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Court-ordered mental health treatment may save money

By Andrew M. Seaman

NEW YORK (Reuters Health) - State-run programs that compel people with serious mental illness to get treatment may reduce costs, according to a new analysis of New York State's system known as Kendra's Law.

Addressing the concerns of some lawmakers, researchers found that treatment costs dropped by about half among those covered under the program in New York City and even more for those in other counties throughout the state, largely as a result of fewer hospital admissions.

"What we're hoping is that people will look at these types of analyses and say, ‘yes there are costs up front but it appears that you realize cost savings over time,'" said Dr. Marvin S. Swartz, one of the study's authors from Duke University in Durham, North Carolina.

The assisted outpatient commitment (AOC) programs apply to people with serious mental disorders and a history of hospitalizations that stem from not sticking with treatments.

Patients in these programs are compelled by court order to show up for their prescribed care, though provisions for enforcement of the court's order are sometimes unclear.

The New York State law, passed in 1999 and named for a young woman pushed to her death onto subway tracks by a mentally ill person that year, authorizes AOC "to prevent a relapse which or deterioration which would likely result in serious harm to the patient or others."

While 45 U.S. states have enacted laws to create AOC programs, the laws remain controversial and often are not used because of concerns about civil rights, resources and costs.

"There is a lot of pushback from people on civil liberty grounds and grounds that it is not good policy. Also, that this is not good use of these funds," Swartz said.

"I'm hoping this kind of (report) can help focus the debate on a more practical ground rather than these rhetorical patterns that pass in space," Jeffrey Swanson, the study's lead author also from Duke University, said.

For their analysis, Swanson and his colleagues compared the costs of services for 520 people in New York City and 114 people in other New York counties during the year before and the two years after they were ordered into the program in 2004 or 2005.

Four-fifths of the patients in New York City and three-quarters of those in the other counties had a diagnosis of a schizophrenia spectrum disorder, the team writes in the American Journal of Psychiatry.

For those in the city, the average cost per patient per year fell from about $105,000 the year before they were ordered into the program to about $53,000 two years after they were ordered into the program.

The reduction was even steeper for those living in other New York counties, with an average cost per patient per year of about $104,000 before the program to $39,000 two years after.

A separate analysis found the cost reductions among those in the court-ordered program were about double what was found among people who were voluntarily seeking treatment.

"The biggest cost driver is hospitalization," Swartz said.

Overall, people in the program were less likely to return to the hospital, to use psychiatric emergency and crisis services and to be arrested. They also increased their use of case management and community treatment services and medication refills.

Dr. Jeffrey L. Geller, professor of psychiatry at the University of Massachusetts Medical School and medical director of the Worcester Recovery Center and Hospital, said the results are positive news.

"It may sway some folks who are in the middle of the issue and it's going to support the people who are already inclined to think the (AOC) is a worthwhile intervention," said Geller, who has researched this type of law but wasn't involved in the new study.

But he added that the results probably won't convince people who believe these laws are a violation of civil rights.

The researchers also caution that the study's results may not be applicable to other states that may have different AOC systems and mental health service infrastructures.

"The message should certainly be that the premise for this to work is that the services need to be available and (AOC) outpatient services are not going to compensate for a fragmented, under resourced mental health system," Swanson said.

SOURCE: http://bit.ly/14ywpw7 American Journal of Psychiatry, online July 30, 2013.

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