States without outpatient commitment:
Source: Treatment Advocacy Center
Tennessee is among six states that do not allow outpatient commitment for the mentally ill.
This means that parents with seriously sick adult children who won't take their medication have had little option but to watch their sons or daughters deteriorate.
But in 2012, after a decade of legislative lobbying, a pilot program was created in Knoxville to test assisted outpatient treatment.
The program isn't off the ground yet, but advocates hope to get it going this year. The goal is to make it a model that can be mimicked across the state, including in Chattanooga, where there is growing concern about the region's capacity to care for its mentally ill.
For some, the program has come too late.
Steve Daugherty's 25-year-old daughter was killed in March 2008 by an untreated schizophrenic man who beat her to death with a brick in downtown Knoxville.
Now Daugherty is one of the most vocal Chattanooga advocates for mandatory outpatient treatment.
At trial, he said, the man's parents testified how they had tried to get their son to stay on his medicine, how they had tried to get him help, but always faced resistance. No system was in place to support them.
"Without mandatory outpatient treatment we are going to have more people hurt, more people murdered," Daugherty said. "If we had had mandatory outpatient treatment, my daughter would be alive today. I am afraid that there are parents all over the state who could make that statement."
Outpatient commitment is a civil process. Typically, parents or providers petition the court for a treatment plan that would force a person to take his or her medications and follow a treatment plan.
The parent gets a lawyer and so does the mentally ill person. Then the judge decides whether the mentally ill person meets the criteria for mandatory outpatient care. If so, a case worker is assigned to monitor the person as needed.
Do no harm
Involuntary commitment to a state hospital usually requires that a person have potential to harm himself or others to be accepted into care. The bar is much lower for outpatient commitment: persistent trouble with medication and growing instability.
In Georgia, for example, mandatory outpatient treatment is pursued when a person is at risk of inpatient commitment and is "unable to voluntarily seek or comply with outpatient treatment."
"Assisted outpatient treatment doesn't wait for a person to commit a crime," said Brian Stettin, policy director for the Treatment Advocacy Center, a national nonprofit organization that helped pass the law for a pilot program in Tennessee.
Because of state funding cuts for mental health services, most states are suffering from a glut of mentally ill inmates in jails and prisons and shrinking hospital systems. The Hamilton County Jail spends more than $6,000 a month on mentally ill inmates, who comprise 45 percent of its population, Sheriff Jim Hammond said.
At Moccasin Bend, the region's state mental hospital, the cost is $562 per bed per day, said Michael Rabkin, a spokesman with the Tennessee Department of Mental Health and Substance Abuse Services.
Mental health court
A mental health court is being discussed as one solution, but it would address only the mentally ill charged with a crime. Some say intervention at that point is too late.
While the cost of outpatient commitment varies, it is much lower than the cost of incarceration and hospitalization, Stettin said.
In New York, where outpatient commitment is used in every jurisdiction, the results have garnered attention: 77 percent fewer people hospitalized, 74 percent fewer homeless and 83 percent fewer arrested, according to Treatment Advocacy Center data.
In Florida, hospital stays were reduced from 64 days to 37 days per patient over an 18-month period for those participating in outpatient commitment. Hospital savings were averaged as $4,463 per person. Participants' jail time fell 72 percent to an average of 4.5 days, according to a study published in Psychiatric Services, the journal of the American Psychiatric Association.
"It has been proved in other states to be a valuable tool," said Tennessee state Sen. Becky Duncan Massey, R-Knoxville, who sponsored the pilot bill last year.
"You don't need to be sending everyone with mental illness to jail," Massey said. "If we can get someone the treatment rather than going to jail, in the long run it's a lot less expensive."
Advocates say the reason involuntary commitment works is that it forces people who have no idea they are sick to face treatment.
Anosognosia, a lack of insight, affects 50 percent of the seriously mentally ill, said Karen Easter, who pushed for years for the pilot program in Knoxville.
Easter's son is bipolar and stopped taking his medicine when he was 18 years old. When his condition worsened, he began getting arrested, and Easter had no way to intervene.
"There are [opponents to outpatient commitment] who say that it is taking away a person's civil liberties," she said. "If you don't have the capacity to make rational decisions, that's a violation of their civil liberties."