Outpatient treatment legislation revisited
On October 22, the Joint Committee on Mental Health and Substance Abuse in Massachusetts held a public hearing on House Bill 1792/Senate Bill 906, which calls for assisted outpatient treatment (AOC). Coincidentally, the non-profit Treatment Advocacy Center (TAC) released a 13-page report that examined available treatment options for those with mental illness in Massachusetts. The Commonwealth earned a failing grade, based on the quality of its treatment laws.
In 1998, at the request of the National Alliance on Mental Illness (NAMI), Kay Khan, Democratic representative for the Eleventh Middlesex District, filed H.B.1792 and during the ensuing years, the legislation has come before a number of committees without any definitive action.
Several supporters of the bill spoke at the recent hearing. “There were many compelling stories and important testimony presented. However, it remains controversial and, unfortunately, I don’t think it will move out of the committee this session,” Khan says. “But there definitely needs to be further discussion about this legislation.”
TAC also strongly supports passage of House Bill 1792/Senate Bill 906. “This legislation would align Massachusetts with the 45 other states that already have provided a statutory option for assisted treatment in the community,” the report states.
According to the report, “Massachusetts: An Assessment on the Commonwealth’s Access to Treatment for Persons with Severe Mental Illness,” approximately 37,284 people with untreated schizophrenia and 48,486 people with untreated severe bipolar disorder live in the state. This population risks several negative consequences including homelessness, arrest, incarceration, victimization, violence, including suicide; unemployment, related medical problems, family issues and other factors that impact quality of life and put a strain on the social services system.
The report gives Massachusetts an F for its current treatment laws, noting that its civil commitment laws are among the most restrictive in the country. In lieu of hospitalization, many more individuals with serious mental illness are being incarcerated.
Moreover, TAC research shows that the prison suicide rate in Massachusetts is four times the national average; in 2011, forty-eight percent of 553 suicides were committed by individuals with a mental health problem.
Researchers at Duke University offered additional reasons to pass assisted outpatient treatment laws with a study published in the July 2013 issue of the American Journal of Psychiatry, which found treatment costs for frequently hospitalized patients in New York City declined 50 percent following the first year an outpatient commitment program was implemented; the second year, costs decreased another 13 percent.
Generalizing these findings to other states depends on a number of factors, including the type of AOT statute in that state, according to Jeffrey W. Swanson, Ph.D., MA, professor in psychiatry and behavioral sciences at Duke. “If the law is not preventive, AOT is unlikely to be used,” he says. “When a court hearing details a person’s dangerousness to himself and others, it’s unlikely that person will be put on outpatient commitment.”
Additionally, the type of services system in place matters. “If you pass AOT with a mental health system that’s fragmented, overburdened and ineffective, AOT will not fix it,” Swanson says. “New York infused a lot of money into its system – about $135 million – to build capacity to assist community treatment and oversight. The availability of evidence-based intensive services is a prerequisite to the law working.”
Moreover, Swanson cites the challenge of trying to apply an AOT law to people who have severe disabling psychiatric diagnoses that affect their ability to function. “These people are isolated, disenfranchised and residentially unstable,” he says. “You can create a solution, but you can’t deliver it to the person if the law doesn’t allow you to override treatment. That’s a challenge.”