Pennsylvania must update its treatment standards
Pennsylvania’s mental health treatment standard is outdated. The practical result of the current law is that community mental health services are only available to those individuals who are able to accept services voluntarily. The most severely ill are left untreated until their condition deteriorates to the point that they pose a “clear and present danger to themselves or others.”1 Pennsylvania essentially forces people who lack insight into their illness to hit rock bottom before they can be helped.
States throughout the nation are recognizing the inherent flaws of standards that force people in need to deteriorate until they are actively dangerous before providing necessary care. In the last six years alone, 16 states have adopted more progressive civil commitment laws: Wyoming (1999), Nevada (1999), New York (1999), South Dakota (2000), Washington (2001), Montana (2001), West Virginia (2001, 2005), Minnesota (2001), Wisconsin (2001), California (2001, 2002), Idaho (2002), Utah (2003), Maryland (2003), Illinois (2003), Florida (2004), and Michigan (2004). And at least three others are currently considering legislation to update their commitment standards.
Pennsylvania’s outdated treatment standard precludes effective outpatient treatment
Pennsylvania’s treatment standard necessitates that a judge find someone to be both a clear and present danger and eligible for outpatient treatment in the community.2 This unnecessarily burdensome combination ensures that very few severely ill individuals are able to benefit from outpatient treatment in Pennsylvania. For these individuals, the only option is hospitalization. States with more progressive outpatient treatment standards utilize the individual’s prior treatment history and ability to make an informed treatment decision in combination with a determination of their need for treatment.
Without effective outpatient treatment procedures, individuals whose illness causes them to be unable to understand that they need care can only receive treatment once they’ve deteriorated to the point that they require inpatient hospitalization. Once stabilized in an inpatient setting, treatment providers have no means of ensuring treatment adherence in the community. Consequently, the individual often stops taking their medication, deteriorates and again requires inpatient care. This cycle repeats until they die, disappear from the system, or face long-term incarceration.
Pennsylvania would benefit from implementing assisted outpatient treatment (AOT)
Assisted outpatient treatment refers to a court order mandating that a person with a severe mental illness adhere to a prescribed community treatment plan, using the possibility of hospitalization for treatment noncompliance as leverage. The main goal of AOT is to enable more consistent adherence to treatment for people whose severe mental illnesses impair their ability to seek and voluntarily comply with treatment.3 AOT has also been shown to:
- Reduce Hospital Readmissions – Pennsylvania’s psychiatric hospital bed capacity is limited, and slated to be reduced further with the closure of Harrisburg State Hospital.4 Programs must be put in place to reduce the need for inpatient hospitalization and ensure continuity of care in the community. AOT has been shown to significantly reduce hospital readmission,5 and should be a component of Pennsylvania’s plan to reduce current hospital capacity.
- Reduce Arrests – Law enforcement officers are increasingly being called on to deal with individuals in the midst of a psychotic crisis.6 This scenario is difficult and dangerous for everyone involved – and all too often ends in tragedy.7 AOT provides treatment professionals with the opportunity to intervene before a crisis occurs, reducing the need for law enforcement intervention.
