Court-ordered outpatient treatment of the mentally ill -- which for Seung-Hui Cho amounted to no treatment at all -- has declined sharply under overhauls to Virginia's mental health system.

Just four people in the Roanoke and New River valleys have been ordered to receive outpatient treatment since July 1, the effective date of new laws prompted by Cho's 2007 shooting rampage at Virginia Tech.

Before the changes, about 75 outpatient treatment orders were issued each year in the seven-county area, mental health officials said.

Up-to-date statewide data are not available. But based on numbers from July through September, use of mandatory outpatient treatment "appears to have nose-dived," according to a December report by a state panel.

The decline is not necessarily what the General Assembly had in mind when it made sweeping changes to Virginia's commitment process. Rather, the goal was to patch some of the holes that Cho slipped through.

A mentally ill Tech student, Cho was ordered by a special justice to receive outpatient treatment in December 2005. He never did, and no one seemed to notice until April 16, 2007, when he killed 32 students and faculty on the Tech campus before committing suicide.

Suddenly, a mental health system that advocates said had been neglected for years was deemed a failure in need of immediate fixing.

At its next session, the General Assembly came up with a new outpatient treatment process -- one that mandated so many levels of supervision that special justices and mental health providers have been reluctant to use it, at least so far.

"In an attempt to clarify, they almost overlegislated and tightened the screw a little too much," said Mira Signer, executive director of the Virginia chapter of the National Alliance on Mental Illness.

Rooting out reasons

Of all the changes effected by last year's overhauls, the drop in mandatory outpatient treatment is one of the most striking, the state's Commission on Mental Health Law Reform said in a December report.

Other legislative changes made in the wake of the Tech shootings include lowering the criteria for civil commitment and beefing up monitoring by local mental health providers.

After finding just 18 outpatient treatment orders statewide during the law's first three months, the commission surveyed community services boards, which provide local treatment, to find out why.

The most commonly given explanation, cited by 63 percent of the respondents, was that the new law placed a greater burden on the special justices who hear commitment cases.

Other reasons included lack of time to come up with a detailed treatment plan required by the law, changes to the civil commitment criteria, insufficient resources at the local level and inadequate funding.

In the Roanoke Valley, special justices have issued outpatient treatment orders in just two cases since July 1. Before the new laws took effect, the region saw about 50 such orders a year, said Gail Burruss of Blue Ridge Behavioral Healthcare.

"My perception is the code seems kind of cumbersome," Burruss said.

House Majority Leader Morgan Griffith, R-Salem, said he found it "curious" that outpatient treatment orders have plummeted. "That was not the intent," he said.

But it's too soon to say whether lawmakers need to tinker again with the process, he said.

How the system is used

The decrease in outpatient treatment orders doesn't necessarily mean that a large number of people are slipping through the cracks the way Cho did, mental health officials said.

That's because outpatient commitment has always been rare.

"There's a small sliver of people who are even meeting the criteria," said Paul Barnett, a special justice in Christiansburg.

The most reliable pre-overhaul data come from May 2007, when there were 73 mandatory outpatient treatment orders statewide. That amounted to just less than 5 percent of the total commitment hearing outcomes for the month.

From July through September 2008, outpatient treatment orders made up just 0.35 percent of the outcomes. Of the 5,141 commitment hearings, an additional 80 percent resulted in voluntary or involuntary hospitalizations. The rest of the cases were dismissed.

Richard Bonnie, a University of Virginia law professor who heads the Commission on Mental Health Law Reform, warned against fixating on outpatient treatment.

"The numbers were always small, so to say there are even fewer is still looking at what has always been an incidental and ancillary part of the system," he said.

The intent of revamping outpatient treatment was not to increase its use, Bonnie said, but to make it more effective when it was used.

It's not clear what is happening now to people who previously got outpatient treatment, Bonnie said. But one possibility raised by the commission is that they are being sent to psychiatric hospitals.

Some critics say Virginia's overhauls didn't go far enough.

Other states, including New York, have a more effective outpatient system that includes a better framework for treatment and a looser criteria of who qualifies for help, said Rosanna Esposito, interim executive director of the Treatment Advocacy Center, a nonprofit group that promotes better treatment for the mentally ill.

"I have to say the changes fell short," Esposito said. "The commonwealth needs to do more."

Commitment standards

Another change to Virginia's mental health system was the rewriting of the legal threshold used to determine when someone can be committed to a psychiatric facility.

For years, special justices could only commit someone who presented an "imminent risk" of harm to themselves or others. A law that took effect July 1 lowered the criteria to those who present a "substantial likelihood" of danger.

So far, the impact of the new language seems minimal.

The Commission on Mental Health Law Reform estimates that the number of commitment hearings has gone up by 5 percent to 8 percent. But the increase began before the new law took effect, the commission's December report noted.

Mary Ann Bergeron, executive director of the Virginia Association of Community Services Boards, said each case has unique factors that defy general terms.

"It's hard to relate it to the thousands of other commitment orders," she said. "It's all judgment -- clinical judgment, legal judgment, but highly individualized in every case."

Trying to make the grade

Although changes to Virginia's mental health system have been less sweeping than some had predicted, by most accounts there has been some progress.

In 2006, the National Alliance on Mental Illness gave Virginia a D for how it treats the mentally ill. This year, the state earned a C. The national average was a D.

"It's great to go from a D to a C, but let's be real," said Signer, the head of NAMI's state chapter. "What did it take to get there? A horrible, horrific tragedy before anyone started to pay attention."

And not long after the state spent $41 million to implement the overhauls, funding was cut as the economy began to falter.

"It's sort of like one step forward and two steps back," Signer said.