Controversial law improves care for serious mental illness

Oct 07, 2010

(PhysOrg.com) -- Mounting evidence supports the benefits of New York State’s much-debated law authorizing court-ordered outpatient psychiatric treatment for people with serious mental illnesses, according to a series of newly published reports led by Duke University Medical Center researchers.

Eleven years ago, the New York State legislature enacted the state’s first involuntary outpatient commitment statute, named “Kendra’s Law,” which was passed after a young woman, Kendra Webdale, was killed by a stranger with untreated schizophrenia.

The law permits court-ordered, closely monitored outpatient treatment for people with serious mental disorders who consistently fail to take their medication and have a history of recurrent hospitalizations, arrest or violent behavior.

Currently 45 states have involuntary outpatient commitment laws, but only a handful are designed with prevention in mind. Kendra’s Law is intended to identify and address at-risk behavior that may trigger the need for hospitalization.

Amid criticism that the law may violate patient rights by mandating treatment, the New York State Office of Mental Health commissioned an independent evaluation of the implementation and effectiveness of the program.

The Duke-led team reports several notable achievements, including reduced rates of hospitalization, improved use of medication and fewer arrests since the program began in 1999.

“Our analysis found that New York State’s assisted outpatient treatment program was able to achieve significant and sustained improvements for many of the patients who participated in the program,” said Marvin Swartz, MD, the lead investigator of the study and professor of psychiatry at Duke.

“Still, in the legislative debate about renewing the program, concerns over state budget constraints and equitable allocation of services resulted in a decision to extend the law, rather than examine the merits of making it permanent.”

An analysis of Medicaid claims found that patients were nearly 50 percent more likely to be taking medication during the first six months of court-ordered treatment than during previous months.

Hospital admissions for psychiatric treatment were reduced by 27 percent during the first six months of court-ordered treatment, and when patients were admitted they spent fewer days in the hospital. If the order continued beyond six months, hospitalizations continued to decline.

The odds of arrest for participants currently receiving court-ordered treatment were nearly 50 percent lower than for individuals who had not yet started the program.

Despite the noted success of the program, researchers found differences when comparing treatment across the state, which points to the need for increased oversight of treatment quality across the public mental health system.

“More than 8,000 people who otherwise may not have been provided with access to the care they need have been treated through this program and the results speak for themselves,” said Jeffrey Swanson, PhD, study co-investigator and professor in psychiatry and behavioral sciences at Duke.

“Adequate treatment for serious is a critical public health issue. We’re talking about people who otherwise may not be able to live safely in the community and are unlikely to voluntarily receive care.”

Some critics of Kendra’s Law point to limited resources for community-based services and ask whether an involuntary treatment program diverts needed resources from people seeking assistance voluntarily.

The authors report that initially the program may have crowded out some individuals but, after the first three years, the increased service capacity funded during the start-up of the program also expanded services for those who did not qualify for court-ordered treatment.

The study was published in a special issue of Psychiatric Services.

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