:Outpatient commitment

In the United States the term "assisted outpatient treatment" (AOT) is often used and refers to a process whereby a judge orders a qualifying person with symptoms of severe untreated mental illness to adhere to a mental health treatment plan while living in the community. The plan typically includes medication and may include other forms of treatment as well.{{Cite web|url=https://mentalillnesspolicy.org/aot/assisted-outpatient-treatment-guide.html|title=AOT (Assisted Outpatient Treatment) Guide|last=Org|first=M. I. P.|website=Mental Illness Policy Org|language=en-US|access-date=2019-11-18}} Patients are often monitored and assigned to case managers or a community dedicated to treating mental health known as assertive community treatment (ACT).{{Cite web|url=https://mentalillnesspolicy.org/aot/assisted-outpatient-treatment-guide.html|title=AOT (Assisted Outpatient Treatment) Guide|last=Org|first=M. I. P.|website=Mental Illness Policy Org|language=en-US|access-date=2019-11-18}}

Australia, Canada, England, and New Zealand use the term "community treatment order" (CTO).{{Citation |url= http://www.mind.org.uk/help/rights_and_legislation/briefing_2_supervised_community_treatment |title= Supervised Community Treatment |publisher= Mind |access-date= 2011-08-28}}

The terminology, "outpatient commitment", and legal construction often equate outpatient commitment with inpatient commitment but providing the patient more freedom.{{efn|name=more-autonomy|When introducing the bill introducing CTO in the UK Lord Warner, then Minister of NHS reform, said "That modern approach strikes a balance between individual autonomy and protection of the patient and the public."{{cite web|url=https://www.theyworkforyou.com/lords/?id=2006-11-28c.654.0#g654.1|title="Hansard 2006"}}

"CTOs were first conceived as a less restrictive alternative to involuntary hospital admission. They allowed patients detainable under mental health legislation to be treated outside hospital and had the same stringent criteria as involuntary admissions. From the perspective of clinicians, patients and their families, as well as human rights lawyers, 'least restrictive' CTOs were considered preferable to hospital detention."{{cite web|url=https://www.cambridge.org/core/services/aop-cambridge-core/content/view/3729AB1BC2DE3E105D0A0BF83C4B84CF/S2056467800002619a.pdf/community_treatment_orders_are_they_useful.pdf |archive-url=https://ghostarchive.org/archive/20221009/https://www.cambridge.org/core/services/aop-cambridge-core/content/view/3729AB1BC2DE3E105D0A0BF83C4B84CF/S2056467800002619a.pdf/community_treatment_orders_are_they_useful.pdf |archive-date=2022-10-09 |url-status=live|title=Community treatment orders: are they useful?}}}} In practice, outpatient commitment may be used in situations where commitment would not be used because it is cheaper than inpatient commitment;{{efn|"it has been argued that economic and financial imperatives, as much asideologies of good practice9 have driven this policy"{{cite journal | last1=Brophy | first1=Lisa | last2=McDermott | first2=Fiona | title=What's Driving Involuntary Treatment in the Community? The Social, Policy, Legal and Ethical Context | journal=Australasian Psychiatry | publisher=SAGE Publications | volume=11 | issue=1_suppl | year=2003 | issn=1039-8562 | doi=10.1046/j.1038-5282.2003.02020.x | pages=S84–S88| s2cid=73876480 }} }} seen as less draconian; and protects mental health professionals from moral, civil or criminal liability.

Outpatient commitment is used in some countries to prevent relapse of mental disorders, as many mental disorders are episodic in nature (for example bipolar disorder or schizophrenia) and it can be difficult to predict whether a mental disorder will reoccur. Some countries use outpatient commitment for first episode psychosis (FEP).{{cite journal | title=Community Treatment Order: Identifying the need for more evidence based justification of its use in first episode psychosis patients | journal=Schizophrenia Research | volume=185 | date=2017-07-01 | issn=0920-9964 | doi=10.1016/j.schres.2016.12.022 | pages=67–72 | url=https://www.sciencedirect.com/science/article/abs/pii/S0920996416305977 | access-date=2020-07-03| last1=Morandi | first1=Stéphane | last2=Golay | first2=Philippe | last3=Lambert | first3=Martin | last4=Schimmelmann | first4=Benno G. | last5=McGorry | first5=Patrick D. | last6=Cotton | first6=Sue M. | last7=Conus | first7=Philippe | pmid=28038921 | s2cid=4522185 | url-access=subscription }}

Discussions of "outpatient commitment" began in the psychiatry community in the 1980s following deinstitutionalization, a trend that led to the widespread closure of public psychiatric hospitals and resulted in the discharge of large numbers of people with mental illness to the community. {{Cite web |title=Deinstitutionalization - Special Reports {{!}} The New Asylums {{!}} FRONTLINE |url=https://www.pbs.org/wgbh/pages/frontline/shows/asylums/special/excerpt.html |access-date=2024-06-17 |website=www.pbs.org}}

Denmark introduced outpatient commitment in 2010 with the Mental Health Act ({{langx|da|Lov om anvendelse af tvang i psykiatrien}}).

In Germany, CTOs were resumed in 2015{{cite web |title=Beschlussempfehlung und Bericht des Rechtsausschusses (6. Ausschuss) zu dem Gesetzentwurf der Fraktionen der CDU/CSU und FDP: Entwurf eines Gesetzes zur Regelung der betreuungsrechtlichen Einwilligung in eine ärztliche Zwangsmaßnahme |date=16 January 2013 |publisher=Deutscher Bundestag |url=https://dserver.bundestag.de/btd/17/120/1712086.pdf |archive-url=https://ghostarchive.org/archive/20221009/https://dserver.bundestag.de/btd/17/120/1712086.pdf |archive-date=2022-10-09 |url-status=live |language=de}} (formerly only for forensic psychiatry{{cite journal |last1=Steinert |first1=Tilman |last2=Noorthoorn |first2=Eric O. |last3=Mulder |first3=Cornelis L. |date=24 September 2014 |title=The use of coercive interventions in mental health care in Germany and the Netherlands: A comparison of the developments in two neighboring countries |journal=Frontiers in Public Health |volume=2 |page=141 |pmid=25309893 |pmc=4173217 |doi=10.3389/fpubh.2014.00141 |doi-access=free }}).

