Briefing Paper
Updated March 2011

It is known that there are over 4 million individuals with schizophrenia and manic-depressive illness (bipolar disorder) in the United States.

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Briefing Paper
Updated March 2011

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SUMMARY: According to the National Institute of Mental Health, 40 percent of individuals with schizophrenia and 51 percent of individuals with bipolar disorder are not receiving treatment for their illness at any given time. The major reason why they are not being treated is because they believe they are not sick, so they refuse treatment. This lack of awareness of one’s own illness is called anosognosia and is also seen in Alzheimer’s disease and in some stroke victims. Among the various options available for assisted treatment, the most effective appear to be assisted outpatient treatment (AOT), conditional release, and mental health courts.

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Outpatient commitment

Outpatient commitment involves a court order for the patient to comply with treatment (usually including medication) as a condition for remaining in the community. Violation of the condition can results in rehospitalization. Some form of outpatient commitment is available in 44 states but is used in very few of them.

Outpatient commitment has been shown to be effective in increasing treatment compliance. 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. In Ohio, 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. 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. And in Iowa, "it appears as though outpatient commitment promotes treatment compliance in about 80 percent of patients while they are on outpatient commitment. After commitment is terminated about three-quarters of that group remain in treatment on a voluntary basis.”

Hiday VA, Scheid-Cook TL. The North Carolina experience with outpatient commitment: a critical appraisal. International Journal of Law and Psychiatry 1987;10:215–232.

Munetz MR, Grande T, Kleist J et al. The effectiveness of outpatient civil commitment. Psychiatric Services 1996;47:1251–1253.

Van Putten RA, Santiago JM, Berren MR. Involuntary outpatient commitment in Arizona: a retrospective study. Hospital and Community Psychiatry 1988;39:953–958.

Rohland BM. The Role of Outpatient Commitment in the Management of Persons with Schizophrenia. (Iowa City: Iowa Consortium for Mental Health, Services, Training, and Research, 1998).

Conditional release

Patients who have been legally committed to a hospital can be released on the condition that they are compliant with medication. Violation of the condition can result in rehospitalization. In most states the hospital director has the authority to do this without asking permission of the courts. Forty states have laws permitting conditional release. In the past, this form of assisted treatment was widely used for both civil and forensic (criminal) cases, but now it is used mostly for the latter.

New Hampshire is apparently the leading state using conditional release for civilly committed patients; in 1998, 27 percent of patients released from the New Hampshire State Hospital were put on conditional release. In the only study of the effectiveness of conditional release on medication compliance reported to date, 26 severely psychiatrically ill patients were conditionally released from the New Hampshire State Hospital with assessment of various measures for the year prior to hospitalization and the two years following conditional release. The results were as follows:

The patients on conditional release thus had markedly improved medication compliance (p < 0.001) and decreased episodes of violence (p < 0.001).

A study of condition release in Australia reported that it decreased the death rate for those on conditional release by 14 percent.

Among forensic (criminally committed) psychiatric patients, conditional release is more widely used. The best known example is Oregon’s Psychiatric Security Review Board, which has been studied and reported to be highly effective in reducing future criminal behavior. Additional studies on the effectiveness of conditional release for insanity defense acquittees have been carried out in Maryland, Illinois, California, New York, and Washington, D.C.

Gorman P. New Hampshire Department of Health and Human Services. Personal communication, September 11, 1998.

O’Keefe C, Potenza DP, Mueser KT. Treatment outcomes for severely mentally ill patients on conditional discharge to community-based treatment. Journal of Nervous and Mental Disease 1997;185:409–411.

Segal SP, Burgess PM. Effect of conditional release from hospitalization on mortality risk. Psychiatric Services 2006;57:1607–1613.

Bloom JD, Williams MH, Rogers JL et al. Evaluation and treatment of insanity acquittees in the community. Bulletin of the American Academy of Psychiatry and the Law 1986;14:231–244.

Bloom JD, Williams MH, Bigelow DA. Monitored conditional release of persons found not guilty by reason of insanity. American Journal of Psychiatry 1991;148:444–448.