- Reduce Incarceration – AOT has been shown to significantly reduce the risk of arrest and incarceration,8 while improving medication compliance – a factor strongly associated with the risk of incarceration.9 Managing individuals with mental illness in correctional facilities is also extremely expensive. The Pennsylvania Department of Corrections estimates that it costs approximately $80 per day to incarcerate an average inmate, compared to $140 per day to incarcerate a person with a serious mental illness.10
- Reduce Victimization – Victimization is a significant consequence of untreated severe mental illness.11 AOT has been shown to reduce victimization, such as assault, rape, burglary or theft of property, of individuals with severe mental illnesses.12
Reduce Violence - Noncompliance with treatment, specifically nonadherence to medication, is strongly associated with violence13 among people with severe mental illnesses. AOT has been shown, both in randomized control experiments and in practice, to reduce violence.14
AOT addresses the most common reason for refusing treatment - lack of insight (anosognosia)
Extensive research since the early 1990s has revealed that some people with schizophrenia and bipolar disorder experience a neurological deficit called “anosognosia,” a condition also commonly found in people suffering other brain disorders such as Alzheimer’s or stroke.15 Anosognosia impairs a person’s ability to recognize that his or her symptoms are caused by a brain disorder.16 A leading researcher detailed the severe consequences of this condition:
[P]oor insight in schizophrenia is associated with poorer medication compliance, poorer psychosocial functioning, poorer prognosis, increased relapses and hospitalization and poorer treatment outcomes.17
- The most common reason that people with severe mental illnesses are not being treated is that they do not believe that they need treatment for a mental illness.18 A severe lack of insight into illness, whether caused by schizophrenia or other impairment, can “seriously interfere with [a patient’s] ability to weigh meaningfully the consequences of various treatment options.”19
New York has seen dramatic success in its first five years using AOT
On March 1, 2005, New York’s Office of Mental Health issued a report detailing the results of the first five years of AOT under Kendra’s Law.20 Among individuals in the program, far fewer experienced hospitalizations (77 percent), episodes of homelessness (74 percent), arrests (83 percent), and incarceration (87 percent) and significantly more individuals had improved medication compliance (103 percent) and participation in substance abuse treatment (65 percent). There were marked reductions in harmful behavior; individuals who were in AOT for longer periods had greater reductions in violent behavior. Hospital days were reduced dramatically from an average of 50 days over a six-month period before starting AOT, to an average of 22 days during the six months of AOT, to an average of only 13 days in the six-month period after AOT. That is a full 74 percent reduction in hospital days six months after termination of the court order when compared with the six months prior to AOT.
People with severe mental illnesses report improved quality of life with AOT
More than 75 face-to-face interviews have been conducted with participants in New York’s AOT program to assess their opinions about AOT including their perceptions of coercion or stigma associated with the court order and their quality of life as a result of AOT. Contrary to what AOT opponents speculate, the interviews of AOT recipients showed that when asked about the impact of the pressures and other measures that people took to get them to stay in treatment:
- 75 percent reported that AOT helped them gain control over their lives,
- 81 percent said that AOT helped them to get well and stay well, and
- 90 percent said AOT made them more likely to keep appointments and take medication.
A randomized control study of AOT showed similar results. Researchers assessed the impact of AOT on quality of life of people with severe mental illnesses, covering a range of areas including social relationships, daily activities, finances, residential living situation, and global life satisfaction. They found remarkable evidence that subjects who underwent sustained periods of AOT had measurably greater subjective quality of life at the end of the study year. It appears that AOT exerts its effect largely by improving treatment adherence and decreasing symptomatology.21
Studies throughout the nation demonstrate that AOT works
- In Washington, D.C., hospital admissions decreased from 1.81 per year to 0.95 per year before and after outpatient commitment.22
- In Ohio, the number of hospital admissions decreased from 1.5 to 0.4 per year. Outpatient commitment increased patients’ compliance with outpatient psychiatric appointments from 5.7 to 13.0 per year and with attendance at day treatment sessions from 23 to 60 per year.23
- In Iowa, the number of hospital admission reduced from 1.3 to 0.3, total number of hospital days reduced from 33.3 to 4.6, and length of stay from 26.7 to 18.6.24
In North Carolina, admissions for patients on outpatient commitment decreased from 3.7 to 0.7 per 1,000 days.25
- In North Carolina, only 30 percent of patients on outpatient commitment refused medication during a six-month period compared to 66 percent of patients not on outpatient commitment.26
- In Arizona, among patients who had been outpatient committed, "71 percent of the patients voluntarily maintained treatment contacts six months after their orders expired" compared to "almost no patients" who had not been put on outpatient commitment.27
A randomized control study further proved that AOT reduces the consequences of nontreatment
The most comprehensive, randomized control study of AOT, referred to as the Duke Study, involved people who “generally did not view themselves as mentally ill or in need of treatment.”28 The study compared people who were offered community mental health services with people who were offered the same services combined with a court order requiring participation in those services (i.e., the difference was the court order). The Duke Study showed that combining a court order with services for a long term (at least six months) reduced hospitalization (up to 72 percent), reduced arrests (74 percent), reduced violence (up to 50 percent), reduced victimization (43 percent), and improved treatment compliance (58 percent).
