Editing Outpatient commitment (section)

===Arguments for and proponents===
{{Multiple issues|section=yes|
{{POV section|date=March 2022}}
{{Over-quotation|section|date=March 2022|many=y}}
}}
While many outpatient commitment laws have been passed in response to violent acts committed by people with mental illness, most proponents involved in the outpatient commitment debate also make arguments based on the quality of life and cost associated with untreated mental illness and "revolving door patients" who experience a cycle of hospitalization, treatment and stabilization, release, and decompensation. While the cost of repeated hospitalizations is indisputable, quality-of-life arguments rest on an understanding of mental illness as an undesirable and dangerous state of being.  Outpatient commitment proponents point to studies performed in [[North Carolina]] and [[New York (state)|New York]] that have found some positive impact of court-ordered outpatient treatment.  Proponents include:  Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Justice, Agency for Healthcare Research and Quality (AHRQ), U. S Department of Health and Human Services, American Psychiatric Association, National Alliance on Mental Illness, International Association of Chiefs of Police. SAMHSA included Assisted Outpatient Treatment in their National Registry of Evidence Based Program and Practices.<ref name=nreppadmin/>  Crime Solutions:<ref name=crimesolutions/>  Management Strategies to Reduce Psychiatric Readmissions.<ref>{{cite report |last1=Gaynes |first1=Bradley N. |last2=Brown |first2=Carrie |last3=Lux |first3=Linda J. |last4=Ashok |first4=Mahima |last5=Coker-Schwimmer |first5=Emmanuel |last6=Hoffman |first6=Valerie |last7=Sheitman |first7=Brian |last8=Viswanathan |first8=Meera |display-authors=3 |date=May 2015 |title=Management Strategies to Reduce Psychiatric Readmissions |type=Technical Brief |series=Effective Health Care Program |publisher=Agency for Healthcare Research and Quality |location=Rockville, MD |docket=15-EHC018-EF |pmid=26020093 |url=https://www.ncbi.nlm.nih.gov/books/NBK294451/ }}</ref> The [[Treatment Advocacy Center]] are an advocacy group that campaign for the use of outpatient commitment.<ref>{{Cite web|last=Administrator|title=Improving Civil Commitment Laws and Standards|url=https://www.treatmentadvocacycenter.org/fixing-the-system/improving-laws-and-standards|access-date=2021-04-27|website=Treatment Advocacy Center|language=en-gb}}</ref>

A systematic review in 2016 that looked at around 200 papers investigating effectiveness of CTOs for patient outcomes. It found that non-randomized trials had dramatically varying results and found that no [[randomized controlled trial]]s showed any benefits to the patient for outpatient commitment apart from a reduction in the risk of being the victim of crime.<ref name="Rugkåsa p. ">{{cite journal | last=Rugkåsa | first=Jorun | title=Effectiveness of Community Treatment Orders: The International Evidence | journal=Canadian Journal of Psychiatry | year=2016 | volume=61 | issue=1 | pages=15–24 | pmid=27582449 | doi=10.1177/0706743715620415 | pmc=4756604 | doi-access=free }}</ref>

The same interventions can have different effects in different countries due to legal, bureaucratic and social factors.

====Cost====

Research published in 2013 showed that [[Kendra's Law]] in New York, which served about 2,500 patients at a cost of $32 million, had positive results in terms of net cost, reduced arrests.<ref name=AJP73013>{{cite journal |last1=Swanson |first1=Jeffrey W. |first2=Richard A. |last2=Van Dorn |first3=Marvin S. |last3=Swartz |first4=Pamela Clark |last4=Robbins |first5=Henry J. |last5=Steadman |first6=Thomas G. |last6=McGuire |first7=John |last7=Monahan |display-authors=3 |title=The Cost of Assisted Outpatient Treatment: Can It Save States Money? |journal=American Journal of Psychiatry |date=July 30, 2013 |doi=10.1176/appi.ajp.2013.12091152 |pmid=23896998 |url=http://ajp.psychiatryonline.org/Article.aspx?ArticleID=1722044 |archive-url=https://web.archive.org/web/20130808111242/http://ajp.psychiatryonline.org/Article.aspx?ArticleID=1722044 |url-status=dead |archive-date=August 8, 2013 |access-date=July 30, 2013 |quote=Assisted outpatient treatment requires a substantial investment of state resources but can reduce overall service costs for persons with serious mental illness. |volume=170 |issue=12 |pages=1423–1432 |s2cid=34004755 |url-access=subscription }}</ref>{{primary source inline|date=October 2017}} About $125 million is also spent annually on improved outpatient treatment for patients who are not subject to the law. In contrast to New York, despite wide adoption of outpatient commitment, the programs were generally not adequately funded.<ref name=NYT73013>{{cite news|title=Program Compelling Outpatient Treatment for Mental Illness Is Working, Study Says|url=https://www.nytimes.com/2013/07/30/us/program-compelling-outpatient-treatment-for-mental-illness-is-working-study-says.html|access-date=July 30, 2013|newspaper=The New York Times|date=July 30, 2013|first=Pam |last=Belluck}}</ref>