Laws regarding implementations are distincts between lander.

The CTOs are renewed every month. They were introduced under Nicolas Sarkozy presidency.{{Cite web | url=https://www.collectifpsychiatrie.fr/?p=3236 | title=> la loi du 5 juillet 2011 : Vers un contrôle social psychiatrique ? | Quelle hospitalité pour la folie ? | date=22 February 2012 }} Persons committed are registered on a national file accessible by police, even if they are not suspected of breaking the law.{{Cite web | url=https://www.santementale.fr/2020/03/le-conseil-d-etat-rejette-les-recours-contre-le-decret-hopsyweb/ | title=Le Conseil d'Etat valide le fichier Hopsyweb | date=30 March 2020 }}

{{As of|2014|post=,}} Dutch law provides for community treatment orders, and an individual who does not comply with the terms of their CTO may be subject to immediate involuntary commitment.

When Norway introduced outpatient commitment in the 1961 Mental Health Act, it could only be mandated for individuals who had previously been admitted for inpatient treatment.{{cite journal |last1=Riley |first1=Henriette |last2=Straume |first2=Bjørn |last3=Høyer |first3=Georg |date=2 May 2017 |title=Patients on outpatient commitment orders in Northern Norway |journal=BMC Psychiatry |volume=17 |issue=1 |page=157 |doi=10.1186/s12888-017-1331-1 |doi-access=free |pmid=28464805 |pmc=5414164 }} Revisions in 1999 and 2006 provided for outpatient commitment without previous inpatient treatment, but this provision is seldom used.

In Sweden, the Compulsory Psychiatric Care Act ({{langx|sv|Lag om psykiatrisk tvångsvård}}) provides for an administrative court to mandate psychiatric treatment to prevent harm to the individual or others.{{cite journal |last=Reitan |first=Therese |date=March–April 2016 |title=Commitment without confinement: Outpatient compulsory care for substance abuse, and severe mental disorder in Sweden |journal=International Journal of Law and Psychiatry |volume=45 |pages=60–69 |doi=10.1016/j.ijlp.2016.02.011 |doi-access=free |pmid=26912456 }}{{rp|61}} The law was created in 1991 and revised in 2008.{{rp|62}}

Changes in service provision and amendments to the Mental Health Act in England and Wales have increased the scope for compulsion in the community.{{Cite journal|last1=Molodynski|first1=A.|last2=Rugkasa|first2=J.|last3=Burns|first3=T.|date=2010-05-25|title=Coercion and compulsion in community mental health care|journal=British Medical Bulletin|volume=95|issue=1|pages=105–119|doi=10.1093/bmb/ldq015|pmid=20501486|issn=0007-1420|doi-access=free}} The Mental Health Act 2007 introduced community treatment orders (CTOs). CTOs are legally defined as a form of outpatient leave for individuals detained under section 3 of the Mental Health Act.{{cite web|last=|first=|date=|title=Mental Health Act 1983: Section 17A|url=http://www.legislation.gov.uk/ukpga/1983/20/section/17A|access-date=|website=}} As such, only members of the medical community are involved in issuing a CTO, though both the section 3 detention underlying the CTO and the CTO itself can be appealed to the Mental Health Tribunal where a panel consisting of medical doctors and a judge will make a decision.The legislation in the UK specifically allows CTOs to be issued after a single admission to hospital for treatment. However, the Royal College of Psychiatrists suggested limiting CTOs to patients with a history of noncompliance and hospitalization, when it reviewed the current mental health legislation.{{efn|name=rspych| "The remit of CTOs should be limited to ensure they are only used when most beneficial. The Review should consider amending the criteria to reflect a history of non-compliance with treatment leading to subsequent compulsory admission(s) within a defined timeframe."{{cite web|url=https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/policy/policy-rcpsych-mha-review-submission-2018.pdf |archive-url=https://ghostarchive.org/archive/20221009/https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/policy/policy-rcpsych-mha-review-submission-2018.pdf |archive-date=2022-10-09 |url-status=live|title=Review of the Mental Health Act 1983 The Royal College of Psychiatrists' submission of evidence}}}}

John Mayer Chamberlain argues that this legislation was triggered by the Killing of Jonathan Zito by an individual who had interactions with mental health services prior this event, which led the then conservative government to argue for CTOs.{{Cite book |last=Chamberlain |first=John Martyn |url=https://books.google.com/books?id=Hnn4CgAAQBAJ |title=Medicine, Risk, Discourse and Power |date=2015-11-19 |publisher=Routledge |isbn=978-1-317-33196-4 |language=en}}{{Rp|127}}

A review of patient data in London found that the average duration of a CTO in the UK was 3 years.{{cite journal | last1=Barkhuizen | first1=Wikus | last2=Cullen | first2=Alexis E | last3=Shetty | first3=Hitesh | last4=Pritchard | first4=Megan | last5=Stewart | first5=Robert | last6=McGuire | first6=Philip | last7=Patel | first7=Rashmi | title=Community treatment orders and associations with readmission rates and duration of psychiatric hospital admission: a controlled electronic case register study | journal=BMJ Open | volume=10 | issue=3 | date=2016-07-31 | pages=e035121 | pmid=32139493 | doi=10.1136/bmjopen-2019-035121 | pmc=7059496 | doi-access=free }} Black people in the UK are more than ten times as likely to be under a CTO as white people.{{Cite web|last=|first=|date=|title=Mental Health Act White Paper 2021|url=https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/951398/mental-health-act-white-paper-web-accessible.pdf|access-date=|website=}}{{Rp|13}} Concerns have been raised about the inability of Independent mental health advocates (IHMAs) to provide services to those under CTOs, since IMHAs cannot make contact with service users under CTOs and case workers could act as gatekeepers not providing referrals.{{Cite journal |last1=Weller |first1=Penelope |last2=Alvarez-Vasquez |first2=Susan |last3=Dale |first3=Matthew |last4=Hill |first4=Nicholas |last5=Johnson |first5=Brendan |last6=Martin |first6=Jennifer |last7=Maylea |first7=Chris |last8=Thomas |first8=Stuart |date=2019-09-01 |title=The need for independent advocacy for people subject to mental health community treatment orders |url=https://www.sciencedirect.com/science/article/pii/S0160252718301845 |journal=International Journal of Law and Psychiatry |language=en |volume=66 |pages=101452 |doi=10.1016/j.ijlp.2019.101452 |pmid=31706387 |s2cid=196580245 |issn=0160-2527|url-access=subscription }}{{Rp|page=6|quote=There was a concern raised over the course of the evaluation that where case managers acted as "gatekeepers", few alternatives exist for consumers to learn about and access the IMHA service.}}

