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With Hospitalization Losing Favor, Judges Order Outpatient Mental Health Treatment

by Kaiser Health News | Updated on 11.13.18

When mental illness hijacks Margaret Rodgers’ mind, she acts out.

Rodgers, 35, lives with depression and bipolar disorder. When left unchecked, the conditions drive the Alabama woman to excessive spending, crying and mania.

Last autumn, Rodgers felt her mind unraveling. Living in Birmingham, she was uninsured, unable to afford treatment and in the throes of a divorce. Although Rodgers traveled south to her brother’s house in Foley, Ala., for respite, she couldn’t escape thoughts of suicide, which one day led her to his gun.

“I hit bottom,” she recalled. But she didn’t pull the trigger.

Rodgers told her brother about the close call. News of the incident reached her mother, who then alerted authorities to Rodgers’ near attempt.

Within days, Rodgers was handcuffed and hauled in front of a judge who ordered her to undergo mental health treatment — but not a hospital commitment. Instead, the judge mandated six months of care that included weekly therapy sessions and medication, all while Rodgers continued living with her family.

Rodgers entered assisted outpatient treatment, also known as involuntary outpatient commitment.

Since its inception, the court-ordered intervention has generated controversy. Proponents say it secures the comprehensive care that people with severe mental illnesses might not recognize they need. Yet other health experts question the effectiveness of the intervention and suggest it represents a quick fix in a mental health system that is not adequately serving patients.

“It’s a stopgap measure that works in the short term,” said Dr. Annette Hanson, director of the University of Maryland Forensic Psychiatry Fellowship, who co-authored a book on the intervention. “But it’s not a good long-term solution because you still have lots of people who need voluntary care who can’t get” it.

Assisted outpatient treatment requires a judge’s order. While the eligibility requirements and compliance standards vary by state, participants typically have a history of arrests and multiple hospitalizations. They stay in their communities while undergoing treatment.

The American Psychiatric Association endorsed its use in 2015, saying assisted outpatient treatment has generally shown positive outcomes under certain circumstances. To effectively treat patients, the position paper said, the APA recommends that the intervention be well-planned, “linked to intensive outpatient services” and last for at least 180 days.

A key advantage to assisted outpatient treatment, supporters say, is that it provides care for people who might not recognize the severity of their illness.

A court’s involvement also increases the likelihood of a participant complying with the program, a phenomenon called the “black robe effect,” they add.

“That is really what we’ve found to be the secret sauce” for success, said John Snook, executive director of the nonprofit Treatment Advocacy Center.

But many areas do not have the necessary community mental health services to provide assisted outpatient treatment effectively, said Ira Burnim, legal director for the Judge David L. Bazelon Center for Mental Health Law.

He also said the law already provides options for hospital treatment for people considered a danger to themselves or others. Any person recommended for assisted outpatient treatment for these reasons should be in a hospital receiving intensive inpatient care, Burnim said, not in the community.

“You know, when people don’t take their medication,” he said, “that’s a clinical problem, not a legal problem.”

Most States Allow The Programs

Assisted outpatient treatment gained popularity after Andrew Goldstein, who was diagnosed with schizophrenia but wasn’t taking his medication, pushed Kendra Webdale in front of an oncoming train in New York City in 1999, killing her. Webdale’s family fought for a change in the law after learning that Goldstein had repeatedly refused treatment while living on his own.

Today, 47 states and the District of Columbia have laws allowing localities to set up assisted outpatient treatment, according to the Treatment Advocacy Center, a nonprofit group that strongly supports assisted outpatient treatment.

Yet, there is no tally of the number of programs or the number of people involuntarily placed in one, said David DeVoursney, chief of the Community Support Programs Branch at the Substance Abuse and Mental Health Services Administration.

There is also little research on its effectiveness. Two randomized studies produced contradictory results about the intervention’s effect on hospitalization rates and the number of arrests afterward. However, other analyses have shown improved outcomes, particularly among participants in New York.

Despite the ambiguity, Congress created grants in 2014 that made up to $60 million available over four years to new assisted outpatient treatment programs. Additionally, the 21st Century Cures Act, passed in 2016 to accelerate drug development, allowed some Department of Justice funding for the intervention.

Experts acknowledge that the scarcity of mental health providers and treatment options causes many patients to go without care. Instead of doctors’ offices, many people with mental illnesses end up in jail — an estimated 2 million every year, according to the National Alliance on Mental Illness.

“What we say very often is basically we have a system that allows people to have heart attacks over and over again,” Snook said. “And then once they have that heart attack, we take them to jail. And then we wonder why the system isn’t working.”

