Published: Apr. 17, 2000
Updated: Nov. 3, 2004
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By Duke Medicine News and Communications
DURHAM, N.C. -- Violent acts committed by people with severe mental illness can be cut in half by using a controversial tactic that forces patients to follow through with psychiatric care, says a team of researchers at Duke University Medical Center.
In a one-year study of 262 severely mentally ill patients, those who were required to undergo at least six months of "involuntary outpatient commitment" were significantly less likely to engage in any violent behavior toward others, compared to patients who underwent shorter periods of commitment or none at all.
Involuntary outpatient commitment is a legal tactic that forces patients to obtain treatment within the community if they are unable to comply with treatment voluntarily, and if they could became dangerous without treatment.
The study found that 26 percent of patients who received six months or more of outpatient commitment became assaultive, compared to 42 percent of patients receiving less than six months. The risk of violence was even lower -- just 13 percent -- among patients who received extended outpatient commitment, made regular visits to a clinician, took medications as prescribed and remained substance-free.
Results of the study, funded by the National Institutes of Mental Health, are published in the April issue of the British Journal of Psychiatry.
"We found that extended outpatient commitment can prevent violence in people with severe mental illness, by helping them stay on prescribed medication and avoid substance abuse. It works best when it's backed up by frequent visits with a mental health clinician -- at least three a month," said Dr. Jeffrey Swanson, lead author of the study.
While forcing patients into community treatment has always been controversial -- opponents say it infringes on a person's civil rights and interferes with the therapeutic climate of trust and hope -- Swanson said the tactic has taken on particular importance in the wake of several highly publicized acts of violence committed by people with severe mental illness.
He points to Michael Goldstein, the schizophrenic man who pushed Kendra Webdale to her death in a New York subway, as an example of how complex and interlined the legal, social and moral issues can become. Goldstein was recently found guilty of murder; at the same time he became the catalyst for a new law mandating outpatient treatment for patients with a history of violence or repeated hospitalizations.
"The Goldstein case highlights the public's disproportionate fear of people with mental illness, only a small percentage of whom ever become violent," said Dr. Marvin Swartz, co-author and lead investigator of the study.
"Goldstein's situation is particularly tragic because he had sought care and had been unable to receive it," said Swartz. "Then,simultaneously, he was held accountable for his actions and was used as an example of why people like himself are unable to make rational decisions and must be forced into treatment."
Similar issues are being debated in states across the nation, many of which are revamping their mental health services and legislation. In North Carolina, a recent audit of the state's mental health system, which Swartz helped to conduct, called for closing Dorothea Dix Hospital and instead creating a standard package of services for severely mentally ill people. Such changes would eliminate the wide variation in the type and quality of care now found in different counties, the audit concluded.
Indeed, the wide variation in the types and number of community services is one reason why mental health care providers seek involuntary outpatient commitment, Swartz said.
Involuntarily commitment creates a legal mandate for the community mental health system to provide adequate services for people who need them, such as medication management, psychotherapy, rehabilitation and case management -- services which the patient might not otherwise receive.
"Involuntary commitment pressures the mental health service system into mobilizing scarce resources for people who are likely to be at risk for relapse and violent behavior," said Swartz.
Access to effective treatment varies widely from state to state, county to county and even from person to person, he said, making treatment for the mentally ill one of the most contentious areas of medical care in the nation. Forcing the person into treatment will not guarantee them appropriate services, but it is an option short of hospitalization and it may improve the odds that a patient will receive at least some of the needed services, said Swartz.
Moreover, it gives therapists a tool to use in seeking out patients who fail to comply with recommended treatment. Patients who skip appointments can be picked up by the police and brought into a mental health center for treatment, although they cannot be forced to actually take medication unless they are hospitalized, according to North Carolina law.
Without such legal strong-arming, patients at risk for violence are often left to their own devices, with little or no incentive to seek or receive treatment. They often fail to take their medications, miss scheduled appointments, abuse substances and tend to drift into impoverished and dangerous environments with little or no social support, said Swanson.
"For someone under these conditions of life with an illness like schizophrenia that impairs thinking and judgment, voluntary participation in treatment may be extremely difficult," Swanson said. "And while outpatient commitment isn't a perfect solution, it may be justifiable for some people if it can prevent them from being re-hospitalized, arrested or becoming violent."
In view of the tactics' controversy, Swartz, Swanson and their colleagues decided to study its actual effect on reducing violent behavior among severely mentally ill patients with a history of violence and repeated hospitalizations.
In the study, they enrolled 262 involuntarily hospitalized patients (half of whom had a history of committing physical assault)who were about to be discharged under outpatient commitment. Subjects were randomly assigned either to continue with court-ordered community treatment or be released to a control group receiving no outpatient commitment. Patients with a recent history of serious violence were automatically assigned to three months of court-ordered community treatment -- a deviation from the randomization procedure that was adjusted for in statistical analysis.
After the initial three-month period, the clinician and the courts decided which patients -- except those in the control group -- had to continue treatment and which did not.
The study found that patients who underwent sustained periods of outpatient commitment showed greater improvement in medication adherence and substance avoidance and thus had the lowest rates of violence.