Pennsylvania cannot afford not to utilize assisted outpatient treatment
As a result of the Community-Hospital Integration Program Projects (CHIPP’s) and the planned closure of Harrisburg State Hospital, Pennsylvania is investing significant resources in community mental health services. To ensure effective and efficient implementation of these services, Pennsylvania must ensure that the most severely ill are able to participate.
For instance, Pennsylvania has begun implementing Programs in Assertive Community Treatment (PACT) teams that comprise the most progressive community service model for people with severe mental illnesses.29 PACT teams provides 24-hour, seven-day a week mobile treatment teams that travel to clients’ homes to provide treatment and are available for “consumers who historically are underserved by traditional services;” that is, people who are treatment resistant and experience frequent rehospitalization. Without assisted outpatient treatment, PACT teams cannot require clients to take medication. The ACT Model manual recognizes that sometimes a court order may be required to ensure that clients benefit from these services.30 Without the ability to require treatment in certain instances, PACT teams cannot achieve optimal effectiveness and services are wasted.
Pennsylvania’s investment in community resources, and concurrent reduction in state hospital beds, places even greater emphasis on the need to limit hospital readmissions. Medication nonadherence is a significant factor in hospital readmissions. A recently published study of Medicaid recipients with schizophrenia in California revealed that “individuals who were [medication] nonadherent were two and one-half times more likely to be hospitalized than those who were adherent.”31 The same study found that those who are nonadherent incur 43 percent more in service costs than those who adhere to medication. In an article in Schizophrenia Bulletin, researchers calculated that nationwide, over two years, the direct costs of rehospitalization attributable to neuroleptic noncompliance is approximately $700 million. AOT has been shown to reduce such costs by improving medication compliance and decreasing rehospitalization rates.
1 50 Pa. Cons. Stat. Ann. § 7301 (2004).
2 50 Pa. Cons. Stat. Ann. § 7304(f) (2004).
3 Swanson, J.W., Swartz, M.S., Elbogen. E.B., Wagner, H.R., Burns, B.J. (2003). Effects of involuntary outpatient commitment on subjective quality of life in persons with severe mental illness. Behavioral Science and the Law, 21, 473-91.
4 Pennsylvania Department of Public Welfare, Rationale for the closure of Harrisburg State Hospital, Retrieved April 27, 2005, from http://www.dpw.state.pa.us/Family/HSHClosure/GeneralInfo/003672143.htm.
5 Swanson, J.W., Borum, R., Swartz, M.S., Hiday, V.A., Wagner, H.R., Burns, B.J. (2000). Involuntary outpatient commitment and reduction of violent behaviour in persons with severe mental illness. Brit. J. Psychiatry , 176, 324-31; New York State Office of Mental Health. (2005, March). Kendra’s Law: Final report on the status of assisted outpatient treatment .
6 Police policy on mentally ill questioned, Philadelphia Inquirer, April 22, 2005.
7 Police fatally shoot armed woman who threatened family, Philadelphia Inquirer, March 13, 2004; Police struggle with approach to the mentally ill, Christian Science Monitor, March 17, 2004; Friend says 'he had given up on himself,' Pittsburgh Post Gazette, March 25, 2005; Mifflinburg man held for trial in police chase, shooting, Sunbury Daily Item, April 8, 2005.
