Involuntary Outpatient Commitment: The Data and the Controversy

Transcription

1 Involuntary Outpatient Commitment: The Data and the Controversy Marvin S. Swartz, M.D. Services Effectiveness Research Program Duke University Medical Center Support from: National Institute of Mental Health MacArthur Research Network on Mandated Community Treatment

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4 Questions CAN OPC be effective and under what conditions? What is the nature of the controversy about OPC? Can it be effective in reducing serious acts of violence?

5 Outline of Presentation Review context and controversy about OPC in US Review past studies of OPC in US Present new findings from evaluation of Assisted Outpatient Treatment in New York

6 Involuntary Outpatient Commitment (OPC) Permitted in all but a few states Explicitly permitted by 42 states and the District of Columbia Despite statutory support, used inconsistently

7 VARIANTS OF OPC Conditional release for involuntarily hospitalized patients Alternative to hospitalization for patients who meet inpatient commitment criteria Alternative status for patients who do not meet inpatient criteria All based on state statutes

8 Controversies about OPC Availability of appropriate services with aggressive outreach might obviate the need Should not be used as a substitute for inadequacies in service systems Applying coercion to patient blames the victim for service deficiencies. Systems of care should be held accountable for gaps in care.

9 The US Debate Views of Outpatient Commitment The medication militia have embarked on a deadly Chemical Crusade to forcibly inject many of us with these powerful neurotoxins, sometimes for life Involuntary Outpatient Commitment [OPC] is literally fascism a profound violation of core values of liberty and freedom. Support Coalition

10 Views of Outpatient Commitment Today, the forced drugging common inside of institutions has climbed over the walls and is now out in our communities. Citizens in the USA & parts of the world, living peacefully at home, are now court ordered to take powerful psychiatric drugs against their will. Typically these are "neuroleptic drugs" that can cause structural brain damage and even kill. David Oaks MindFreedom

11 Views of Outpatient Commitment Civil libertarians have made it almost impossible to treat psychotic individuals who refuse care. These misguided activists have created a morass of legal obstacles that prevents us from helping many psychotic individuals until they have a finger on a trigger...it's time to reverse course. Mandatory treatment for those too ill to recognize they need help is far more humane than our present mandatory nontreatment. E. Fuller Torrey

12 Views of Outpatient Commitment Laws change for a single reason, in reaction to highly publicized incidents of violence. People care about public safety. I am not saying it is right, I am saying this is the reality... So if you're changing [OPC] laws in your state, you have to understand that... You have to take the debate out of the mental health arena and put it in the criminal justice/public safety arena. D. J. Jaffe

13 Criteria for OPC in N.C. Presence of a serious mental illness Capacity to survive in the community with available supports Clinical history indicating a need for treatment to prevent deterioration that would predictably result in dangerousness Mental status that limits or negates the individual's ability to make informed decisions to seek or comply voluntarily with recommended treatment

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15 Odds ratio for hospital readmission during any given month of 1-year trial Odds Ratio 95% CI p value ====================================== Control group [1.00] OPC group 0.64 ( ) p<

16 Involuntary Outpatient Commitment (OPC): Percent Subjects With Any Psychiatric Hospital Admissions by Days of OPC Percent Admitted Controls <180 days OPC 180+ days OPC

17 Mean Number of Psychiatric Hospital Admissions by Days of OPC Mean Hospital Admissions Controls <180 days OPC 180+ days OPC

18 Mean Psychiatric Hospital Days by Days of OPC Mean Hospital Days Controls <180 days OPC 180+ days OPC

19 < 3 Service Events per Month > 3 Service Events per Month Number of Outpatient Commitment Days Cumulative Psychiatric Hospital Admissions Month Month

20 Summary of NC OPC Study OPC can reduce hospital recidivism However: OPC must be applied for an extended period It is only effective when delivered in combination with frequent mental health services.

21 Summary (continued) Other findings: OPC can reduce violence, victimization, family strain, arrests and improve medication adherence and quality of life. However: To be effective, it must be delivered for an extended period AND in combination with regular mental health services. Limitations: the dose of OPC and service intensity could not be controlled.

