regularly,'” he said. “Outpatient commitment is one piece of the entire spectrum of coercion or leverage applied to people in outpatient settings.”
Although outpatient commitment causes lots of controversy because of its coercive aspects, that's the wrong thing to focus on, according to Stephen J. Morse, Ph.D., professor of psychology and law in psychiatry at the University of Pennsylvania, Philadelphia. Dr. Morse noted that there are 25 million people in the United States suffering from schizophrenic disorder, serious or moderate major depressive disorder, or bipolar disorder.
“Now how many doctoral and clinical psychologists and psychiatrists are there? About 90,000 altogether,” he said. “That's one treating professional for every 232 people” suffering from just those three conditions; assuming only half would consent to voluntary outpatient treatment, that would still be one provider for every 116 people–and that doesn't take into account people who suffer from other disorders and assumes all providers would be spending 100% of their time on patient care.
“Suppose we said to 25 million people, 'We can help keep you out of hospital, help you get along with your family, help keep you out of the criminal justice system; we can do all those things for you if you just come for at least 6 months, three times a week.' You couldn't begin to treat all the people who would accept under those conditions,” Dr. Morse said. “Why are we talking about coercion of one sort of another when what we ought to talk about is forcing the legislature to produce the services that would make coercion not necessary?”