October 2010: This Month's Highlights

Forty-four states have statutes allowing involuntary outpatient commitment of people with mental illness. With "Kendra's Law" in 1999, New York State undertook its own approach—assisted outpatient treatment (AOT). In 2005 when the State Legislature reauthorized the law for another five years, it made renewal contingent on an evaluation of the AOT program, largely because of fierce ongoing debate about its effectiveness as well as it costs—in terms not only of public resources but also of the liberty of consumers. This month's issue features a special section of five reports of key findings from that evaluation, which was conducted by researchers at Duke University and Policy Research Associates, Inc. Marvin S. Swartz, M.D., one of the a principal investigators and an Editorial Board member of Psychiatric Services, served as guest editor of the section, which begins with an overview by Dr. Swartz ( page 967 ). The first report describes notable regional differences in AOT implementation in various regions of New York, which raise questions about the fairness of the law's application ( page 970 ). The second study, which examined a range of outcomes using several data sources, found that consumers under an AOT order had lower rates of hospitalization and shorter stays and were more likely to possess an adequate supply of medication and to engage in case management services than before the court order ( page 976 ). The evaluators also examined whether AOT has longer-term outcomes—after the court order is lifted. The third article describes findings of sustained improvements in medication possession and hospitalization, especially for persons whose former court order was kept in place for more than six months ( page 982 ). Because the law gave AOT consumers privileged access to services, a critical concern was whether voluntary service recipients were crowded out. The fourth study reported here provided an answer: initially yes, but after three years, the increased service capacity benefited all consumers ( page 988 ). The fifth article presents findings of reduced likelihood of arrest among AOT recipients ( page 996 ). In a related article, not included in the special section, findings of regional differences in medication possession after implementation of AOT are reported ( page 1000 ). In a Taking Issue commentary on the special section articles, Annette Christy, Ph.D., points out the importance of context in policy implementation and research ( page 955 ).

Research indicates that the incidence of involuntary treatment may be a proxy measure of the overall functioning of the public mental health system. Over the past five years, California's Mental Health Services Act (MHSA) has distributed more than $3 billion in new tax revenues to community mental health systems. Tim A. Bruckner, Ph.D., and colleagues tested the hypothesis that the incidence of involuntary civil commitment would fall as a result of MHSA service enhancements. They found a decrease in the expected level of 14-day civil commitments but not 72-hour holds ( page 1006 ). In Europe, the EUNOMIA project—European Evaluation of Coercion in Psychiatry and Harmonization of Best Clinical Practice—analyzed national variations in the use of coercion in inpatient care. An analysis of data from a sample of 2,030 involuntarily hospitalized patients in ten countries by Jiří Raboch, M.D., and colleagues found considerable variation in use of coercive measures by country—from 21% of detainees in Spain to 59% in Poland. Countries also varied in the number of measures applied per patient ( page 1012 ). In a one-year follow-up of involuntary inpatients in the Netherlands, Antoon van Baars, M.D., and colleagues found that more than half (52%) reported that their commitment was beneficial and that certain demographic and clinical factors predicted perceived benefit among these former inpatients ( page 1024 ).

• The Law & Psychiatry column discusses laws that permit people with severe mental illness to give out-of-court statements instead of having to undergo the stress of appearing in court to testify ( page 958 ).

• A Canadian study of 369 nonprofit mental health and addiction services providers found that the level of charitable giving to these organizations—4% of $915.4 million in total revenues—cannot compensate for the relatively low levels of government funding ( page 1032 ).

• The Public-Academic Partnerships column describes the University of Hawai'i Rural Health Collaboration, which increases access to rural areas, primarily via telepsychiatry ( page 961 ).

• Four exemplary programs are winners of the American Psychiatric Association's 2010 Gold, Silver, and Bronze Achievement Awards ( page 1039 ).