In a 2021 paper reviewing the mental health act, the UK government proposed a new form of indefinite outpatient commitment allowing for deprivation of liberties an continuous supervision termed supervised discharge. This discharge would be reviewed yearly, and only apply to individuals who would not benefit from treatment in a hospital setting and would be based on risk.{{Rp|77}} Further, this legislation would only apply to restricted patients who have been diverted to the mental health care system from courts.{{Cite web|last=|first=|date=|title=Restricted Patients 2018 - Ministry of Justice Statistics Bulletin|url=https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/796926/restricted-patients-statistical-bulletin-2018.pdf|access-date=|website=}}

Scotland has a different community commitment regime from England and Wales introduced in the 2003 Mental Health Act.{{cite web|url=http://www.legislation.gov.uk/asp/2003/13/part/7|title=Mental Health Act (Scotland) 2003: Pat 7 }} There is ongoing debate in the UK on the place of coercion and compulsion in community mental health care.

Patients may be recalled if they don't abide to conditions on residence or medical supervision decided by a psychiatrist on discharge for 3 months after having been released from an involuntary commitment.{{Cite web |title=Law of 10th December 2009 relating to hospitalization on people with mental conditions without consent (Loi du 10 décembre 2009 a) relative à l'hospitalisation sans leur consentement de personnes atteintes de troubles mentaux) |url=https://legilux.public.lu/eli/etat/leg/loi/2009/12/10/n1/jo |access-date=2022-03-20 |website=legilux.public.lu}}{{Rp|page=5.27}}

In the last decade of the 20th century and the first of the 21st, "outpatient commitment" laws were passed in a number of U.S. states and jurisdictions in Canada.{{citation needed|date=October 2017}}

File:Canada CTOs.svg

In the mid-1990s, Saskatchewan became the first Canadian province to implement community treatment orders, and Ontario followed in 2000.{{cite journal |last=Kisely |first=Steve |date=January 2016 |title=Canadian Studies on the Effectiveness of Community Treatment Orders |journal=Canadian Journal of Psychiatry |volume=61 |issue=1 |pages=7–14 |pmid=27582448 |pmc=4756603 |doi=10.1177/0706743715620414 |doi-access=free }} {{As of|2016|1|post=,}} New Brunswick was the only province without legislation that provided for either CTOs or extended leave.

{{clear}}

File:Map of USA with state names AOT.svg

{{As of|2010|alt=By the end of 2010,}} 44 U.S. states had enacted some version of an outpatient commitment law. In some cases, passage of the laws followed widely publicized tragedies, such as the murders of Laura Wilcox and Kendra Webdale.{{Cite web|url=https://www.sfgate.com/opinion/openforum/article/Laura-s-Law-an-opportunity-to-improve-life-3181356.php|title=Laura's Law - an opportunity to improve life|last1=Hanly|first1=Elizabeth|last2=Biasotti|first2=Michael C.|date=2010-07-19|website=SFGate|access-date=2020-02-03}}{{Cite web|url=https://www.aei.org/articles/sane-mental-health-laws/|title=Sane Mental Health Laws?|website=American Enterprise Institute - AEI|language=en-US|access-date=2020-02-03}}

{{clear}}

Australia and New Zealand introduced community treatment orders in the 1980s and 1990s.{{cite journal |last1=Rugkåsa |first1=Jorun |date=January 2016 |title=Effectiveness of Community Treatment Orders: The International Evidence |journal=Canadian Journal of Psychiatry |volume=61 |issue=1 |pages=15–24 |pmid=27582449 |pmc=4756604 |doi=10.1177/0706743715620415 |doi-access=free }}

In the Australian state of Victoria, community treatment orders last for a maximum of twelve months{{Cite web|url=https://www.legalaid.vic.gov.au/find-legal-answers/mental-health-and-your-rights/compulsory-treatment-orders|title=Compulsory treatment orders|last=Askew|first=Maddy|date=2012-10-15|website=Victoria Legal Aid|language=en-AU|access-date=2020-02-03}} but can be renewed after review by a tribunal.{{citation needed|date=October 2017}}

{{Pro and con list|section|date=October 2017}}

Proponents have argued that outpatient commitment improves mental health, increases the effectiveness of treatment, lowers incidence of homelessness, arrest, incarceration and hospitalization and reduces costs. Opponents of outpatient commitment laws argue that they unnecessarily limit freedom, force people to ingest dangerous medications, impede on their human rights, or are applied with racial and socioeconomic biases.

