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Treatment Advocacy Center Briefing Paper
Last updated March 2005
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Assisted outpatient treatment
SUMMARY: Forty-two states permit the
use of assisted outpatient treatment, also called outpatient commitment. Assisted
outpatient treatment is court-ordered treatment (including medication) for individuals who
have a history of medication noncompliance, as a condition of remaining in the community.
Studies and data from states using assisted outpatient treatment (AOT) prove that AOT is
effective in reducing the incidents and duration of hospitalization, homelessness, arrests
and incarcerations, victimization, and violent episodes. AOT also increases treatment
compliance and promotes long-term voluntary compliance.
* * *
Assisted outpatient treatment is court-ordered
treatment (including medication) for individuals who have a history of medication
noncompliance, as a condition of remaining in the community. Typically, violation of the
court-ordered conditions can result in the individual being hospitalized for further
treatment.
Forty-two states permit the use of assisted
outpatient treatment (AOT), also called outpatient commitment. The eight states that do
not have assisted outpatient treatment are Connecticut, Maine, Maryland, Massachusetts,
New Jersey, New Mexico, Nevada and Tennessee. Florida adopted an AOT law on June 30, 2004.
Assisted outpatient treatment reduces
hospitalization
Several studies have clearly established the
effectiveness of assisted outpatient treatment in decreasing hospital admissions.
Data from the New York Office of Mental Health on the first
five years of implementation of Kendra's Law indicate that of those participating, 77
percent fewer experienced hospitalization (97 percent versus 22 percent).1
A randomized controlled study in North Carolina
(hereinafter “the North Carolina study”), demonstrated that intensive routine
outpatient services alone, without a court order, did not reduce hospital admission. When
the same level of services (at least three outpatient visits per month with a median of
7.5 visits per month) were combined with long-term AOT (six months or more), hospital
admissions were reduced 57 percent and length of hospital stay by 20 days compared with
individuals without court-ordered treatment. The results were even more dramatic for
individuals with schizophrenia and other psychotic disorders for whom long-term AOT
reduced hospital admissions by 72 percent and length of hospital stay by 28 days compared
to individuals without court-ordered treatment. The participants in the North Carolina
study were from both urban and rural communities and “generally did not view
themselves as mentally ill or in need of treatment.”2
In Washington, D.C., admissions decreased from 1.81 per
year to 0.95 per year before and after assisted outpatient treatment.3
In Ohio, the decrease was from 1.5 to 0.44 and in Iowa, from
1.3 to 0.3.5
In an earlier North Carolina study, admissions for patients
on assisted outpatient treatment decreased from 3.7 to 0.7 per 1,000 days.6
Only two studies have failed to definitively find assisted
outpatient treatment effective in reducing admissions. One was a Tennessee study in which
it was evident that “outpatient clinics are not vigorously enforcing the law”
and thus nonadherence had no consequences.7
The second was a study of the Bellevue Pilot Program in New
York City in which the authors acknowledged that a “limit on [the study’s]
ability to draw wide-ranging conclusions is the modest size of [the] study group.”
Additionally, during the period of the study, there was no procedure in place to transport
individuals to the hospital for evaluation if they did not comply with treatment orders.
As in the Tennessee study, nonadherence to a treatment order had no consequences. Although
not statistically significant because of the small study group, the New York study
suggests that the court orders did in fact help reduce the need for hospitalization.
Patients in the court-ordered group spent a median of 43 days in the hospital during the
study, while patients in the control group spent a median of 101 days in the hospital. The
difference just misses statistical significance at the level of p = 0.05.8
Assisted outpatient treatment reduces
homelessness
A tragic consequence for many individuals with untreated
mental illnesses is homelessness. At any given time, there are more people with
untreated severe psychiatric illnesses living on America’s streets than are receiving
care in hospitals. In New York, when compared to three years prior to participation
in the program, 74 percent fewer AOT recipients experienced homelessness.
Assisted
outpatient treatment reduces arrests
Arrests for New York’s Kendra’s Law participants
were reduced by 83 percent, plummeting from 30 percent prior to the onset of a court order
to only 5 percent after participating in the program. When compared with a similar
population of mental health service recipients, participants in the program were 50
percent more likely to have had contact with the criminal justice system prior to their
court order.
