Maryland, where we live, is one of only five states that does not have forced outpatient care for psychiatric patients. The more familiar euphemism is "assisted outpatient treatment" or AOT, but it’s a term that sugarcoats what happens, and even if it’s the right thing to legislate, we might as well call it what it is, since psychiatry has long been accused of being overly coercive. This week, the Maryland General Assembly proposed legislation to bring AOT to our state, and the swords are set to be drawn.
Recently, I had the pleasure of hearing Jeffrey Swanson, Ph.D., a medical sociologist at Duke University, speak at the Sheppard and Enoch Pratt Hospital in Baltimore on "Outpatient Commitment as Crisis-Driven Law: Evaluating Policy Options and Effectiveness Through the Lens of Gun Violence." I don’t know what that title means, but I do know it’s a good one for driving up the blood pressure of many people, my own included. If Dr. Swanson could have somehow added abortion, Obamacare, and Woody Allen to his title, the entire country could have chimed in. I’m going to summarize some of the key points of Dr. Swanson’s lecture below.
He started by discussing the controversial topic of mandated community treatment, a practice that inspires "strident disagreement." "Should we have outpatient commitment? And what does it mean to ask if it works?"
Starting with the tragic massacre in Newtown on Dec. 14, 2012, Dr. Swanson noted that in addition to the Sandy Hook victims, 85 other people died from gun fatalities that same day. But Newtown stimulated the conversation. Is it the guns? Our violent culture? The failure of the mental health system? "It’s not in our repertoire," he noted, "to limit access to guns as other nations have done, so instead, we’ve looked to limiting the right to own those guns."
A national opinion poll in 2013 shows that 60% of the U.S. public believes that people with schizophrenia are likely to be violent, and 45% believe that people with mental illness are "far more dangerous" than the general public. In fact, 1 in 70,000 people with schizophrenia kills a stranger and this, said Dr. Swanson, "is what people are really about." He went on to say that curing major mental illness would reduce serious violence by 4%. Meanwhile, 3.5 million people with serious psychiatric disorders go without treatment. "You could tell that story several different ways; it doesn’t have a lot to do with violence."
In New York, legislation to Secure Ammunition and Firearms Enforcement (the NY SAFE Act of 2013), included an expansion of that state’s outpatient forced treatment; it now lasts longer, is required for released prisoners with mental illness, and follows patients when they move to other counties. As I’ve noted in a past column, it also requires mental health professionals to report patients who are believed likely to be violent.
"It’s interesting," Dr. Swanson noted, "that they are connected as part of a gun control package."
Last month, Dr. Swanson said, the White House issued two executive actions aimed at reducing gun violence. Among the executive actions was one that seeks to strengthen gun background checks for gun permits to include people who were on AOT, in addition to people committed to hospitals involuntarily. The executive actions further remove barriers (including Health Insurance Portability and Accountability Act, or HIPAA requirements) that make it difficult to submit information about these patients.
Dr. Swanson then discussed the basic facts about outpatient commitment. It extends the state’s authority from the institution to community-based care and includes a civil court order that requires the patient to comply with recommended treatment and receive services. "It emerged from the ashes of deinstitutionalization as a way to get the treatment to people that they needed." Dr. Swanson noted that there is no requirement for forced medication in the outpatient setting.
There are three types of outpatient commitment. It can be used as a conditional release from the hospital (40 states), as an alternative to hospitalization for people meeting inpatient commitment criteria (33 states, but infrequently used), and as a preventive court-ordered treatment authorized at a lower threshold to prevent further deterioration in a patient’s condition (10 states). Of the states that have outpatient commitment statutes, there is little use of it outside New York. Dr. Swanson noted that this entails "nested prediction in the law" with regard to how likely patients are to comply with treatment and how likely they are to become dangerous.