{{Multiple issues|section=yes|

{{POV section|date=March 2022}}

{{Over-quotation|section|date=March 2022|many=y}}

}}

While many outpatient commitment laws have been passed in response to violent acts committed by people with mental illness, most proponents involved in the outpatient commitment debate also make arguments based on the quality of life and cost associated with untreated mental illness and "revolving door patients" who experience a cycle of hospitalization, treatment and stabilization, release, and decompensation. While the cost of repeated hospitalizations is indisputable, quality-of-life arguments rest on an understanding of mental illness as an undesirable and dangerous state of being. Outpatient commitment proponents point to studies performed in North Carolina and New York that have found some positive impact of court-ordered outpatient treatment. Proponents include: Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Justice, Agency for Healthcare Research and Quality (AHRQ), U. S Department of Health and Human Services, American Psychiatric Association, National Alliance on Mental Illness, International Association of Chiefs of Police. SAMHSA included Assisted Outpatient Treatment in their National Registry of Evidence Based Program and Practices. Crime Solutions: Management Strategies to Reduce Psychiatric Readmissions.{{cite report |last1=Gaynes |first1=Bradley N. |last2=Brown |first2=Carrie |last3=Lux |first3=Linda J. |last4=Ashok |first4=Mahima |last5=Coker-Schwimmer |first5=Emmanuel |last6=Hoffman |first6=Valerie |last7=Sheitman |first7=Brian |last8=Viswanathan |first8=Meera |display-authors=3 |date=May 2015 |title=Management Strategies to Reduce Psychiatric Readmissions |type=Technical Brief |series=Effective Health Care Program |publisher=Agency for Healthcare Research and Quality |location=Rockville, MD |docket=15-EHC018-EF |pmid=26020093 |url=https://www.ncbi.nlm.nih.gov/books/NBK294451/ }} The Treatment Advocacy Center are an advocacy group that campaign for the use of outpatient commitment.{{Cite web|last=Administrator|title=Improving Civil Commitment Laws and Standards|url=https://www.treatmentadvocacycenter.org/fixing-the-system/improving-laws-and-standards|access-date=2021-04-27|website=Treatment Advocacy Center|language=en-gb}}

A systematic review in 2016 that looked at around 200 papers investigating effectiveness of CTOs for patient outcomes. It found that non-randomized trials had dramatically varying results and found that no randomized controlled trials showed any benefits to the patient for outpatient commitment apart from a reduction in the risk of being the victim of crime.{{cite journal | last=Rugkåsa | first=Jorun | title=Effectiveness of Community Treatment Orders: The International Evidence | journal=Canadian Journal of Psychiatry | year=2016 | volume=61 | issue=1 | pages=15–24 | pmid=27582449 | doi=10.1177/0706743715620415 | pmc=4756604 | doi-access=free }}

The same interventions can have different effects in different countries due to legal, bureaucratic and social factors.

Research published in 2013 showed that Kendra's Law in New York, which served about 2,500 patients at a cost of $32 million, had positive results in terms of net cost, reduced arrests.{{cite journal |last1=Swanson |first1=Jeffrey W. |first2=Richard A. |last2=Van Dorn |first3=Marvin S. |last3=Swartz |first4=Pamela Clark |last4=Robbins |first5=Henry J. |last5=Steadman |first6=Thomas G. |last6=McGuire |first7=John |last7=Monahan |display-authors=3 |title=The Cost of Assisted Outpatient Treatment: Can It Save States Money? |journal=American Journal of Psychiatry |date=July 30, 2013 |doi=10.1176/appi.ajp.2013.12091152 |pmid=23896998 |url=http://ajp.psychiatryonline.org/Article.aspx?ArticleID=1722044 |archive-url=https://web.archive.org/web/20130808111242/http://ajp.psychiatryonline.org/Article.aspx?ArticleID=1722044 |url-status=dead |archive-date=August 8, 2013 |access-date=July 30, 2013 |quote=Assisted outpatient treatment requires a substantial investment of state resources but can reduce overall service costs for persons with serious mental illness. |volume=170 |issue=12 |pages=1423–1432 |s2cid=34004755 |url-access=subscription }}{{primary source inline|date=October 2017}} About $125 million is also spent annually on improved outpatient treatment for patients who are not subject to the law. In contrast to New York, despite wide adoption of outpatient commitment, the programs were generally not adequately funded.{{cite news|title=Program Compelling Outpatient Treatment for Mental Illness Is Working, Study Says|url=https://www.nytimes.com/2013/07/30/us/program-compelling-outpatient-treatment-for-mental-illness-is-working-study-says.html|access-date=July 30, 2013|newspaper=The New York Times|date=July 30, 2013|first=Pam |last=Belluck}}

"Although numerous AOT programs currently operate across the United States, it is clear that the intervention is vastly underutilized."{{cite web |last=Stettin |first=Brian |date=February 2015 |title=Intervention Summary: Assisted Outpatient Treatment (AOT) |website=NREPP: SAMHSA'S National Registry of Evidence-based Programs and Practices |url=http://legacy.nreppadmin.net/ViewIntervention.aspx?id=401 |access-date=11 January 2016 |archive-url=https://web.archive.org/web/20170201202522/http://legacy.nreppadmin.net/ViewIntervention.aspx?id=401 |archive-date=1 February 2017 |url-status=dead |df=dmy-all }}

The National Institute of Justice considers assisted outpatient treatment an effective crime prevention program.{{cite web |date=March 26, 2012 |title=Program Profile: Assisted Outpatient Treatment (AOT) |website=CrimeSolutions.gov |publisher=National Institute of Justice |url=http://www.crimesolutions.gov/ProgramDetails.aspx?ID=228 |access-date=25 September 2014 }} Some studies in the US have found that AOT programs have reduced the chances of arrest.{{efn|name=us-arrest-rate| {{blockquote|"For those who received AOT, the odds of any arrest were 2.66 times greater (p<.01) and the odds of arrest for a violent offense 8.61 times greater (p<.05) before AOT than they were in the period during and shortly after AOT. The group never receiving AOT had nearly double the odds (1.91, p<.05) of arrest compared with the AOT group in the period during and shortly after assignment."{{cite journal |last1=Link |first1=Bruce G. |last2=Epperson |first2=Matthew W. |last3=Perron |first3=Brian E. |last4=Castille |first4=Dorothy M. |last5=Yang |first5=Lawrence H. |display-authors=3 |title=Arrest Outcomes Associated With Outpatient Commitment in New York State |journal=Psychiatric Services |volume=62 |issue=5 |pages=504–8 |year=2011 |pmid=21532076 |pmc=5826718 |doi=10.1176/ps.62.5.pss6205_0504 }}{{Primary source inline|date=October 2017}}}}

