Outpatient commitment

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Outpatient commitment refers to mental health law which allows the compulsory, community-based treatment of individuals with mental illness.

In the United States the term "Assisted Outpatient Treatment" is often used and refers to the practice of courts requiring those it has found to be mentally ill to take medication or to comply with other restrictions, while not ordering involuntary commitment. The courts will often specify that if the orders are not complied with, the person under court order will be subject to involuntary commitment. In England the Mental Health Act 2007 introduced "Community Treatment Orders". In Australia they are also called Community Treatment Orders and last for a maximum of twelve months but can be renewed after review by a tribunal.

The exact form of these laws varies by country, and often by state. Some require court hearings and others require that treating psychiatrists comply with a set of requirements before compulsory treatment is instituted. When a court process is not required, there is usually a form of appeal to the courts or appeal to or scrutiny by tribunals set up for that purpose. Community treatment laws have generally followed the worldwide trend of community treatment. See mental health law for details of countries which do not have laws that regulate compulsory treatment.

Contents

History

Discussions of "outpatient commitment" began in the psychiatry community in the 1980s, following widespread Deinstitutionalization where large numbers people with mental illness were released from psychiatric institutions. In the last decade of the 20th century and the first of the 21st, "outpatient commitment" laws were passed in a number of states in the US (New York 1999, California 2002) and jurisdictions in Canada. Some notable events that helped precipitate these laws include the Laura Wilcox and Kendra Webdale tragedies. A landmark report by the RAND Corporation [1]was commissioned by the Senate Committee on Rules in 2001 when a bill that would expand involuntary outpatient treatment was being debated in California (this law would later become Laura's Law). This 176 page report was an evidence based review that both searched the literature and interviewed key informants for their perceptions of the assisted outpatient system. The summary of the responses from key informants are below-

  • There was a widespread support among key informants for outpatient commitment, although quite a few expressed only qualified support for the practice in their own states.
  • Three things were deemed critical to the success of outpatient commitment: having the infrastructure to support it; having the services to make it work for patients; and having a service system that can deliver those services rationally.
  • The outpatient commitment laws are used infrequently in most states and are used primarily as a discharge-planning vehicle rather than an alternative to hospitalization.
  • As part of their commitment process, at least three states use mechanisms to involve the patient in development of a consensus plan for compliance with mental health treatment.
  • There is disagreement as to whether the outpatient commitment order is "reciprocal"(i.e., commits the provider or mental health system to provide services as well as committing the patient to receive them).
  • Provider liability is a concern but not an overwhelming one.
  • Not all outpatient commitment orders are specific about which agency will provide services and what the specific treatment will be. Medication is not necessarily a part of the commitment orders.
  • In most states, forcible medication is not allowed under outpatient commitment orders.
  • The burden of monitoring outpatient commitment orders most often falls to treatment providers, most of whom do not have the resources to provide high levels of supervision.
  • States differ widely in the extent to which their outpatient commitment orders have "teeth"(i.e., are enforceable).

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