8 New York State Office of Mental Health. (2005, March). Kendra’s Law: Final report on the status of assisted outpatient treatment; Swartz, M.S., Swanson, J.W., Wagner, H.R., Burns, B.J., Hiday, V.A., Borum, R. (1999). Can inv oluntary outpatient commitment reduce hospital recidivism? American Journal of Psychiatry, 156, 1968-75.
9 Munetz, M.R., Grande, T.P., Chambers, M.R. (2001). The incarceration of individuals with severe mental disorders. Community Mental Health, 34, 361-71 (Nearly 90 percent of a sample of individuals with severe mental illness in a local jail were partially or completely non-complaint with medication in the year before they were incarcerated).
10 Council of State Governments. Criminal Justice / Mental Health Consensus Project (2002, June) Fact sheet: fiscal implications. Retrieved March 17, 2005, from http://www.consensusproject.org/infocenter/factsheets/fact_fiscal_implications.
11 Treatment Advocacy Center (2003, Oct.) Victimization: One of the consequences of failing to treat severe mental illness. Retrieved April 21, 2005, from http://www.psychlaws.org/BriefingPapers/BP5.htm.
12 Hiday, V.A., et al., Impact of outpatient commitment on victimization of people with severe mental illness. American Journal of Psychiatry, 159, 140.-11.
13 Swartz, M.S., Swanson, J.W., Hiday, V.A., Borum, R., Wagner, H.R., Burns, B.J. (1998). Violence and severe mental illness: The effects of substance abuse and nonadherence to medication. American Journal of Psychiatry, 155, 226-31 (Substance abuse, medication non-compliance and low insight into illness operate together to increase violence risk).
14 Swanson, J.W., Borum, R., Swartz, M.S., Hiday, V.A., Wagner, H.R., Burns, B.J. (2000). Involuntary outpatient commitment and reduction of violent behaviour in persons with severe mental illness. Brit. J. Psychiatry , 176, 324-31; Treatment Advocacy Center (2005, Mar.) Assisted outpatient treatment: Results from New York’s Kendra’s Law. Retrieved April 22, 2005 from http://www.psychlaws.org/BriefingPapers/BP18.htm.
15 Treatment Advocacy Center (2003, Oct.) Impaired awareness of illness (anosognosia): A major problem for individuals with schizophrenia and bipolar disorder. Retrieved February 21, 2005, from http://www.psychlaws.org/BriefingPapers/BP14.htm; McGlynn, S.M., & Schacter, D.L. (1997). The neuropsychology of insight: Impaired awareness of deficits in a psychiatric context. Psychiatric Annals 27, 806-11; Amador, X. (2000). I Am Not Sick, I Don’t Need Help (1 st ed.) New York: Vida Press.
16 Amador, X.F., Flaum, M., Andreason, N.C., Strauss, D.H., Yale, S.A., Clark, S.C., et al. (1994). Awareness of illness in schizophrenia and schizoaffective and mood disorders,Archives Gen. Psychiatry , 51, 826-36; Fennig, S., Everett, E., Bromet, E.J., Jandorf, L., Fenning, S.R., Tanenberg-Karant, et al., (1996). Insight in first-admission psychotic patients.Schizophrenia Research, 22, 257-63.
17 Schwartz, R.C. (1998). The relationship between insight, illness, and treatment outcome in schizophrenia. Psychiatric Quarterly, Spring, 19-22.
18 Kessler, R.C., Berglund, P.A., Bruce, M.L., Koch, J.R., Laska, E.M., Leaf, P.J., et al. (2001). The prevalence and correlates of untreated serious mental illness.Health Services Research, 36, 987-1007; Treatment Advocacy Center. What percentage of individuals with severe mental illnesses are untreated and why . Retrieved February 21, 2005 from http://www.psychlaws.org/BriefingPapers/BP13.pdf.
19 Grisso, T., & Appelbaum, P.S. (1998). Assessing competence to consent to treatment: A guide for physicians and other health professionals. New York: Oxford University Press.