{{blockquote|1="The odds of arrest for participants currently receiving AOT were nearly two-thirds lower (OR=.39, p<.01) than for individuals who had not yet initiated AOT or signed a voluntary service agreement."{{cite journal |last1=Gilbert |first1=Allison R. |last2=Moser |first2=Lorna L. |last3=Van Dorn |first3=Richard A. |last4=Swanson |first4=Jeffrey W. |last5=Wilder |first5=Christine M. |last6=Robbins |first6=Pamela Clark |last7=Keator |first7=Karli J. |last8=Steadman |first8=Henry J. |last9=Swartz |first9=Marvin S. |display-authors=3 |title=Reductions in Arrest Under Assisted Outpatient Treatment in New York |journal=Psychiatric Services |volume=61 |issue=10 |pages=996–9 |year=2010 |pmid=20889637 |doi=10.1176/ps.2010.61.10.996 |s2cid=28455017 }}{{Primary source inline|date=October 2017}}}}

}} Kendra's Law has lowered risk of violent behaviors, reduced thoughts about suicide. {{efn|name=kendra-violence|Patients given mandatory outpatient treatment—who were more violent to begin with—were nevertheless four times less likely than members of the control group to perpetrate serious violence after undergoing treatment. Patients who underwent mandatory treatment reported higher social functioning and slightly less stigma, rebutting claims that mandatory outpatient care is a threat to self-esteem.{{cite journal |last1=Phelan |first1=Jo C. |last2=Sinkewicz |first2=Marilyn |last3=Castille |first3=Dorothy M. |last4=Huz |first4=Steven |last5=Link |first5=Bruce G. |display-authors=3 |title=Effectiveness and Outcomes of Assisted Outpatient Treatment in New York State |journal=Psychiatric Services |volume=61 |issue=2 |pages=137–43 |year=2010 |pmid=20123818 |doi=10.1176/ps.2010.61.2.137 |s2cid=25304234 }}{{Primary source inline|date=October 2017}}

55% fewer recipients engaged in suicide attempts or physical harm to self. 47% fewer physically harmed others. 46% fewer damaged or destroyed property. 43% fewer threatened physical harm to others. Overall, the average decrease in harmful behaviors was 44%.{{citation needed|date=August 2016}}

{{blockquote|"Subjects who were ordered to outpatient commitment were less likely to be criminally victimized than those who were released without outpatient commitment."{{cite journal |last1=Hiday |first1=Virginia Aldigé |last2=Swartz |first2=Marvin S. |last3=Swanson |first3=Jeffrey W. |last4=Borum |first4=Randy |last5=Wagner |first5=H. Ryan |display-authors=3 |title=Impact of Outpatient Commitment on Victimization of People With Severe Mental Illness |journal=American Journal of Psychiatry |volume=159 |issue=8 |year=2002 |pages=1403–11 |doi=10.1176/appi.ajp.159.8.1403 |pmid=12153835 }}{{Primary source inline|date=October 2017}}}}

}}

AOT "programs improve adherence with outpatient treatment and have been shown to lead to significantly fewer emergency commitments, hospital admissions, and hospital days as well as a reduction in arrests and violent behavior."{{cite web |date=17 November 2016 |title=Extensive New Independent Support for Assisted Outpatient Treatment from AHRQ Report |website=Mental Illness Policy Org |url=https://mentalillnesspolicy.org/national-studies/extensive-new-independent-support-for-assisted-outpatient-treatment-from-ahrq-report-pdf.html }}

{{blockquote|"The likelihood of psychiatric hospital admission was significantly reduced by approximately 25% during the initial six-month court order...and by over one-third during a subsequent six-month renewal of the order.... Similar significant reductions in days of hospitalization were evident during initial court orders and subsequent renewals.... Improvements were also evident in receipt of psychotropic medications and intensive case management services. Analysis of data from case manager reports showed similar reductions in hospital admissions and improved engagement in services."{{cite journal |last1=Swartz |first1=Marvin S. |last2=Wilder |first2=Christine M. |last3=Swanson |first3=Jeffrey W. |last4=Van Dorn |first4=Richard A. |last5=Robbins |first5=Pamela Clark |last6=Steadman |first6=Henry J. |last7=Moser |first7=Lorna L. |last8=Gilbert |first8=Allison R. |last9=Monahan |first9=John |display-authors=3 |title=Assessing Outcomes for Consumers in New York's Assisted Outpatient Treatment Program |journal=Psychiatric Services |volume=61 |issue=10 |pages=976–81 |date=October 2010 |pmid=20889634 |doi=10.1176/ps.2010.61.10.976 |doi-access= }}{{Primary source inline|date=October 2017}}}}

74% fewer participants experienced homelessness. 77% fewer experienced psychiatric hospitalization. 56% reduction in length of hospitalization. 83% fewer experienced arrest. 87% fewer experienced incarceration. 49% fewer abused alcohol. 48% fewer abused drugs. Consumer participation and medication compliance improved. The number of individuals exhibiting good adherence to meds increased 51%. The number of individuals exhibiting good service engagement increased 103%. Consumer perceptions were positive. 75% reported that AOT helped them gain control over their lives. 81% said AOT helped them get and stay well. 90% said AOT made them more likely to keep appointments and take meds. 87% of participants said they were confident in their case manager's ability. 88% said they and their case manager agreed on what was important to work on.{{citation needed|date=August 2016}}

In Nevada County, CA, AOT ("Laura's Law") decreased the number of psychiatric hospital days 46.7%, the number of incarceration days 65.1%, the number of homeless days 61.9%, and the number of emergency interventions 44.1%. Laura's Law implementation saved $1.81–$2.52 for every dollar spent, and receiving services under Laura's Law caused a "reduction in actual hospital costs of $213,300" and a "reduction in actual incarceration costs of $75,600."{{Primary source inline|date=October 2017}}

In New Jersey, Kim Veith, director of clinical services at Ocean Mental Health Services, noted the AOT pilot program performed "beyond wildest dreams." AOT reduced hospitalizations, shortened inpatient stays, reduced crime and incarceration, stabilized housing, and reduced homelessness. Of clients who were homeless, 20% are now in supportive housing, 40% are in boarding homes, and 20% are living successfully with family members.{{cite web |date=September 2, 2014 |title=Success of AOT in New Jersey 'Beyond Wildest Dreams' |website=Treatment Advocacy Center |url=http://www.treatmentadvocacycenter.org/about-us/our-blog/110-nj/2625-success-of-aot-in-new-jersey-beyond-wildest-dreams |access-date=25 September 2014 }}{{Unreliable medical source|date=October 2017|reason=Blog post describes early analysis of data from a single U.S. state.}}