A Morning Surprise

One recipient of federal funding is AltaPointe Health Systems Inc., a community health center that provides services to residents — including Rodgers — in two Alabama counties. The program has received nearly $1.1 million in federal funding, according to Cindy Gipson, assistant director of intensive services.

She said the center applied for the federal grant to reduce the number of hospitalizations among residents living with severe mental illnesses.

“We were having a lot of people who would go to the hospital, then be discharged,” she said. “And they’d do well for a couple of weeks — maybe even a month. Then, they’d go right back in.”

The program, which began in 2017, has served 71 patients, Gipson said. On average, patients stay about 150 days. And roughly 60 percent of referrals come from family members, she said. The majority of people entering have a history of multiple hospitalizations and arrests.

Rodgers said she had never been in handcuffs before the day the Alabama police officer came to her brother’s home and awakened her around 7 a.m. The sheriff gave her five minutes to change and brush her teeth. He then cuffed her wrists, placed her in the back of his car and drove her straight to court. After she was asked a few questions about how she was doing, Rodgers said, she sat down in front of a judge and learned about assisted outpatient treatment for the first time.

Despite how she entered care, Rodgers said the mandated treatment has brought her stability. She sees a therapist once a week, and once a month a nurse at the community health center administers a shot of the antipsychotic drug Abilify. She now is working part time cleaning condos and lives with her mother. She said she has learned strategies to not dwell on the past.

After her first six months of treatment, Rodgers and her care team decided to continue care through the rest of the year. She plans to return to Birmingham and find a better job after completing the program.

Right now, she said, “staying positive is the main thing I want.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

Kaiser Health News

Written by Kaiser Health News

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(44)
  • Jeffrey
    Voted Sad
    11/13/2018
    ···

    Mental illness is something that should not be ignored...if someone with a diagnosed history of mental history then hospitalization should be considered. This may be the only way to stabilize them. The key with mentally disturbed people is that they MUST have family backing and support. Without that support then they will fall back into their cycle of highs and lows, depression and euphoria and suicidal thoughts. This needs to be addressed in depth.

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  • Kjr52
    Voted Happy
    11/13/2018
    ···

    Mental illness needs to be addressed on a case by case basis because no two people are the same. The way we are categorizing people with mental illnesses is really making things worse. Unless we are willing to genuinely help those who are currently suffering with a mental illness, it will only.continue to get worse.

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  • David
    11/14/2018
    ···

    In reading the postings ridiculing mental health problems I have some questions. Let me preface these by noting I have 45 years experience as a MH Therapist working with seriously mentally ill persons, have run programs for these people, and designed treatment programs recognized at the national level. 1) How many of you know someone who is seriously mentally ill? 2) Do you know that the mentally ill have a lower rate of violence than the general population? 3) Are you aware that funding for mental healthcare started to be cut under Ronald Reagan and has been cut by every Administration since? 4) Did you know that when budgets get tight the first cuts are to mental health programs? 5) Are you aware that children who score higher on the ACES childhood trauma scale have more physical problems as they grow up and mature? 6) Do you know that up to 25% of people in this country are likely to experience a mental illness at some point in their life? 7) That many of the problems physicians deal with daily are exacerbated by mental health problems in those patients. 8) Treating people in vivo is more effective, more efficient, and cheaper than hospitalization. 9) Do you know that mental illness is not respectful of social, financial, or political boundaries? Liberals can be just as mentally ill as conservatives. Before you blame, be absolutely sure you know what you are talking about. You could be part of that 25% and just be undiagnosed.

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  • burrkitty
    Voted Apathetic
    11/14/2018
    ···

    You know... a universal single payer healthcare system would give mental healthcare access to everyone. Just saying.

    Like (8)
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  • SneakyPete
    Voted Sad
    11/13/2018
    ···

    🥵 OUR JUDICIARY ARE BECOMING OVER BURDENED 😱 OMG..... ARE WE NOW SEEING JUDICIAL ASPIRATES WHO ARE NOW PERFORMING MEDICAL DUTIES , IN ADDITION TO THEIR PERFORMANCE OF LEGISLATIVE DUTIES, WHILE COMBINED WITH THEIR PRIMARY RESPONSIBILITIES AS INTERPRETERS OF THE LAW OF THE LAND. PRAY TELL HOW CAN THEY PERFORM ALL THESE MULTITUDES OF CRITICAL IMPORTANT DUTIES. SneakyPete..... 😥😥😥😥. 11*13*18.....