20 New York State Office of Mental Health. (2005, March). Kendra’s Law: Final report on the status of assisted outpatient treatment.
21 Swanson, J.W., Swartz, M.S., Elbogen. E.B., Wagner, H.R., Burns, B.J. (2003). Effects of involuntary outpatient commitment on subjective quality of life in persons with severe mental illness. Behavioral Science and the Law, 21, 473-91.
22 Zanni, G, deVeau, L. (1986) Inpatient stays before and after outpatient commitment. Hospital and Community Psychiatry 37, 941–942.
23 Munetz, M.R., Grande, T, Kleist, J, Peterson G.A. (1996). The effectiveness of outpatient civil commitment. Psychiatric Services 47, 1251–1253.
24 Rohland. B.M., Rohrer, J.E., Richards, C.R. (2000). The long-term effect of outpatient commitment on service use. Administration and Policy in Mental Health, 27, 383-393.
25 Fernandez, G.A., Nygard S. (1990). Impact of involuntary outpatient commitment on the revolving-door syndrome in North Carolina. Hospital and Community Psychiatry 41, 1001–1004.
26 Hiday, V.A., Scheid-Cook, T.L. (1987). The North Carolina experience with outpatient commitment: a critical appraisal. International Journal of Law and Psychiatry 10, 215–232.
27 Van Putten, R.A., Santiago, J.M., Berren, M.R. (1988). Involuntary outpatient commitment in Arizona: a retrospective study. Hospital and Community Psychiatry, 39, 953–958.
28 Swartz, M.S., Swanson, J.W., Hiday, V.A., Wagner, H.R., Burns, B.J., Borum, R. (2001). A randomized controlled trial of outpatient commitment in North Carolina. Psychiatric Services, 52, 325 - 329; Swartz, M.S., Swanson, J.W., Wagner, H.R., Burns, B.J., Hiday, V.A., Borum, R. (1999). Can inv oluntary outpatient commitment reduce hospital recidivism? American Journal of Psychiatry, 156, 1968-75; Swanson, J.W., Borum, R., Swartz, M.S., Hiday, V.A., Wagner, H.R., Burns, B.J. (2001). Can involuntary outpatient commitment reduce arrests among persons with severe mental illness? (2001). Criminal Justice and Behavior, 28, 156- 89.; Swanson, J.W., Borum, R., Swartz, M.S., Hiday, V.A., Wagner, H.R., Burns, B.J. (2000). Involuntary outpatient commitment and reduction of violent behaviour in persons with severe mental illness. Brit. J. Psychiatry , 176, 324-31; Hiday, V.A., Swartz, M.S., Swanson, J.W., Borum, R.,Wagner, H.R. (2002). Impact of outpatient commitment on victimization of people with severe mental illness. American Journal of Psychiatry, 159, 1403-11; Swartz, M.S., Swanson, J.W., Wagner, H.R., Burns, B.J., Hiday, V.A. (2001). Effects of involuntary outpatient commitment and depot antipsychotics on treatment adherence in persons with severe mental illness. J. Nerv. and Mental Diseases, 189, 583-92.
29 Editorial: A pact not made, Philadelphia Inquirer, January 27, 2003.
30 The ACT Manual recognizes that:
some clients who enter PACT treatment voluntarily later refuse treatment and may become candidates for involuntary services if they relapse… In this case the PACT team first tries to stay involved with the client who declines treatment … If the client’s behavior … meets the commitment law criteria, the PACT team participates in the commitment process.
Allness, D., Knoedler, W.H. (2003, June). A manual for ACT start-up: Based on the PACT model for community-based treatment for persons with severe and persistent mental illnesses (2003 ed.). Virginia: NAMI
31 Gilmer, T.P., Dolder, C.R., Lacro, J.P. Folsom, D.P., Garcia, P., et al. (2004). Adherence to treatment with antipsychotic medication and health care costs among Medicaid beneficiaries with schizophrenia. American Journal of Psychiatry, 161, 692-9.
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