"Although numerous AOT programs currently operate across the United States, it is clear that the intervention is vastly underutilized."<ref name=nreppadmin>{{cite web |last=Stettin |first=Brian |date=February 2015 |title=Intervention Summary: Assisted Outpatient Treatment (AOT) |website=NREPP: SAMHSA'S National Registry of Evidence-based Programs and Practices |url=http://legacy.nreppadmin.net/ViewIntervention.aspx?id=401 |access-date=11 January 2016 |archive-url=https://web.archive.org/web/20170201202522/http://legacy.nreppadmin.net/ViewIntervention.aspx?id=401 |archive-date=1 February 2017 |url-status=dead |df=dmy-all }}</ref>

====Arrests, danger, and violence====
The [[National Institute of Justice]] considers assisted outpatient treatment an effective crime prevention program.<ref name=crimesolutions>{{cite web |date=March 26, 2012 |title=Program Profile: Assisted Outpatient Treatment (AOT) |website=CrimeSolutions.gov |publisher=National Institute of Justice |url=http://www.crimesolutions.gov/ProgramDetails.aspx?ID=228 |access-date=25 September 2014 }}</ref> Some studies in the US have found that AOT programs have reduced the chances of arrest.{{efn|name=us-arrest-rate| {{blockquote|"For those who received AOT, the odds of any arrest were 2.66 times greater (p<.01) and the odds of arrest for a violent offense 8.61 times greater (p<.05) before AOT than they were in the period during and shortly after AOT. The group never receiving AOT had nearly double the odds (1.91, p<.05) of arrest compared with the AOT group in the period during and shortly after assignment."<ref>{{cite journal |last1=Link |first1=Bruce G. |last2=Epperson |first2=Matthew W. |last3=Perron |first3=Brian E. |last4=Castille |first4=Dorothy M. |last5=Yang |first5=Lawrence H. |display-authors=3 |title=Arrest Outcomes Associated With Outpatient Commitment in New York State |journal=Psychiatric Services |volume=62 |issue=5 |pages=504–8 |year=2011 |pmid=21532076 |pmc=5826718 |doi=10.1176/ps.62.5.pss6205_0504 }}</ref>{{Primary source inline|date=October 2017}}}}

{{blockquote|1="The odds of arrest for participants currently receiving AOT were nearly two-thirds lower (OR=.39, p<.01) than for individuals who had not yet initiated AOT or signed a voluntary service agreement."<ref>{{cite journal |last1=Gilbert |first1=Allison R. |last2=Moser |first2=Lorna L. |last3=Van Dorn |first3=Richard A. |last4=Swanson |first4=Jeffrey W. |last5=Wilder |first5=Christine M. |last6=Robbins |first6=Pamela Clark |last7=Keator |first7=Karli J. |last8=Steadman |first8=Henry J. |last9=Swartz |first9=Marvin S. |display-authors=3 |title=Reductions in Arrest Under Assisted Outpatient Treatment in New York |journal=Psychiatric Services |volume=61 |issue=10 |pages=996–9 |year=2010 |pmid=20889637 |doi=10.1176/ps.2010.61.10.996 |s2cid=28455017 }}</ref>{{Primary source inline|date=October 2017}}}}
}} [[Kendra's Law]] has lowered risk of violent behaviors, reduced thoughts about suicide. {{efn|name=kendra-violence|Patients given mandatory outpatient treatment—who were more violent to begin with—were nevertheless four times less likely than members of the control group to perpetrate serious violence after undergoing treatment. Patients who underwent mandatory treatment reported higher social functioning and slightly less stigma, rebutting claims that mandatory outpatient care is a threat to self-esteem.<ref>{{cite journal |last1=Phelan |first1=Jo C. |last2=Sinkewicz |first2=Marilyn |last3=Castille |first3=Dorothy M. |last4=Huz |first4=Steven |last5=Link |first5=Bruce G. |display-authors=3 |title=Effectiveness and Outcomes of Assisted Outpatient Treatment in New York State |journal=Psychiatric Services |volume=61 |issue=2 |pages=137–43 |year=2010 |pmid=20123818 |doi=10.1176/ps.2010.61.2.137 |s2cid=25304234 }}</ref>{{Primary source inline|date=October 2017}}