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  • TrulyTexan
    11/14/2018
    ···

    Oh James, what must have happened to you to make you such a horrible, unchristian person? Please seek the help you need to get better so you can function in society, possibly for the first time.

    Like (5)
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  • Susan
    Voted Happy
    11/13/2018
    ···

    With the NRA and gun lovers defending all types of weapons, it is more important than ever to address mental health issues. Something MUST be done to keep guns out of the hands of unstable people.

    Like (4)
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  • I.Got.an.Idea...
    Voted Apathetic
    11/14/2018
    ···

    In modern times, the Citizens were delivered great injustice when The Bush administration cut mental health funding and services to give to the wealthy. Conservatism is on the rise and along with that is great oppression upon the citizens. How much of the depression and mental health issues may be attributed to Conservative oppression? We need to tackle root cause. Identify what is causing an increase in depression and other mental health issues. If we address root cause ( I believe Conservatism) , then we may not need judges involved in prescribing mental health care and if we provided Universal Health Care for all, which appropriately provides mental healthcare, then this issue would not be allowed to exasperate and negatively impact society.

    Like (3)
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  • Steve
    Voted Sad
    11/14/2018
    ···

    Mental health should not be separated from general health care.

    Like (6)
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  • Ronald
    Voted Sad
    11/14/2018
    ···

    "Hospitalization losing favor" is the reason mentally ill people act out. Sometimes the kill other people. Gun control is not the answer. Mentally ill people control is the answer. How many must die before society fixes the problem. It is better for the mentally ill, and all the rest of us. Do make sure the institutions are humane. Do not let past failures prevent solving present problems.

    Like (4)
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  • Robert j.
    Voted Sad
    11/14/2018
    ···

    Defunding mental healthcare has been a stock move by congress since Pharma arrived with outpatient drug therapy in the 1960s. It seems to be not working if you consider the number of people in jail with mental illness.

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  • James
    11/13/2018
    ···

    All liberals are mentally ill! Just go to “Go Fund Me” and raise for your cause! What the hell made you a Nut? Don’t expect the taxpayer to pay more out for this! As the normal everyday guy I am, I advocate for normal even headed, even tempered people! As I Am! I need funding too!

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  • Vanessa
    Voted Apathetic
    11/14/2018
    ···

    I don’t think this ought to be a law. It’s not good to handle medical treatments through laws. I don’t know what the answers are, but I shudder at the thought of making this a law.

    Like (3)
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  • Christopher
    Voted Sad
    11/13/2018
    ···

    If there were universal healthcare she could obtain care without a court order and live a productive and healthy life. Not everyone needs this level of care but when you consider the cost to receive emergency care the costs are unmanageable.

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  • Sean
    Voted Sad
    11/14/2018
    ···

    Many seriously ill mental health victims require periodic hospitalization !

    Like (3)
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  • Lee f
    Voted Happy
    11/14/2018
    ···

    The American Psychiatric Association endorsed outpatient treatment in 2015, saying assisted outpatient treatment has generally shown positive outcomes under certain circumstances. To effectively treat patients, the position paper said, the APA recommends that the intervention be well-planned, “linked to intensive outpatient services” and last for at least 180 days. We are also witnessing a focus on mental health issues, it appears, from the highest level of government and its propensity to lie about facts. Our mental health as a nation is being attacked. Please support more mental health especially a focus on community reconciliation and conflict resolution workshops. Thank you

    Like (2)
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  • Shannon
    Voted Happy
    11/13/2018
    ···

    Sounds good. Treatment is needed more often than not. Most Americans just pretend nothing is wrong and let it go until they blow up. Meaning their stress levels reach unmanageable highs.

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  • Tom
    11/14/2018
    ···

    There is real mental health problems and then there is the Trump Derangement Syndrome fund the first one Trump Derangement go to that fund page thing

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  • Marylynn
    11/14/2018
    ···

    Funny how many of these cases of mental illness are related to veterans? We need to do more to treat mental illness, the statistics are staggering. Some people need to be hospitalized and our health insurance should cover this kind of treatment.

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  • Leslie
    Voted Apathetic
    11/14/2018
    ···

    OMG, CONGRESS HAD DAMN WELL BETTER PUT A LAW IN PLACE TO MAKE SURE THE MENTALLY ILL ARE HOSPITALIZED, ESPECIALLY SINCE IT WAS THE ONLY PRESIDENT THE GOP CAN TALK ABOUT, REAGAN IS THE PERSON WHO GOT RID OF ALL THE MENTAL HEALTH FUNDING IN THE UNITED STATES OF AMERICA.

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