Virginia attorney general wants more outpatient treatment for mentally ill

By Tom Jackman
Washington Post Staff Writer
Thursday, February 4, 2010

One of the best ways to treat severely mentally ill people, experts say, is with mandatory outpatient treatment rather than forcing them into hospitals or institutions. After the shootings at Virginia Tech by a mentally ill student in 2007, the Virginia General Assembly changed the law the next year to allow more outpatient treatment.

But even fewer people were ordered into outpatient treatment in the law's first year.

So on Thursday, new Attorney General Ken Cuccinelli II (R) will push for a new law that would allow doctors to order patients into outpatient treatment after they are stabilized in a hospital or institution.

The law could save Virginia considerable money and open up more bed space by getting stable patients out of hospitals, Cuccinelli said. The attorney general also is seeking an increase in the time allowed for mental-health professionals to examine and evaluate people once they are taken into custody. That also would give patients more time to stabilize.

"If we could get everything we're advancing," Cuccinelli said, "I think we would be making one of the most beneficial changes the system has seen in decades." Cuccinelli will testify before House and Senate committees considering nearly identical bills, sponsored by Del. David Albo (R-Fairfax) and Sen. George L. Barker (D-Fairfax).

Cuccinelli's experience in mental-health law dates to the 1990s, when he first volunteered to represent mentally ill people in the often grueling process of involuntary commitment hearings. When a person's family, or local authorities, believe a person needs to be forced into treatment, the person is taken into custody, examined by a mental health professional, and then taken before a local judge or special justice for an evidentiary hearing. The person is represented by a lawyer, usually appointed by the court, and witnesses testify about why the person should or should not be forced to receive mental treatment.

The judge or special justice then has several options. He can ask the person to commit himself voluntarily for a minimum of five days. This happens about a quarter of the time, Virginia statistics show.

A judge can order the patient committed to an institution involuntarily, which happened about 56 percent of the time last year in Virginia. The judge can find there is not enough evidence to commit the person and release them, which happened in about 19 percent of hearings.

Or the judge can order the person to take outpatient treatment. In the fiscal year that ended in June, this happened less than 0.3 percent of the time, or 62 such orders out of nearly 22,000 commitment hearings.

Virginia has only recently begun collecting data on commitment hearings, but reports by the state's Commission on Mental Health Law Reform said the number of outpatient orders had clearly dropped from the previous fiscal year. The commission said there were a variety of reasons: judges were hesitant to place people back on the streets when they were eligible for inpatient treatment, there hadn't been enough time to devise an outpatient plan, and there weren't enough resources for local Community Service Boards to monitor the outpatients.

"The majority of judges thought the standard for inpatient and mandatory outpatient treatment was the same," Albo said. "They don't think we want mandatory outpatient."

Under the proposed law, a judge or special justice at a commitment hearing could commit a person to inpatient treatment, but add the option for doctors to release the person, once stabilized, to outpatient treatment. The process is known as "step-down," from inpatient to outpatient.

"Currently, you're either in or you're out," Albo said. "These people aren't criminals. If there's a court order for them to take their meds, they take their meds."

In addition to working in mental-health law, Cuccinelli had personal experience with mental-health tragedy when his neighbor and friend, Fairfax police Officer Michael Garbarino, was shot and killed by a mentally ill teenager in 2006. Before taking office last month, Cuccinelli donated $100,000 of the money for his inauguration to the Daily Planet, a Richmond center for the homeless and mentally ill.

"The goal" of the proposed law, Cuccinelli said, "is to have someone making the decision who has the patient's best medical interests in mind. But they still have the compulsion of the court order," and the law would require outpatient services to be available before they can be ordered.

And in times of tight budgets, the attorney general said, "if you reduce inpatient stays by four days, then you can't do anything but save money."

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