55% fewer recipients engaged in suicide attempts or physical harm to self.  47% fewer physically harmed others.  46% fewer damaged or destroyed property.  43% fewer threatened physical harm to others.  Overall, the average decrease in harmful behaviors was 44%.{{citation needed|date=August 2016}}

{{blockquote|"Subjects who were ordered to outpatient commitment were less likely to be criminally victimized than those who were released without outpatient commitment."<ref>{{cite journal |last1=Hiday |first1=Virginia Aldigé |last2=Swartz |first2=Marvin S. |last3=Swanson |first3=Jeffrey W. |last4=Borum |first4=Randy |last5=Wagner |first5=H. Ryan |display-authors=3 |title=Impact of Outpatient Commitment on Victimization of People With Severe Mental Illness |journal=American Journal of Psychiatry |volume=159 |issue=8 |year=2002 |pages=1403–11 |doi=10.1176/appi.ajp.159.8.1403 |pmid=12153835 }}</ref>{{Primary source inline|date=October 2017}}}}
}}

====Outcomes and hospital admissions====
AOT "programs improve adherence with outpatient treatment and have been shown to lead to significantly fewer emergency commitments, hospital admissions, and hospital days as well as a reduction in arrests and violent behavior."<ref>{{cite web |date=17 November 2016 |title=Extensive New Independent Support for Assisted Outpatient Treatment from AHRQ Report |website=Mental Illness Policy Org |url=https://mentalillnesspolicy.org/national-studies/extensive-new-independent-support-for-assisted-outpatient-treatment-from-ahrq-report-pdf.html }}</ref>

{{blockquote|"The likelihood of psychiatric hospital admission was significantly reduced by approximately 25% during the initial six-month court order...and by over one-third during a subsequent six-month renewal of the order.... Similar significant reductions in days of hospitalization were evident during initial court orders and subsequent renewals.... Improvements were also evident in receipt of psychotropic medications and intensive case management services. Analysis of data from case manager reports showed similar reductions in hospital admissions and improved engagement in services."<ref name=pmid20889634>{{cite journal |last1=Swartz |first1=Marvin S. |last2=Wilder |first2=Christine M. |last3=Swanson |first3=Jeffrey W. |last4=Van Dorn |first4=Richard A. |last5=Robbins |first5=Pamela Clark |last6=Steadman |first6=Henry J. |last7=Moser |first7=Lorna L. |last8=Gilbert |first8=Allison R. |last9=Monahan |first9=John |display-authors=3 |title=Assessing Outcomes for Consumers in New York's Assisted Outpatient Treatment Program |journal=Psychiatric Services |volume=61 |issue=10 |pages=976–81 |date=October 2010 |pmid=20889634 |doi=10.1176/ps.2010.61.10.976 |doi-access= }}</ref>{{Primary source inline|date=October 2017}}}}

74% fewer participants experienced homelessness. 77% fewer experienced psychiatric hospitalization. 56% reduction in length of hospitalization. 83% fewer experienced arrest. 87% fewer experienced incarceration. 49% fewer abused alcohol. 48% fewer abused drugs. Consumer participation and medication compliance improved. The number of individuals exhibiting good adherence to meds increased 51%. The number of individuals exhibiting good service engagement increased 103%. Consumer perceptions were positive. 75% reported that AOT helped them gain control over their lives. 81% said AOT helped them get and stay well. 90% said AOT made them more likely to keep appointments and take meds. 87% of participants said they were confident in their case manager's ability. 88% said they and their case manager agreed on what was important to work on.{{citation needed|date=August 2016}}