Writing in the British Journal of Psychiatry in 2013, Jorun Rugkåsa and John Dawson stated, "The current evidence from {{abbr|RCTs|randomized controlled trials}} suggests that {{abbr|CTOs|community treatment orders}} do not reduce readmission rates over 12 months."{{cite journal |last1=Rugkåsa |first1=Jorun |last2=Dawson |first2=John |title=Community treatment orders: current evidence and the implications |journal=British Journal of Psychiatry |volume=203 |issue=6 |pages=406–8 |date=December 2013 |pmid=24297787 |doi=10.1192/bjp.bp.113.133900 |doi-access=free }}

"We find that New York State's AOT Program improves a range of important outcomes for its recipients, apparently without feared negative consequences to recipients."{{cite quote|date=October 2017}}

"The increased services available under AOT clearly improve recipient outcomes, however, the AOT court order, itself, and its monitoring do appear to offer additional benefits in improving outcomes."{{cite quote|date=August 2016}}

{{blockquote|"AOT has been instrumental in increasing accountability at all system levels regarding delivery of services to high need individuals. Community awareness of AOT has resulted in increased outreach to individuals who had previously presented engagement challenges to mental health service providers."}}

{{blockquote|"Improved treatment plan development, discharge planning, and coordination of service planning. Processes and structures developed for AOT have resulted in improvements to treatment plans that more appropriately match the needs of individuals who have had difficulties using mental health services in the past."}}

{{blockquote|"Improved collaboration between mental health and court systems. As AOT processes have matured, professionals from the two systems have improved their working relationships, resulting in greater efficiencies, and ultimately, the conservation of judicial, clinical, and administrative resources. There is now an organized process to prioritize and monitor individuals with the greatest need; AOT ensures greater access to services for individuals whom providers have previously been reluctant to serve; There is now increased collaboration between inpatient and community-based providers."{{cite report |author=New York State Office of Mental Health |date=2005 |title=Kendra's Law: Final Report on the Status of Assisted Outpatient Treatment |type=Report to Legislature |publisher=New York State |location=Albany |page=60 |url=http://mentalillnesspolicy.org/kendras-law/research/kendras-law-study-2005.pdf |archive-url=https://ghostarchive.org/archive/20221009/http://mentalillnesspolicy.org/kendras-law/research/kendras-law-study-2005.pdf |archive-date=2022-10-09 |url-status=live |access-date=8 February 2015 }}}}

In New York City net costs declined 50% in the first year after assisted outpatient treatment began and an additional 13% in the second year. In non-NYC counties, costs declined 62% in the first year and an additional 27% in the second year. This was in spite of the fact that psychotropic drug costs increased during the first year after initiation of assisted outpatient treatment, by 40% and 44% in the city and five-county samples, respectively. The increased community-based mental health costs were more than offset by the reduction in inpatient and incarceration costs. Cost declines associated with assisted outpatient treatment were about twice as large as those seen for voluntary services.{{primary source inline|date=October 2017}}

{{blockquote|"In all three regions, for all three groups, the predicted probability of an {{abbr|MPR|Medication Possession Ratio}} ≥80% improved over time (AOT improved by 31–40 percentage points, followed by enhanced services, which improved by 15–22 points, and 'neither treatment,' improving 8–19 points). Some regional differences in MPR trajectories were observed."{{cite journal |last1=Busch |first1=Alisa B. |last2=Wilder |first2=Christine M. |last3=Van Dorn |first3=Richard A. |last4=Swartz |first4=Marvin S. |last5=Swanson |first5=Jeffrey W. |display-authors=3 |title=Changes in Guideline-Recommended Medication Possession After Implementing Kendra's Law in New York |journal=Psychiatric Services |volume=61 |issue=10 |year=2010 |pages=1000–5 |doi=10.1176/ps.2010.61.10.1000 |pmid=20889638 |pmc=6690587 }}{{primary source inline|date=October 2017}}}}

{{blockquote|"In tandem with New York's AOT program, enhanced services increased among involuntary recipients, whereas no corresponding increase was initially seen for voluntary recipients. In the long run, however, overall service capacity was increased, and the focus on enhanced services for AOT participants appears to have led to greater access to enhanced services for both voluntary and involuntary recipients."{{cite journal |last1=Swanson |first1=Jeffrey W. |last2=Van Dorn |first2=Richard A. |last3=Swartz |first3=Marvin S. |last4=Cislo |first4=Andrew M. |last5=Wilder |first5=Christine M. |last6=Moser |first6=Lorna L. |last7=Gilbert |first7=Allison R. |last8=McGuire |first8=Thomas G. |display-authors=3 |title=Robbing Peter to Pay Paul: Did New York State's Outpatient Commitment Program Crowd Out Voluntary Service Recipients? |journal=Psychiatric Services |volume=61 |issue=10 |year=2010 |pages=988–95 |doi=10.1176/ps.2010.61.10.988 |pmid=20889636 |doi-access=free }}{{primary source inline|date=October 2017}}}}

{{blockquote|"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."{{cite quote|date=August 2016}}}}

{{blockquote|"We find no evidence that the AOT Program is disproportionately selecting African Americans for court orders, nor is there evidence of a disproportionate effect on other minority populations. Our interviews with key stakeholders across the state corroborate these findings."}}

{{blockquote|"We found no evidence of racial bias. Defining the target population as public-system clients with multiple hospitalizations, the rate of application to white and black clients approaches parity."{{cite journal |last1=Swanson |first1=Jeffrey |last2=Swartz |first2=Marvin |last3=Van Dorn |first3=Richard A. |last4=Monahan |first4=John |last5=McGuire |first5=Thomas G. |last6=Steadman |first6=Henry J. |last7=Robbins |first7=Pamela Clark |display-authors=3 |title=Racial Disparities In Involuntary Outpatient Commitment: Are They Real? |journal=Health Affairs |volume=28 |issue=3 |year=2009 |pages=816–26 |doi=10.1377/hlthaff.28.3.816 |doi-access= |pmid=19414892 }}{{primary source inline|date=October 2017}}}}

