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Controversial Legal Tactic Reduces Violence Among Severely Mentally Ill People

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Duke Health News 919-660-1306

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.

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