In Nevada County, CA, AOT ("Laura's Law") decreased the number of psychiatric hospital days 46.7%, the number of incarceration days 65.1%, the number of homeless days 61.9%, and the number of emergency interventions 44.1%. Laura's Law implementation saved $1.81–$2.52 for every dollar spent, and receiving services under Laura's Law caused a "reduction in actual hospital costs of $213,300" and a "reduction in actual incarceration costs of $75,600."<ref name="Van Dorn et al 2010"/>{{Primary source inline|date=October 2017}}

In New Jersey, Kim Veith, director of clinical services at Ocean Mental Health Services, noted the AOT pilot program performed "beyond wildest dreams." AOT reduced hospitalizations, shortened inpatient stays, reduced crime and incarceration, stabilized housing, and reduced homelessness. Of clients who were homeless, 20% are now in supportive housing, 40% are in boarding homes, and 20% are living successfully with family members.<ref>{{cite web |date=September 2, 2014 |title=Success of AOT in New Jersey 'Beyond Wildest Dreams' |website=Treatment Advocacy Center |url=http://www.treatmentadvocacycenter.org/about-us/our-blog/110-nj/2625-success-of-aot-in-new-jersey-beyond-wildest-dreams |access-date=25 September 2014 }}</ref>{{Unreliable medical source|date=October 2017|reason=Blog post describes early analysis of data from a single U.S. state.}}

Writing in the ''[[British Journal of Psychiatry]]'' in 2013, Jorun Rugkåsa and John Dawson stated, "The current evidence from {{abbr|RCTs|randomized controlled trials}} suggests that {{abbr|CTOs|community treatment orders}} do not reduce readmission rates over 12 months."<ref>{{cite journal |last1=Rugkåsa |first1=Jorun |last2=Dawson |first2=John |title=Community treatment orders: current evidence and the implications |journal=British Journal of Psychiatry |volume=203 |issue=6 |pages=406–8 |date=December 2013 |pmid=24297787 |doi=10.1192/bjp.bp.113.133900 |doi-access=free }}</ref>

"We find that New York State's AOT Program improves a range of important outcomes for its recipients, apparently without feared negative consequences to recipients."{{cite quote|date=October 2017}}

"The increased services available under AOT clearly improve recipient outcomes, however, the AOT court order, itself, and its monitoring do appear to offer additional benefits in improving outcomes."{{cite quote|date=August 2016}}

====Effect on mental illness system====
=====Access to services=====
{{blockquote|"AOT has been instrumental in increasing accountability at all system levels regarding delivery of services to high need individuals. Community awareness of AOT has resulted in increased outreach to individuals who had previously presented engagement challenges to mental health service providers."}}

{{blockquote|"Improved treatment plan development, discharge planning, and coordination of service planning. Processes and structures developed for AOT have resulted in improvements to treatment plans that more appropriately match the needs of individuals who have had difficulties using mental health services in the past."}}

{{blockquote|"Improved collaboration between mental health and court systems. As AOT processes have matured, professionals from the two systems have improved their working relationships, resulting in greater efficiencies, and ultimately, the conservation of judicial, clinical, and administrative resources. There is now an organized process to prioritize and monitor individuals with the greatest need; AOT ensures greater access to services for individuals whom providers have previously been reluctant to serve;  There is now increased collaboration between inpatient and community-based providers."<ref>{{cite report |author=New York State Office of Mental Health |date=2005 |title=Kendra's Law: Final Report on the Status of Assisted Outpatient Treatment |type=Report to Legislature |publisher=New York State |location=Albany |page=60 |url=http://mentalillnesspolicy.org/kendras-law/research/kendras-law-study-2005.pdf |archive-url=https://ghostarchive.org/archive/20221009/http://mentalillnesspolicy.org/kendras-law/research/kendras-law-study-2005.pdf |archive-date=2022-10-09 |url-status=live |access-date=8 February 2015 }}</ref>}}

