AOT: Effective but underused

As regular TAC Blog readers know, 42 states have Assisted Outpatient Treatment (AOT) laws that permit a court to order community based treatment for some people with severe mental illness who meet the state’s strict eligibility requirement. This legal mechanism has been proven to reduce consequences of nontreatment like hospitalizations, incarcerations, victimization, and violence.

Florida passed its law - known in that state as “The Baker Act Reform” and “Involuntary Outpatient Placement” - in 2005. At the time the legislature was considering the measure, opponents asserted that the law would affect several thousand people resulting in a total hardship on the courts, public defenders, and the mental health system. As it turns out, the reality is that it is used for a very select few individuals and to great benefit.

But the most important question to ask is, “Does assisted outpatient treatment help some people with severe mental illness to achieve better outcomes?” And the answer in Florida, as in other states and in the research, is a solid “YES.” Results from the most used program in Florida were recently published in a letter in Psychiatric Services. For patients in the program, when the length of time in the program was compared to an identical length of time before the patient entered the program:

• The average number of hospital days per patient decreased from 64.0 to 36.8, a 43% decrease.
• The savings in hospital costs averaged $14,463 per patient.
• The average number of days incarcerated per patient decreased from 16.1 to 4.5, a 72% decrease.

After Virginia Tech - much activity, little accomplishment

On Tuesday, the Virginia legislature sent a package of bills to the Governor containing its proposed changes to the state’s commitment laws. Although the end-result was essentially inevitable after a bill to establish a progressive assisted outpatient treatment system was shuttled off to a study committee, the Virginia Legislature made it official on Tuesday – there was much busy work in the wake of the tragedies at Blacksburg but nothing approaching rational treatment laws for the state.

House Bill 499, the chief bill of the package, reworks the present procedural system for outpatient commitment fairly well and offers a slight improvement to the eligibility standard but still leaves Virginia’s laws among the most restrictive of treatment in the country. Essentially, HB 499 will move Virginia law in this area from among the worst to just plain bad.

With the pressure created by the Blacksburg tragedies, the legislators in Richmond realistically had no choice but to (1) do away with the state’s “imminent danger” standard and (2) shore up of the outpatient commitment procedural provisions that let Seung-Hui Cho be placed on outpatient commitment and then just slip away from the treatment system.

HB 499 does both of these.

1. “Imminent danger” is changed to “the person will, in the near future, cause serious physical harm to himself or others as evidenced by recent behavior causing, attempting, or threatening harm.” That is more or less just substituting “near future” rather than “imminent” in exchange for the new requirement of recent acts, attempts or threats of violence.

2. HB 499 sets out and strengthens outpatient commitment procedures. This includes making sure that assigned treatment providers are involved in the outpatient commitment process and responsible for those placed under orders.

The only significant way in which HB 499 exceeds that “bare minimum” in the wake of Virginia Tech is in a modest but significant addition to the “substantially unable to care for oneself” prong of the present commitment standard.

HB 499 adds a new clause that allows the placement in treatment of a person over come by a severe mental illness who is substantially likely to “suffer serious harm due to substantial deterioration of his capacity to protect himself from harm or to provide for his basic human needs as evidenced by current circumstances.” Although still falling far short of the progressive commitment criteria in many other states, that at least is an improvement for Virginia legislators to justifiably claim as an accomplishment, albeit a small one.

Sadly, a small change is not good enough for Virginian’s with the most severe mental illnesses

Danielle Steel urges treatment

"When people aren't medicated it can be lethal," she said, adding that she hadn't realized that when dealing with her own son. "I thought it could ruin his life. I really didn't understand how high the possibility was that it could cost him his life."

Steel -- who will release her 72nd novel "Honor Thyself" on February 26 -- believes the laws need to be changed to allow mentally ill people to be hospitalized against their will.

"Usually bipolars present extremely well and they can bounce into court ... look very together and be a complete mess three hours later on the streets somewhere," she said. "There's nothing you can do."

- Author Danielle Steel in an interview with Reuter's about Britney Spears

Is treating severe mental illness less important than treating a heart attack?

Doctors at the Barnes- Jewish hospital in St. Louis meet periodically to analyze every patient who entered the hospital in previous months in the midst of a heart attack.

