Involuntary Outpatient Commitment in the US

Civil commitment laws in the United States variably give authority to mental health providers, law enforcement, and others to compel someone to receive treatment if they may be a danger to themselves or others because of mental illness. These laws have long been a topic of discussion, but there has been limited research on their impact to patients and their communities, largely because the laws have not been effectively or reliably catalogued. The Policy Surveillance Program has been actively collecting and coding state civil commitment laws and regulations to create an index.

The research breaks down civil commitment into three categories: short-term, long-term, and involuntary outpatient commitment.

Under involuntary outpatient commitment laws, individuals with mental illness who meet certain criteria, such as danger to self or others, are required to receive mandatory treatment in an outpatient setting. An individual may be placed directly into outpatient treatment with a court order or after the patient has already been placed in an inpatient treatment facility (more commonly referred to as conditional release).

The involuntary outpatient commitment dataset, which was just re-released to now include laws from January 1, 2000 to August 2015, explores specifically who can initiate the process, the duration of commitment, refusal of medication, consequences for non-compliance, and firearm possession by a patient — all of which make outpatient commitment a complex issue.

Through this dataset, we can begin to observe trends and themes across state laws.

The passage of Kendra’s Law in 1999, which established outpatient commitment in New York, has served as a catalyst for the spread of outpatient commitment laws, and many states have adopted laws that function similarly.

Gradually, legislators across the United States have progressed from a restrictive setting approach which places patients in an unfamiliar environment, (i.e., a mental health facility), to an approach where patients can receive mental health treatment while in their communities.

Today, 41116 states and the District of Columbia have laws permitting outpatient commitment. Only four states have not introduced outpatient commitment laws: Connecticut, Maryland, Massachusetts, and New Mexico.

While the criteria for outpatient commitment vary from state to state, there are two main criteria that seem to persist across jurisdictions: whether the patient has to be showing signs of mental illness and whether the patient must pose a danger to themselves and others.

Twenty states have outpatient commitment laws that follow a predictive model. A predictive model is a new variation of outpatient commitment laws that addresses whether a person who is mentally ill is likely to deteriorate to a condition where he/she could potentially pose a risk to himself/herself or someone else. This predictive model, in general, takes the less-restrictive outpatient civil commitment approach a step further.

Currently, twenty-two states are adopting preventative models, which are meant to commit potentially dangerous individuals and reduce recidivism by committing patients who are most likely to deteriorate. The research on this model is minimal at this point, therefore it is unclear how this trend can impact public safety and patient care going forward.

There are many factors, most of which involve a combination of resources and rights, that have propelled the changes in these laws over time. The structure of outpatient commitment laws continues to emerge, particularly as the United States continues to debate mental illness in the context of violence. Monitoring these laws makes it possible to track these changes and understand the cross-jurisdictional implications.

Temple University Center for Public Health Law Research

Temple University Center for Public Health Law Research

Based at the Temple University Beasley School of Law, the Center for Public Health Law Research supports the widespread adoption of scientific tools and methods for mapping and evaluating the impact of law on health. It works by developing and teaching public health law research and legal epidemiology methods (including legal mapping and policy surveillance); researching laws and policies that improve health, increase access to care, and create or remove barriers to health (e.g., laws or policies that create or remove inequity); and communicating and disseminating evidence to facilitate innovation.

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