22 Assisted Outpatient Treatment (AOT) in NYC: Summary of Pilot Study New York enacted a pilot statute to be tested in NYC Bellevue Hospital Study of pilot NYC Law (pre-kendra s Law) by order of Legislature. Consumers randomly received AOT + Enhanced Services vs. Enhanced Services Alone. Findings: No differences between AOT vs. Enhanced Services Limitations: Law was in start-up and sample was small. Accompanied by fierce opposition the law was headed to sunset

23 January 1999: In an incident that has gnawed at New Yorkers' sense of security, Kendra Webdale was killed in January 1999 when Andrew Goldstein, a 30-year-old schizophrenic, picked her up on the platform of a 23rd Street subway station and threw her into the path of an oncoming train. (New York Times, 3/23/2000) New York passed preventive OPC statute in Statute was named Kendra s Law Kendra Webdale

24 The Carrot: NY Kendra s Law Fiscal Changes $32 million directly allocated yearly in support of the OPC program $15 million -- medication grant program $4.4 million -- prison and jail discharge managers $2.4 million -- oversight programs $9.55 million -- new case management slots $0.65 million -- drug monitoring $125 million yearly for enhanced community services Used to increase ICM and ACT Used to develop Single Point of Access Program (SPOA)

25 Preventive OPC laws named for victims of homicides by people with schizophrenia New York Kendra s Law (1999) California Laura s Law (2003) Michigan Kevin s Law (2005)

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27 Report Outline 1. Description of AOT program and regional variations 2. Service engagement during AOT 3. Recipient outcomes 4. Recipient perceptions of AOT 5. Service engagement and outcomes after AOT ends 6. Impact of AOT on New York s public mental health system

28 Regional Variations: Findings Considerable variability in how AOT is implemented across NY State In nearly 3/4s of all cases, used as a discharge planning tool for hospitalized patients Regional difference in use of enhanced voluntary service (EVS) agreements: In New York City: AOT First model In other counties: EVS First model.

29 2005 AOT order density compared to estimated total SMI population Dots represent distribution of AOT orders in 2005

30 Service Engagement: Findings First six months on AOT, service engagement was comparable to service engagement of voluntary patients not on AOT After 12 months or more, when combined with intensive services, AOT increases service engagement compared to voluntary treatment.

31 Exhibit 2.2. Adjusted* percent with good or excellent service engagement by treatment and legal status. Results contain observations for 12 or more months of treatment only. 60% 50% 54.6% 56.0% 40% 43.1% Adjusted percent 30% 20% 10% 0% ACT ** AOT + ACT AOT + ICM *Adjusted probability estimates were generated from repeated measures regression models controlled for time, region, race, age, sex, diagnosis, baseline hospitalizations, baseline service engagement, education level, marital status, substance use, medication adherence, and GAF. Statistical models used multiple imputation of missing data. ** Odds are less than 1 in 1000 that the difference between ACT and the other groups would occur by chance. Data source = CAIR and AOT Evaluation databases.

32 Recipient Outcomes During AOT: Findings Substantial reduction in psychiatric hospitalizations and in days in the hospital Modest evidence that AOT reduces arrests Substantial increases in receipt of intensive case management services More likely to adhere to psychotropic medications Subjective improvements in personal functioning.

33 Exhibit 3.8 Adjusted percent* with psychiatric inpatient admission in month, by AOT status 16% 14% 14% 12% 10% 11% Adjusted percent 8% 6% 4% 9% 2% 0% Pre-AOT AOT 1-6 months AOT 7-12 months *Adjusted probability estimates were generated from repeated measures regression models controlled for time, region, race, age, sex, diagnosis, and co-insurance status. Models were also weighted for propensity to initially receive AOT and to receive more than 6 months of AOT. Source: Medicaid claims and OMH admissions data.

34 Exhibit 3.9. Adjusted* average inpatient days during any 6 month period, by AOT status Average number of days Pre-AOT AOT 1-6 months AOT 7-12 months *Adjusted mean estimates were generated from repeated measures regression models controlled for time, region, race, age, sex, diagnosis, and co-insurance status. Models were also weighted for propensity to initially receive AOT and to receive more than 6 months of AOT. Source: Medicaid claims and AOT Evaluation database.

35 Exhibit 3.10 Adjusted percent* with at least 80% medication possession in month by AOT status 55% 50% 50% Adjusted percent 45% 40% 35% 35% 44% 30% 25% 20% Pre-AOT AOT 1-6 months AOT 7-12 months *Adjusted probability estimates were generated from repeated measures regression models controlled for time, region, race, age, sex, diagnosis, and co-insurance status. Models were also weighted for propensity to initially receive AOT and to receive more than 6 months of AOT. Source: Medicaid and OMH records.