Since minutes and even seconds count when treating cardiac arrest, the doctors analyze their response time and what can be done to get life-saving treatment to people faster and more efficiently. Since the hospital began this analysis the Centers for Medicare and Medicaid Services has increased its rating to one of the top 17 hospitals in the nation for treating heart attacks.

Efficient, effective treatment is certainly vital when someone is in cardiac crisis.

It’s also vital when someone is in psychiatric crisis.

Yet in St. Louis, and all across the country, people with severe mental illnesses are forced to wait not minutes or seconds, but weeks and months until they’re sicker or until danger is imminent until they can get treatment.

Failing society and the person in need

As the Virginia General Assembly prepares to convene next week, the tragedy of Virginia Tech and the need for mental health reform loom large over the Commonwealth. One aspect of Virginia’s flawed mental system health that has received a great deal of notoriety is the commitment standard – one of the most restrictive in the nation.

Many have focused on the commitment standard’s inability to address those who may pose a danger to others, but few have commented on its similar failure to protect the individuals themselves who are in crisis. As Virginia Delegate Dave Albo explains, the current standard renders families just as powerless to help their loved ones in those situations.

"You have to wait for the person to deteriorate so much that they fit that definition [of imminent danger]. You have to wait right up until the very end when the person is about to kill themselves before you call," said Albo.

Do psychiatric advance directives help?

The Wall Street Journal ran an interesting story earlier this week about Psychiatric Advance Directives (PADs) which points out some of the strengths and weaknesses of using them as a planning tool for treating severe mental illnesses:

With PADs, patients with mental illness can state preferences for, or dislikes of, specific treatments, designate a proxy decision-maker or make other advance decisions about care, says Jeffrey Swanson, associate professor at Duke University, who has researched PADs. Twenty-five states, including Illinois, currently have laws authorizing such directives, and more are considering them, according to the National Resource Center on Psychiatric Advance Directives.

…Most state laws contain such an "override" clause, according to Swanson, but to actually force a treatment or hospitalize patients involuntarily for being a danger to themselves or others requires following state law regarding involuntarily treatment, which often involves a court hearing.

Many clinicians worry that PADs allow patients to refuse all treatment or make unreasonable or unsound demands. There are also questions about how to judge if patients are well enough to create PADs, and what to do if they change their minds later if they appear to be getting more symptomatic.

PADS are one more tool for helping individuals who have capacity to make decisions about the mental health treatment they will get if they become incapacitated. But, PADs are not a replacement for treatment laws. For individuals with chronic and persistent symptoms, PADs only work AFTER someone is stabilized and recovered enough to properly execute a PAD. Sometimes, this might require hospitalization or outpatient commitment. Thus, the treatment laws and PADs are tools to be used for situations that require different treatment solutions.

Guest Blog: Mental Illness and the Law

Guest Blog:
Written by Robert Gerard

The specific issue in the Virginia Tech shooting has to do with the criteria for having someone like Cho Seung-Hui hospitalized involuntarily. Ask any mental health professional about the criteria for involuntary hospitalization. It’s a joke! To be hospitalized involuntarily, the person must demonstrate behavior that demonstrates “immediate danger to self or others.” In our current zealous pursuit of civil rights, this means that the troubled person must be in the process of cutting her wrist or putting a noose around her head or explicitly threatening someone. “Ideation” (the psycho-babble label for expressing thoughts or ideas about harming self or others) doesn’t qualify.

Does anyone remember New York Mayor Koch’s heroic attempts to find shelters for homeless people during the bitter winter of 1987? In the wake of sub-zero temperatures, the Mayor insisted that the homeless, who were curled up on city streets, be taken to shelters for their own safety. One mentally ill person refused assistance, and the Mayor received a firestorm of criticism from civil rights advocates who rushed to protect those who had no insight into the danger they faced.

While video cameras, campus police, and other sources of security are important, the solution to avoiding another tragedy like the one at Virginia Tech lies in promoting and passing legislation that broadens the criteria for involuntary hospitalization of mentally ill persons who demonstrate a “potential” danger to self or to other members of the community.

Just think about what might not have happened if Professor Lucinda Roy’s appeal for intervention for Cho had been supported by the law and the mental health system.

Robert Gerard is a Professor Emeritus at Mount Saint Mary’s University in Emmitsburg Maryland, and has worked as a volunteer in a community mental health center. He is a member of the National Alliance for the mentally Ill (NAMI) and the parent of a child who is mentally ill.