Mental Health Counts

Mental health courts are courts set up specifically to adjudicate only those cases in which a person with a mental illness has been charged with a crime. Some mental health courts take both misdemeanors and felonies, others only the former. Mental health courts are a form of jail diversion for mentally ill individuals charged with crimes. In most cases, the judge gives the defendant the choice of going to jail or cooperating with an outpatient treatment program, including medication. If the person refuses to follow the treatment plan, he/she can be sent to jail. Mental health courts have been shown to be very effective in keeping people on medication. The main limitation of such courts is that a mentally ill person has to have committed a crime in order to be eligible.

Hiday VA, Ray B. Arrests two years after exiting a well-established mental health court. Psychiatric Services 2010;61:463–468.

Lamb HR, Weinberger LE. Mental health courts as a way to provide treatment to violent persons with severe mental illness. Journal of the American Medical Association 2008;300:722–724.

Moore ME, Hiday VA. Mental health court outcomes: a comparison of re-arrest and re-arrest severity between mental health court and traditional court participants. Law and Human Behavior 2006:30:659–674.

Assertive case management

Under assertive case management, case managers actively seek out at their homes or elsewhere in the community patients who do not follow up with appointments. The Program of Assertive Community Treatment (PACT or ACT teams) is the best known example of this. Multiple studies have demonstrated that PACT teams decrease rehospitalization days. In a Baltimore study of homeless individuals with severe psychiatric disorders, 77 were assigned to a PACT team and compared with 75 others assigned to traditional outpatient treatment. During the following year, those treated by the PACT team had fewer hospital days (35 versus 67), fewer days living on the streets (10 versus 24), and fewer days in jail (9 versus 19). Those treated by the PACT team also had increased medication compliance (either intermittently or fully compliant), from 29 percent at the start to 55 percent after one year; however, "approximately one-third of the subjects were noncompliant at any given time point.” Assertive case management would therefore appear to be an effective method of assisted treatment for some patients but not others.

Lehman AF, Dixon LB, Kernan E et al. A randomized trial of assertive community treatment for homeless persons with severe mental illness. Archives of General Psychiatry 1997;54:1038–1043.

Dixon L, Weiden P, Torres M et al. Assertive community treatment and medication compliance in the homeless mentally ill. American Journal of Psychiatry 1997;154:1302–1304.

Representative payee

To assist with money management, a patient’s SSI, SSDI, or VA disability check can be assigned to the patient’s family, case manager, or psychiatric clinic as the representative payee. Studies have shown that using a representative payee reduces hospitalization days, substance abuse, and days spent homeless. No study has been done on the effect of using representative payees to improve medication compliance. Anecdotal information, however, suggests that this arrangement is not unusual, e.g., the patient must accept a depot antipsychotic injection as a condition for being given his/her monthly check. In a U.S. Third Circuit Court of Appeals ruling, the court ruled that a man with epilepsy and borderline mental retardation was not entitled to SSDI benefits unless he demonstrated compliance with his anti-epileptic medication (Brown v. Bowen, 845 F2d 1211, 3rd Circuit, 1988).

Luchins DJ, Hanrahan P, Conrad KJ et al. An agency-based representative payee program and improved community tenure of persons with mental illness. Psychiatric Services 1998;49:1218–1222.

Rosenheck R, Lam J, Randolph F. Impact of representative payees on substance use among homeless persons with serious mental illness and substance abuse. Psychiatric Services 1997;48:800–806.

Stoner MR. Money management services for the homeless mentally ill. Hospital and Community Psychiatry 1989;40:751–753.

Paying patients

Several studies of nonpsychiatric patients have demonstrated that paying patients to take their medication is effective. Cash, vouchers, lottery tickets, and gifts have been used to improve compliance for patients taking medication for tuberculosis, hypertension, and substance abuse. One study was also done for a small number of patients with serious mental illnesses taking depot antipsychotics.

Carey KB, Carey MP. Enhancing the treatment attendance of mentally ill chemical abusers. Journal of Behavior Therapy and Experimental Psychiatry 1990;21:205–209.

Giuffrida A, Torgerson DJ. Should we pay the patient? Review of financial incentives to enhance patient compliance. British Medical Journal 1997;315:703–707.

Claasen D, Fakhoury WK, Ford R et al. Money for medication: financial incentives to improve medication adherence in assertive outreach. Psychiatric Bulletin 2007;31:4–7.