36 Exhibit 3.2. Adjusted* percent arrested in month by current receipt of AOT and EVS Adjusted percent arrested in month Pre-AOT and Pre-EVS Current AOT Current EVS *Adjusted arrest rate estimates were produced using multivariable time-series regression analysis, controlling for time, region, age, sex, race, education, and diagnosis. Months spent in hospital are excluded from analysis. Source: 6-county interviews and Division of Criminal Justice Services.

37 Recipient Perceptions of AOT: Findings AOT recipients feel neither more positive nor more negative about their MH treatment experiences than comparable individuals who are not under AOT In particular, no significant differences between AOT and non-aot recipients in perceived coercion, working alliance, barriers to treatment, treatment satisfaction, or life satisfaction.

38 Engagement/Outcomes After AOT: Findings After 6 months, decreased hospitalization and improved medication adherence only sustained if intensive services continued after AOT ends After 12 months or longer, decreased hospitalization and improved medication adherence sustained whether or not intensive services are continued after AOT ends.

39 Exhibit 5.2 Adjusted percent* with psychiatric inpatient treatment in month over long-term AOT course 14% 12% Before AOT During long-term AOT After long-term AOT 10% 11% Adjusted percent 8% 6% 8% ACT-ICM No ACT-ICM 7% 7% 4% 2% 0% Pre-AOT, no ACT or ICM AOT w ith ACT-ICM for 7-12 months Discontinues AOT after 7-12 months, but remains on ACT- ICM Discontinues both AOT and ACT-ICM after 7-12 months *Adjusted probability estimates were generated from repeated measures regression models controlled for time, region, race, age, sex, diagnosis, and co-insurance status.

40 Exhibit 5.4 Adjusted percent* with at least 80% medication possession in month over long-term AOT course 70% 60% Before AOT During long-term AOT After long-term AOT Adjusted percent 50% 40% 30% 37% 52% ACT-ICM 50% No ACT-ICM 43% 20% 10% 0% Pre-AOT, no ACT or ICM AOT w ith ACT-ICM for 7-12 months Discontinues AOT after 7-12 months, but remains on ACT- ICM Discontinues both AOT and ACT-ICM after 7-12 months *Adjusted probability estimates were generated from repeated measures regression models controlled for time, region, race, age, sex, diagnosis, and co-insurance status.

41 The Impact of AOT on New York s Public Mental Health System: Summary of Findings First several years of the AOT Program, between , preference for intensive case management services was given to AOT cases. After 2003, new AOT orders leveled off in the state and then declined. After ramp-up of the AOT programs intensive community-based services increased for individuals on AOT and not on AOT alike. It is impossible to generalize these findings to states where services do not simultaneously increase.

42 Exhibit 6.4 Non-AOT share of ACT-ICM services by month Number of ACT/ICM claims Percent of total ACT-ICM Medicaid claims for non-aot recipients (2000) Month (2007)

43 Overall Summary of Findings (1) New York State s AOT Program improves a range of important outcomes for its recipients. The increased services available under AOT clearly improve recipient outcomes, however, the AOT court order and its monitoring do appear to offer additional benefits in improving outcomes. It is also important to recognize that the AOT order exerts a critical effect on service providers stimulating their efforts to prioritize care for AOT recipients.

44 Lack of continued growth of new service dollars will likely increase competition for access to services once again. Overall Summary of Findings (2) Improvements are more likely sustained post-aot among those who receive intensive treatment services or had longer periods of AOT especially 6 months or longer. In its early years the AOT Program did appear to reduce access to services for non-aot recipients, but in recent years the reduction in new AOT cases has attenuated this effect.

45 Overall Summary of Findings (3) Limited assessment of whether voluntary agreements are effective alternatives to initiating or continuing AOT. We found some evidence that AOT recipients are at lower risk of arrest than their counterparts in enhanced voluntary services. AOT combined with ACT services substantially lowers risk of hospitalization compared to receiving ACT alone.

46 Is OPC a Remedy for Acts of Severe Violence like Tucson, Arizona? Data available indicate OPC can reduce minor acts of violence Acts of serious violence are far too infrequent to study accurately Might infer that improving treatment adherence may reduce serious violence but there is no evidence. OPC law should be considered on merits of improving treatment adherence and reducing relapse not as violence prevention per se.