The opinions expressed by guest bloggers are their own and not necessarily that of the Treatment Advocacy Center.Want to be a guest blogger? Tell us why at info@treatmentadvocacycenter.org.

"Imminent Danger" in the Washington Post

Two opinion pieces in yesterday’s Washington Post addressed the “imminent danger” standard in Virginia.

An editorial from the Washington Post:

Virginia currently requires that authorities determine that an individual poses an "imminent danger" to self or others, or be unable to care for himself, before they can order involuntary detention. That high hurdle, once embraced by a majority of states, has kept many unstable and dangerous people from receiving the care they need.

An op-ed from Pete Earley describing his experience in getting treatment for his son who has a severe mental illness:

When I rushed my college-age son -- in the throes of a psychotic breakdown -- to a Fairfax hospital, I was told he wasn't "sick enough." He could not be treated involuntarily until he posed an "imminent danger" to himself or someone else, doctors said. His mental illness had been diagnosed two years earlier, he had been hospitalized twice and he had done well on medication. But still doctors couldn't legally intervene.

The worst mistake of his life

A recent article from the Pittsburgh Post-Gazette led to a powerful letter from Bill Shane, a former Pennsylvania legislator who called his work in passing the clear and present danger standard, “the worst mistake of his life.”

Pennsylvania’s treatment standard is one of the most restrictive in the nation, requiring an individual to first pose a clear and present danger before receiving necessary care. The result is countless tragedies, and a system that is unresponsive to many of the most severely ill, despite being one of the best funded in the nation. We stand in awe of Mr. Shane’s honesty, and hope his words will help spur needed reform.

A monumental victory in Illinois

Yesterday, Illinois Governor Rod Blagojevich signed Senate Bill 234 into law. The measure – the culmination of a five-year effort – is a dramatic change to the Illinois commitment standard for both inpatient and outpatient assisted treatment.

When SB 234 takes effect next June, the short and simple-appearing legislation will be the greatest reform to Illinois commitment law in decades.

We cannot more commend the capability and compassion of Senator and chief bill sponsor Dale Righter, who doggedly pursued the measure over five years and three legislative sessions, and Representative David Leitch, who successfully guided SB 234 through the Illinois House.

NAMI–Illinois stood steadfastly behind this monumental reform each and every step along its path to becoming law.

But most of all – this monumental victory is a tribute to those who wrote, called, testified, and fought for SB 234 and treatment. A group of determined advocates decided to change a law that mandated non-treatment for many of those in their state lost to severe mental illnesses – and they did.

He is a great person...when he is on his meds

Approximately 2 million individuals with schizophrenia and bipolar disorder are receiving no treatment for their illness at any given time. Every day we hear stories from family members desperate to get help for the people they love. And every morning when we read the newspapers, we see quotes like these.

“If I could get her on her medications for three days, she would be fine.” [According to her aunt, Melissa Haygood,] who was discharged from a state mental institution when she was 16, rejected by her parents and left at her door, is perfectly normal when using her prescriptions, but trouble starts when the medicines are not used.

"He is a wonderful dad," Rowland said. "He is great as long as he is not sick. When he is sick, then we have problems."

"He had been doing pretty good," Donald Cummings said. "It was only within the last month he decided not to continue his medication. He subsequently shut everyone down. He shut them out totally." When Ronald Cummings chose to take his medication he was a kind, compassionate person who enjoyed cooking and listening to gospel music, his brother said.

If you are a family member facing a similar situation, start by really understanding your state’s commitment law (not all states require someone to be dangerous, though many people think that is the case), then prepare for crisis.

Is the law really dangerous?

Mental health professionals and others frequently say that, “by law, you have to be a danger to self or others” in order to get court-ordered treatment for severe mental illness. But, is that actually TRUE?

No. In most states, an individual with severe mental illness may qualify for court-ordered inpatient or outpatient treatment before deteriorating to a point of “dangerousness.” Many states have provisions for treating who are “gravely disabled” and some permit treating people based on their “need for treatment.”

Don’t just accept the word of your local officials – read the law for yourself and be accurately informed! TAC has online resources to help: a compilation of TEXT excerpts from the actual state commitment codes and a CHART summarizing the required criteria for treatment in each state.