For some people with severe mental illness, life is a cycle of hospitalization, skipped medication, decline and then rehospitalization. They may deny they have psychiatric disorders, refuse treatment and cascade into out-of-control behavior that can be threatening to themselves or others.
Now, a study has found that a controversial program that orders these patients to receive treatment when they are not hospitalized has had positive results. Patients were much less likely to end up back in psychiatric hospitals and were arrested less often. Use of outpatient treatment significantly increased, as did refills of medication. Costs to the mental health system and Medicaid of caring for these patients dropped by half or more.
The study evaluated the program run by New York State, known as Kendra's Law because it was enacted after Kendra Webdale was pushed to her death on the New York City subway tracks by a man with untreated schizophrenia in 1999. Forty-four other states have some form of Kendra's Law, but New York's is by far the most developed because the state has invested significant resources into paying for it, experts say.
From the start, Kendra's Law has had staunch defenders and detractors. But the new analysis, led by researchers at Duke University and published in The American Journal of Psychiatry, joins a series of studies that suggest the program can be helpful for patients who, while they constitute only a small number of the people with mental illness, are some of the most difficult and expensive to care for.
"Is Kendra's Law a good thing?" said Dr. Paul S. Appelbaum, director of the Division of Law, Ethics and Psychiatry at Columbia University's medical school, who has not been involved in any of the research. While "none of these studies are perfect," he said, "these programs are likely to be helpful for a group of patients who are often called revolving-door patients."
In the shadow of the massacres in Newtown, Conn.; Aurora, Colo.; and Tucson, programs like these are drawing renewed attention — even though people who commit such crimes are not always those who would qualify for measures like Kendra's Law. This year, the sweeping gun control law New York passed augmented some aspects of Kendra's Law and extended it until 2017.
The program, which costs New York $32 million for the 2,000 to 2,500 people under court order each year, provides intensive monitoring by caseworkers, who are supposed to ensure that patients attend therapy and adhere to medication. Under the law, New York also spends $125 million a year for enhanced outpatient mental health services for others.
Among other states, North Carolina's program is also well-developed, while California has hardly financed its program. Proponents of the program say they hope New York's experience will persuade other states to invest.
Some opponents say programs like this — called outpatient commitment or assisted outpatient treatment — infringe on civil liberties of people who have not been involuntarily committed to hospitals. Others worry that intensively monitoring patients in the community could increase costs or shift services away from other people with mental illness — something the authors say can happen in states that, unlike New York, fail to put money into the program.
Robert Bernstein, president of the Bazelon Center for Mental Health Law in Washington, said good mental health care should not have to lean "on the courts to intervene rather than getting involved earlier and better" to persuade patients to accept non-coerced treatment.
He said New York's success "may not be the court order," but the "whole array of services that New York attaches" to the program. "If outpatient commitment was so beneficial either clinically or financially, states would have flocked to use it," he said.
The Duke study examined costs for 634 people who received court orders between January 2004 and December 2005. It compared costs in the year before the court orders, the year after and two years after. Jeffrey Swanson, a psychiatry professor at Duke and lead author of the study, said the results suggested that "if you pour some money into assisted outpatient treatment, if you target it correctly, there are some significant savings."
A co-author, Dr. Marvin Swartz, head of Duke's social and community psychiatry division, said a study in 2010 by the team found that patients "were less likely to return to the hospital, if they went to the hospital they had shorter lengths of stay, they were more likely to be adherent to medication, and generally they functioned better in the community."
Michael and Barbara Biasotti would agree. Ms. Biasotti's daughter became ill at 23. Now 41, she has been hospitalized more than 20 times, Ms. Biasotti said.
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