Conservatorship

Conservatorships and guardianships occur when a court appoints an individual to make treatment decisions for another individual who is believed to be mentally incompetent. They are used most frequently for individuals with mental retardation and with severe neurological diseases such as Alzheimer’s disease; they are less often used for individuals with severe psychiatric illnesses except in California. In one study done in that state, "of the 35 patients who were placed on conservatorship, 29 (83 percent) remained stable as long as the conservatorship lasted," but for the 21 patients whose conservatorship was terminated, only 9 (43 percent) remained stable after termination.”

Lamb HR, Weinberger LE. Conservatorship for gravely disabled psychiatric patients: a four-year follow-up study. American Journal of Psychiatry 1992;149:909–913.

Substituted judgment

This is closely related to outpatient commitment and conservatorship. In Massachusetts, which does not have an outpatient commitment statute, patients with severe psychiatric illnesses have the right to refuse medication. A mental health professional can take such an individual to court; if the court finds that the patient is incompetent, it may use a substituted judgment standard, appoint a guardian, and order the patient to take medication. In a six-month study of patients subjected to such a procedure, their admissions decreased from 1.6 to 0.6, and hospital days decreased from 113 to 44. Reflecting on substituted judgment, Dr. Jeffrey Geller noted: "In one of the more ironic outcomes of mental health law over the last two decades, the right to refuse treatment court decisions have become the basis in Massachusetts for involuntary community treatment orders.”

Geller J, Grudzinskas AJ Jr., McDermeit M et al. The efficacy of involuntary outpatient treatment in Massachusetts. Administration and Policy in Mental Health 1998;25:271–285.

Geller JL. On being "committed" to treatment in the community. Innovations and Research 1993;2:23–27.

Advance directives

Increasingly used in all areas of medicine, individuals formulate directives at the time they are well regarding what they want to happen when they become sick. In a few states, individuals with severe psychiatric disorders, during a period of remission, can sign an advance directive instructing that they be treated or not be treated if they become sick again. Advance directives are also known as "Ulysses contracts" after the Greek hero who, while sailing past the island of the deadly seductive Sirens, instructed his crew to bind him to the mast and "be strictly enjoined, whatever he might say or do, by no means to release him till they should have passed the Sirens’ island.”

The efficacy of advance directives as assisted treatment has not been studied. One possible problem is that advance directives can be signed by individuals who have no awareness of their illness at the time they sign. In such cases advance directives may become an impediment to necessary treatment rather than being a form of assisted treatment.

Campbell LA, Kisely SR. Advance treatment directives for people with severe mental illness. Cochrane Database of Systematic Reviews 2009, Issue 1.

Swanson JW, McCrary SV, Swartz MS et al. Superseding psychiatric advance directives: ethical and legal considerations. Journal of the American Academy of Psychiatry and the Law 2006;34:385–394.

Appelbaum PS. Commentary: psychiatric advance directives at a crossroads—when can PADs be overridden? Journal of the American Academy of Psychiatry and the Law 2006;34:395–397.

"Benevolent coercion"

"Benevolent coercion" is Dr. Geller’s term for threatening to institute legal proceedings to compel treatment for patients who do not comply with treatment. Geller reported that he informed his patients that "if the lithium level fell below 0.5 meq/liter, the patient would be involuntarily admitted to a state hospital.” According to Geller, such "benevolent coercion" is an effective method of assisted treatment. Anecdotal evidence suggests that it is used widely but rarely discussed publicly.

Geller JL. Rights, wrongs, and the dilemma of coerced community treatment. American Journal of Psychiatry 1986;143:1259–1264.

Conclusions

Assisted treatment for individuals with severe psychiatric disorders can be achieved by different methods. In publications it is usually implied that only one such method is being used, but in fact more than one are often being used at the same time. For example, the PACT program of assertive case management is sometimes combined with the use of guardianship in Wisconsin. And many of the patients in the Baltimore PACT study of homeless individuals were given representative payees as well as assertive case managers.

Although all forms of assisted treatment appear to be effective for some patients with severe psychiatric illnesses, efficacy for treatment compliance has only been clearly established for outpatient commitment. The paucity of research on assisted treatment is surprising given its importance.