{{blockquote|"After 12 months or more on AOT, service engagement increased such that AOT recipients were judged to be more engaged than voluntary patients. This suggests that after 12 months or more, when combined with intensive services, AOT increases service engagement compared to voluntary treatment alone."}}

Consumers approve. Despite being under a court order to participate in treatment, current AOT recipients feel neither more positive nor more negative about their treatment experiences than comparable individuals who are not under AOT."{{failed verification|date=October 2017}}

{{blockquote|"When the court order was for seven months or more, improved medication possession rates and reduced hospitalization outcomes were sustained even when the former AOT recipients were no longer receiving intensive case coordination services."{{cite journal |last1=Van Dorn |first1=Richard A. |last2=Swanson |first2=Jeffrey W. |last3=Swartz |first3=Marvin S. |last4=Wilder |first4=Christine M. |last5=Moser |first5=Lorna L. |last6=Gilbert |first6=Allison R. |last7=Cislo |first7=Andrew M. |last8=Robbins |first8=Pamela Clark |display-authors=3 |title=Continuing Medication and Hospitalization Outcomes After Assisted Outpatient Treatment in New York |journal=Psychiatric Services |volume=61 |issue=10 |date=October 2010 |pages=982–7 |doi=10.1176/ps.2010.61.10.982 |doi-access= |pmid=20889635 }}{{primary source inline|date=October 2017}}}}

In Los Angeles, CA, the AOT pilot program reduced incarceration 78%, hospitalization 86%, hospitalization after discharge from the program 77%, and cut taxpayer costs 40%.{{cite report |last=Southard |first=Marvin |date=February 24, 2011 |title=Assisted Outpatient Treatment Program Outcomes Report |publisher=Los Angeles County Department of Mental Health |location=Los Angeles, CA |url=http://lauras-law.org/states/california/lalauraslawstudy.pdf |access-date=24 September 2014 |url-status=dead |archive-url=https://web.archive.org/web/20131228224756/http://lauras-law.org/states/california/lalauraslawstudy.pdf |archive-date=28 December 2013 }}

In North Carolina, AOT reduced the percentage of persons refusing medications to 30%, compared to 66% of patients not under AOT.{{cite journal |last1=Hiday |first1=Virginia Aldigé |last2=Scheid-Cook |first2=Teresa L. |title=The North Carolina experience with outpatient commitment: A critical appraisal |journal=International Journal of Law and Psychiatry |volume=10 |issue=3 |year=1987 |pages=215–32 |doi=10.1016/0160-2527(87)90026-4 |pmid=3692660 }}

In Ohio, AOT increased attendance at outpatient psychiatric appointments from 5.7 to 13.0 per year. It increased attendance at day treatment sessions from 23 to 60 per year. "During the first 12 months of outpatient commitment, patients experienced significant reductions in visits to the psychiatric emergency service, hospital admissions, and lengths of stay compared with the 12 months before commitment."{{cite journal |title=The effectiveness of outpatient civil commitment |journal=Psychiatric Services |volume=47 |issue=11 |date=November 1996 |pages=1251–3 |doi=10.1176/ps.47.11.1251 |pmid=8916245 |last1=Munetz |first1=M.R. |last2=Grande |first2=T. |last3=Kleist |first3=J. |last4=Peterson |first4=G.A. |display-authors=3 |citeseerx=10.1.1.454.5055 }}{{primary source inline|date=October 2017}}

In Arizona, "71% [of AOT patients] ... voluntarily maintained treatment contacts six months after their orders expired" compared with "almost no patients" who were not court-ordered to outpatient treatment.{{cite journal |vauthors=Van Putten RA, Santiago JM, Berren MR |title=Involuntary outpatient commitment in Arizona: a retrospective study |journal=Hospital & Community Psychiatry |volume=39 |issue=9 |pages=953–8 |date=September 1988 |pmid=3215643 |doi=10.1176/ps.39.9.953 }}{{primary source inline|date=October 2017}}

In Iowa, "it appears as though outpatient commitment promotes treatment compliance in about 80% of patients... After commitment is terminated, about ¾ of that group remain in treatment on a voluntary basis."{{cite report |last=Rohland |first=Barbara |date=1998 |title=The role of outpatient commitment in the management of persons with schizophrenia |publisher=Iowa Consortium for Mental Health Services, Training and Research |url=http://www.healthcare.uiowa.edu/icmh/archives/reports/finalrpt.pdf |access-date=25 September 2014 |archive-url=https://web.archive.org/web/20160204112043/http://www.healthcare.uiowa.edu/icmh/archives/reports/finalrpt.pdf |archive-date=4 February 2016 |url-status=dead }}

Human rights advocate considers it a violation of freedom of thought or opinion, or views the use of neuroleptic as degrading treatment that can also impede on their right to work due to sometimes handicapping side effects. Other argue for a right of self-determination or self ownership, considering it a paternalistic approach that can be wrongly applied considering psychiatry criteria for diagnosis are very subjective backed by some studies questioning diagnosis (see Rosenhan experiment), the unlimited duration with often lack or no foresight to an end from the patient is also criticised.