In New York City net costs declined 50% in the first year after assisted outpatient treatment began and an additional 13% in the second year. In non-NYC counties, costs declined 62% in the first year and an additional 27% in the second year. This was in spite of the fact that psychotropic drug costs increased during the first year after initiation of assisted outpatient treatment, by 40% and 44% in the city and five-county samples, respectively. The increased community-based mental health costs were more than offset by the reduction in inpatient and incarceration costs. Cost declines associated with assisted outpatient treatment were about twice as large as those seen for voluntary services.<ref name=AJP73013/>{{primary source inline|date=October 2017}}

{{blockquote|"In all three regions, for all three groups, the predicted probability of an {{abbr|MPR|Medication Possession Ratio}} ≥80% improved over time (AOT improved by 31–40 percentage points, followed by enhanced services, which improved by 15–22 points, and 'neither treatment,' improving 8–19 points). Some regional differences in MPR trajectories were observed."<ref>{{cite journal |last1=Busch |first1=Alisa B. |last2=Wilder |first2=Christine M. |last3=Van Dorn |first3=Richard A. |last4=Swartz |first4=Marvin S. |last5=Swanson |first5=Jeffrey W. |display-authors=3 |title=Changes in Guideline-Recommended Medication Possession After Implementing Kendra's Law in New York |journal=Psychiatric Services |volume=61 |issue=10 |year=2010 |pages=1000–5 |doi=10.1176/ps.2010.61.10.1000 |pmid=20889638 |pmc=6690587 }}</ref>{{primary source inline|date=October 2017}}}}

{{blockquote|"In tandem with New York's AOT program, enhanced services increased among involuntary recipients, whereas no corresponding increase was initially seen for voluntary recipients. In the long run, however, overall service capacity was increased, and the focus on enhanced services for AOT participants appears to have led to greater access to enhanced services for both voluntary and involuntary recipients."<ref>{{cite journal |last1=Swanson |first1=Jeffrey W. |last2=Van Dorn |first2=Richard A. |last3=Swartz |first3=Marvin S. |last4=Cislo |first4=Andrew M. |last5=Wilder |first5=Christine M. |last6=Moser |first6=Lorna L. |last7=Gilbert |first7=Allison R. |last8=McGuire |first8=Thomas G. |display-authors=3 |title=Robbing Peter to Pay Paul: Did New York State's Outpatient Commitment Program Crowd Out Voluntary Service Recipients? |journal=Psychiatric Services |volume=61 |issue=10 |year=2010 |pages=988–95 |doi=10.1176/ps.2010.61.10.988 |pmid=20889636 |doi-access=free }}</ref>{{primary source inline|date=October 2017}}}}

{{blockquote|"It is also important to recognize that the AOT order exerts a critical effect on service providers stimulating their efforts to prioritize care for AOT recipients."{{cite quote|date=August 2016}}}}

=====Race=====
{{blockquote|"We find no evidence that the AOT Program is disproportionately selecting African Americans for court orders, nor is there evidence of a disproportionate effect on other minority populations. Our interviews with key stakeholders across the state corroborate these findings."}}

{{blockquote|"We found no evidence of racial bias. Defining the target population as public-system clients with multiple hospitalizations, the rate of application to white and black clients approaches parity."<ref>{{cite journal |last1=Swanson |first1=Jeffrey |last2=Swartz |first2=Marvin |last3=Van Dorn |first3=Richard A. |last4=Monahan |first4=John |last5=McGuire |first5=Thomas G. |last6=Steadman |first6=Henry J. |last7=Robbins |first7=Pamela Clark |display-authors=3 |title=Racial Disparities In Involuntary Outpatient Commitment: Are They Real? |journal=Health Affairs |volume=28 |issue=3 |year=2009 |pages=816–26 |doi=10.1377/hlthaff.28.3.816 |doi-access= |pmid=19414892 }}</ref>{{primary source inline|date=October 2017}}}}

=====Service engagement=====
{{blockquote|"After 12 months or more on AOT, service engagement increased such that AOT recipients were judged to be more engaged than voluntary patients. This suggests that after 12 months or more, when combined with intensive services, AOT increases service engagement compared to voluntary treatment alone."}}
Consumers approve.  Despite being under a court order to participate in treatment, current AOT recipients feel neither more positive nor more negative about their treatment experiences than comparable individuals who are not under AOT."<ref name=pmid20889634/>{{failed verification|date=October 2017}}

