Involuntary outpatient treatment for mentally ill spurs new debate

Forty-two states have laws requiring involuntary outpatient treatment for severely mentally ill people, but a recent legislative fight in New Mexico and a case before the U.S. Supreme Court show that the issue is still divisive.

Even in states with such laws, their success is debated because the statutes have been passed without simultaneously providing the funds for mental health services. Critics say that not enough research has been done to test the laws' efficacy.

In February, New Mexico attempted to pass legislation to allow family members or doctors to seek court-ordered outpatient treatment, such as medication or therapy, for the mentally ill who refuse services. The measure, backed by Gov. Bill Richardson, was defeated in the Legislature after facing opposition from such groups as the American Civil Liberties Union of New Mexico.

Advocates say they are most concerned with getting treatment for the mentally ill to protect the public, as well as the patients, before violence occurs.

Doctors and advocates say the laws are aimed at a subpopulation of people with severe mental illness, such as schizophrenia or bipolar disorder, who require repeated hospitalization or treatment. Once such patients go off medication, they have difficulty recognizing that they are ill or that the medication will keep them stable.

"The core issue is how do you get someone into treatment when they don't know they are ill," a condition known as anosognosia, said Mary Zdanowicz, executive director for the Treatment Advocacy Center, Arlington, Va., which supports involuntary outpatient treatment laws.

In addition to supporting such measures at the state level, the center is attempting to get the attention of the U.S. Supreme Court. In April justices are scheduled to hear the case of a schizophrenic who, in a delusional state, shot and killed a police officer in Flagstaff, Ariz. Eric Clark was sentenced to 25 years in prison.

The underlying issue before the Supreme Court is the insanity defense, on which the center has not taken a position. But the group filed a friend-of-the-court brief stating its concern that "the insanity defense is becoming a scapegoat for problems actually created by unworkable state civil commitment laws."

Some state's statutes make it too difficult to force treatment, the group says. It argues that in states with less restrictive outpatient treatment laws, earlier care has been shown to reduce violence and arrest rates.

"We're most concerned with getting treatment before the danger occurs" using outpatient treatment laws, Zdanowicz said. Traditional inpatient commitment laws order hospitalization for those who pose an immediate threat to themselves or others, she said. But in Clark's case, for example, his family could not get him care when he refused because he was not dangerous enough, she added.

"It's not the underlying case, but it's what leads to a case like this," Zdanowicz said.

Treatment laws a "short-term" fix

On the other hand, opponents say involuntary outpatient treatment laws violate the civil liberties of the mentally ill by imposing a legislative solution on a medical decision. They dispute evidence that such laws reduce violence and arrest rates.

"If people are not dangerous, they should be able to be in the community without a court order hanging over their head waiting for them to fail," said Tammy Seltzer, senior staff attorney for the Bazelon Center for Mental Health Law in Washington, D.C. People who violate these orders can be forced into inpatient treatment.

For those who lack competency, there are tools available to help patients make a medical decision, such as guardianship or advance directives so people can plan ahead before mental deterioration occurs, she said.

Seltzer called the laws a "short-term fix, instead of focusing on long-term recovery" by improving access to mental health services. "It seems strange to me we would go to draconian measures before we expanded services so we know what works."

The National Mental Health Assn. also opposes outpatient treatment laws, calling them a "simplistic response." The NMHA encourages laws that enforce advance directives and points to studies supporting the success of comprehensive mental health services. It disputes evidence that outpatient treatment reduces "adverse outcomes."

But whether those services are available or not, "If a person doesn't understand they can benefit from them and express a willingness, it doesn't really matter," said Fred Frese, PhD, a psychologist who has been diagnosed and treated for schizophrenia for nearly 40 years.

Dr. Frese, an officer with the Treatment Advocacy Center, recommends including the voices of patients, along with those of legal and medical professionals, in the discussion over implementing outpatient treatment laws.

The American Psychiatric Assn., which "mildly supports" such laws, argues that more research is needed to find an effective model.

"Just passing a statute on its own isn't going to do anything unless you make available the resources that people being committed need," said Paul Appelbaum, MD, a psychiatrist and past president of the American Psychiatric Assn.

He said violent acts are rare and difficult to predict, and that laws that have resulted from some of these events probably wouldn't have helped prevent the crime.

New York's law, commonly referred to as "Kendra's law" after the woman who was pushed in front of a subway train by a mentally ill person in 1999, has been upheld as a model by some mental health experts. "New York was farsighted in that it simultaneously provided the funds for services," Dr. Appelbaum said.

The statute has also been touted by advocates because it survived a test in the 2nd U.S. Court of Appeals.

A 2005 report by New York's Office of Mental Health stated that the law was successful in reducing rates for hospitalizations, homelessness, arrests and incarcerations.

The American Medical Association does not take a position on outpatient treatment laws. But the AMA advocates for removing barriers to care for the mentally ill by improving public awareness and ensuring the supply of psychiatrists. The Association "urges physicians to become more involved in pre-crisis intervention, treatment and integration of chronic mentally ill patients into the community to prevent unnecessary hospitalization or jail confinement," the policy states.