Some opponents dispute the effects of compulsory treatment as positive, questioning the methodology of studies that show effectiveness. Some point to disparities in the way these laws are applied.{{citation needed|date=August 2016}}

Opponents claim they are giving medication to the patient, but there are no brain chemical imbalances to correct in "mental illness".{{cite web |url=http://www.psychiatrictimes.com/blogs/couch-crisis/psychiatry-new-brain-mind-and-legend-chemical-imbalance |title=Psychiatry's New Brain-Mind and the Legend of the Chemical Imbalance |first1=Ronald W. |last1=Pies |date=July 11, 2011 |work=Psychiatric Times }} Our ability to control ourselves and reason comes from the mind, and the brain is being reduced in size from the psychiatric medications.{{cite journal |last1=Ho |first1=Beng-Choon |last2=Andreasen |first2=Nancy C. |last3=Ziebell |first3=Steven |last4=Pierson |first4=Ronald |last5=Magnotta |first5=Vincent |display-authors=3 |title=Long-term Antipsychotic Treatment and Brain Volumes |journal=Archives of General Psychiatry |volume=68 |issue=2 |pages=128–37 |year=2011 |pmid=21300943 |pmc=3476840 |doi=10.1001/archgenpsychiatry.2010.199 }}{{cite journal |last1=Dorph-Petersen |first1=Karl-Anton |last2=Pierri |first2=Joseph N. |last3=Perel |first3=James M. |last4=Sun |first4=Zhuoxin |last5=Sampson |first5=Allan R. |last6=Lewis |first6=David A. |display-authors=3 |title=The Influence of Chronic Exposure to Antipsychotic Medications on Brain Size before and after Tissue Fixation: A Comparison of Haloperidol and Olanzapine in Macaque Monkeys |journal=Neuropsychopharmacology |volume=30 |issue=9 |pages=1649–61 |year=2005 |pmid=15756305 |doi=10.1038/sj.npp.1300710 |doi-access=free }}{{cite journal |last1=Radua |first1=J. |last2=Borgwardt |first2=S. |last3=Crescini |first3=A. |last4=Mataix-Cols |first4=D. |last5=Meyer-Lindenberg |first5=A. |last6=McGuire |first6=P.K. |last7=Fusar-Poli |first7=P. |display-authors=3 |title=Multimodal meta-analysis of structural and functional brain changes in first episode psychosis and the effects of antipsychotic medication |journal=Neuroscience & Biobehavioral Reviews |volume=36 |issue=10 |pages=2325–33 |year=2012 |pmid=22910680 |doi=10.1016/j.neubiorev.2012.07.012 |doi-access=free }}{{cite journal |last1=Harrow |first1=Martin |last2=Jobe |first2=Thomas H. |title=Factors involved in outcome and recovery in schizophrenia patients not on antipsychotic medications: a 15-year multifollow-up study |journal=The Journal of Nervous and Mental Disease |volume=195 |issue=5 |pages=406–14 |year=2007 |pmid=17502806 |doi=10.1097/01.nmd.0000253783.32338.6e |s2cid=6423448 }}

The slippery slope argument of "If government bodies are given power, they will use it in excess." was proven when 350–450 CTOs were expected to be issued in 2008 and more than five times that number were issued in the first few months. Every year there are increasing numbers of people subject to CTO's.{{cite news |url=http://www.politics.co.uk/comment-analysis/2014/10/07/community-treatment-orders-politics-and-psychiatry-in-a-cult |title=Community Treatment Orders: Politics and psychiatry in a culture of fear |first1=Ken |last1=McLaughlin |date=October 7, 2014 |publisher=Politics.co.uk }}{{cite press release |title=Inpatients Formally Detained in Hospitals Under the Mental Health Act 1983 and Patients Subject to Supervised Community Treatment, England - 2014-2015, Annual figures |publisher=NHS Digital |date=October 23, 2015 |url=http://digital.nhs.uk/catalogue/PUB18803 |access-date=August 14, 2016 }}{{cite press release |title=Number of Mental Health detentions and Community Treatment Order rises |publisher=NHS Digital |date=October 23, 2012 |url=http://digital.nhs.uk/article/2282/Number-of-Mental-Health-detentions-and-Community-Treatment-Order-rises |access-date=August 14, 2016 |url-status=dead |archive-url=https://web.archive.org/web/20160820122826/http://digital.nhs.uk/article/2282/Number-of-Mental-Health-detentions-and-Community-Treatment-Order-rises |archive-date=August 20, 2016 }}

The psychiatric survivors movement opposes compulsory treatment on the basis that the ordered drugs often have serious or unpleasant side-effects such as tardive dyskinesia, neuroleptic malignant syndrome, akathisia, excessive weight gain leading to diabetes, addiction, sexual side effects, increased risk of suicide and QT prolongation. The New York Civil Liberties Union has denounced what they see as racial and socioeconomic biases in the issuing of outpatient commitment orders.{{cite web |publisher=New York Lawyers for the Public Interest |title=Implementation of 'Kendra's Law' is Severely Biased |date=April 7, 2005 |url=http://www.nylpi.org/wp-content/uploads/bsk-pdf-manager/149_DLC_-_REPORT_ON_KENDRA'S_LAW.PDF |archive-url=https://ghostarchive.org/archive/20221009/http://www.nylpi.org/wp-content/uploads/bsk-pdf-manager/149_DLC_-_REPORT_ON_KENDRA'S_LAW.PDF |archive-date=2022-10-09 |url-status=live }}{{cite web |url=http://www.nyclu.org/aot_program_tstmny_040805.html |title=Testimony On Extending Kendra's Law |website=NYCLU |access-date=2006-04-02 |url-status=dead |archive-url=https://web.archive.org/web/20060109153452/http://www.nyclu.org/aot_program_tstmny_040805.html |archive-date=2006-01-09 }} The main opponents to any kind of coercion, including the outpatient commitment and any other form of involuntary commitment, are Giorgio Antonucci and Thomas Szasz.{{citation needed|date=August 2016}}

US specific:

• Laura's Law
• MindFreedom International

General:

• Deinstitutionalisation
• Psychiatric reform in Italy
• Giorgio Antonucci

{{notelist}}

{{reflist}}

• [http://www.treatmentadvocacycenter.org Treatment Advocacy Center]
• [http://treatmentadvocacycenter.org/legal-resources/state-standards Civil commitment laws and standards by state]
• [http://www.mindfreedom.org MindFreedom]
• [http://www.mhselfhelp.org/ National Mental Health Consumers' Self-Help Clearinghouse]
• [http://www.mentalillnesspolicy.org Mental Illness Policy Org]
• [https://web.archive.org/web/20160413045058/http://kendras-law.org/ Kendra's Law]
• [https://web.archive.org/web/20160110182514/http://lauras-law.org/ Laura's Law]

{{Mental health law}}

Category:Psychosis

Category:Mental health law

Category:Deinstitutionalisation