{{blockquote|"When the court order was for seven months or more, improved medication possession rates and reduced hospitalization outcomes were sustained even when the former AOT recipients were no longer receiving intensive case coordination services."<ref name="Van Dorn et al 2010">{{cite journal |last1=Van Dorn |first1=Richard A. |last2=Swanson |first2=Jeffrey W. |last3=Swartz |first3=Marvin S. |last4=Wilder |first4=Christine M. |last5=Moser |first5=Lorna L. |last6=Gilbert |first6=Allison R. |last7=Cislo |first7=Andrew M. |last8=Robbins |first8=Pamela Clark |display-authors=3 |title=Continuing Medication and Hospitalization Outcomes After Assisted Outpatient Treatment in New York |journal=Psychiatric Services |volume=61 |issue=10 |date=October 2010 |pages=982–7 |doi=10.1176/ps.2010.61.10.982 |doi-access= |pmid=20889635 }}</ref>{{primary source inline|date=October 2017}}}}

In Los Angeles, CA, the AOT pilot program reduced incarceration 78%, hospitalization 86%, hospitalization after discharge from the program 77%, and cut taxpayer costs 40%.<ref>{{cite report |last=Southard |first=Marvin |date=February 24, 2011 |title=Assisted Outpatient Treatment Program Outcomes Report |publisher=Los Angeles County Department of Mental Health |location=Los Angeles, CA |url=http://lauras-law.org/states/california/lalauraslawstudy.pdf |access-date=24 September 2014 |url-status=dead |archive-url=https://web.archive.org/web/20131228224756/http://lauras-law.org/states/california/lalauraslawstudy.pdf |archive-date=28 December 2013 }}</ref>

In North Carolina, AOT reduced the percentage of persons refusing medications to 30%, compared to 66% of patients not under AOT.<ref>{{cite journal |last1=Hiday |first1=Virginia Aldigé |last2=Scheid-Cook |first2=Teresa L. |title=The North Carolina experience with outpatient commitment: A critical appraisal |journal=International Journal of Law and Psychiatry |volume=10 |issue=3 |year=1987 |pages=215–32 |doi=10.1016/0160-2527(87)90026-4 |pmid=3692660 }}</ref>

In Ohio, AOT increased attendance at outpatient psychiatric appointments from 5.7 to 13.0 per year. It increased attendance at day treatment sessions from 23 to 60 per year. "During the first 12 months of outpatient commitment, patients experienced significant reductions in visits to the psychiatric emergency service, hospital admissions, and lengths of stay compared with the 12 months before commitment."<ref>{{cite journal |title=The effectiveness of outpatient civil commitment |journal=Psychiatric Services |volume=47 |issue=11 |date=November 1996 |pages=1251–3 |doi=10.1176/ps.47.11.1251 |pmid=8916245 |last1=Munetz |first1=M.R. |last2=Grande |first2=T. |last3=Kleist |first3=J. |last4=Peterson |first4=G.A.  |display-authors=3 |citeseerx=10.1.1.454.5055 }}</ref>{{primary source inline|date=October 2017}}

In Arizona, "71% [of AOT patients] ... voluntarily maintained treatment contacts six months after their orders expired" compared with "almost no patients" who were not court-ordered to outpatient treatment.<ref>{{cite journal |vauthors=Van Putten RA, Santiago JM, Berren MR |title=Involuntary outpatient commitment in Arizona: a retrospective study |journal=Hospital & Community Psychiatry |volume=39 |issue=9 |pages=953–8 |date=September 1988 |pmid=3215643 |doi=10.1176/ps.39.9.953 }}</ref>{{primary source inline|date=October 2017}}

In Iowa, "it appears as though outpatient commitment promotes treatment compliance in about 80% of patients... After commitment is terminated, about ¾ of that group remain in treatment on a voluntary basis."<ref>{{cite report |last=Rohland |first=Barbara |date=1998 |title=The role of outpatient commitment in the management of persons with schizophrenia |publisher=Iowa Consortium for Mental Health Services, Training and Research |url=http://www.healthcare.uiowa.edu/icmh/archives/reports/finalrpt.pdf |access-date=25 September 2014 |archive-url=https://web.archive.org/web/20160204112043/http://www.healthcare.uiowa.edu/icmh/archives/reports/finalrpt.pdf |archive-date=4 February 2016 |url-status=dead }}</ref>