The North Carolina study found that for individuals who had
a history of multiple hospital admissions combined with arrests and/or violence in the
prior year, long-term assisted outpatient treatment reduced the risk of arrest by 74
percent. The arrest rate for individuals in long-term AOT was 12 percent, compared with 47
percent for those who had services without a court order.9
Assisted outpatient treatment reduces
violence
Kendra’s Law resulted in dramatic reductions in the
incidence of harmful behaviors for AOT recipients at six months in AOT as compared to a
similar period of time prior to the court order. Among individuals participating in
AOT: 55 percent fewer recipients engaged in suicide attempts or physical harm to self; 47
percent fewer physically harmed others; 46 percent fewer damaged or destroyed property;
and 43 percent fewer threatened physical harm to others. Overall, the average
decrease in harmful behaviors was 44 percent.
The North Carolina study found that long-term AOT combined
with intensive routine outpatient services was significantly more effective in reducing
violence and improving outcomes for severely mentally ill individuals than the same level
of outpatient care without a court order. Results from that study showed a 36 percent
reduction in violence among severely mentally ill individuals in long-term assisted
outpatient treatment (180 days or more) compared to individuals receiving less than
long-term assisted outpatient treatment (0 to 179 days). Among a group of individuals
characterized as seriously violent (i.e., committed violent acts within the four-month
period prior to the study), 63.3 percent of those not in long-term AOT repeated violent
acts while only 37.5 percent of those in long-term AOT did so. Long-term AOT combined with
routine outpatient services reduced the predicted probability of violence by 50 percent.10
Assisted outpatient treatment reduces
victimization
The North Carolina study demonstrated that individuals with
severe psychiatric illnesses who were not on assisted outpatient treatment "were
almost twice as likely to be victimized as were outpatient commitment subjects."
Twenty-four percent of those on assisted outpatient treatment were victimized, compared
with 42 percent of those not on assisted outpatient treatment. The authors noted
"risk of victimization decreased with increased duration of outpatient commitment,”
and suggest that "outpatient commitment reduces criminal victimization through
improving treatment adherence, decreasing substance abuse, and diminishing violent
incidents" that may evoke retaliation.11
Assisted outpatient treatment
improves treatment compliance
Assisted outpatient treatment has also been shown to be
extremely effective in increasing treatment compliance. In New York, the number of
individuals exhibiting good service engagement increased by 51 percent (from 41 percent to
62 percent), and the number of individuals exhibiting good adherence to medication
increased by 103 percent (from only 34 percent to 69 percent).
In North Carolina, only 30 percent of patients on AOT
orders refused medication during a six-month period compared to 66 percent of patients not
on AOT orders.12 In Ohio, AOT increased compliance with
outpatient psychiatric appointments from 5.7 to 13.0 per year; it also increased
attendance at day treatment sessions from 23 to 60 per year.
AOT also promotes long-term voluntary treatment compliance.
In Arizona, "71 percent [of AOT patients] ... voluntarily maintained treatment
contacts six months after their orders expired" compared with "almost no
patients" who were not court-ordered to outpatient treatment.13
In Iowa "it appears as though outpatient commitment promotes treatment compliance in
about 80 percent of patients while they are on outpatient commitment. After commitment is
terminated, about three-quarters of that group remained in treatment on a voluntary
basis."
Assisted
outpatient treatment improves substance abuse treatment
Individuals who received a court order under New
York’s Kendra’s Law were 58 percent more likely to have a co-occurring substance
abuse problem compared with a similar population of mental health service recipients. The
incidence of substance abuse at six months in AOT as compared to a similar period of time
prior to the court order decreased substantially: 49 percent fewer abused alcohol (from 45
percent to 23 percent) and 48 percent fewer abused drugs (from 44 percent to 23 percent).
ENDNOTES
1 N.Y.
State Office of Mental Health (March 2005). Kendra’s
law: Final report on the status of assisted outpatient treatment. New York: Office of
Mental Health.
2 Swartz,
M.S., J.W. Swanson, R.H. Wagner, et al. Can involuntary outpatient commitment reduce
hospital recidivism? American Journal of Psychiatry, 156:1968-75 (1999).
3 Zanni,
G. and L. DeVeau. Inpatient stays before and after outpatient commitment. Hospital and
Community Psychiatry 37:941–42 (1986).
4 Munetz,
M.R., T. Grande, J. Kleist, and G.A. Peterson. The effectiveness of outpatient civil
commitment. Psychiatric Services 47:1251–53 (1996).
5
Rohland, B.M. The role of outpatient commitment in the management of persons with
schizophrenia. Iowa Consortium for Mental Health, Services, Training, and Research
(May 1998).
6
Fernandez, G.A. and S. Nygard. Impact of involuntary outpatient commitment on the
revolving-door syndrome in North Carolina. Hospital and Community Psychiatry 41:1001–4
(1990).
7 Bursten
B. Posthospital mandatory outpatient treatment. American Journal of Psychiatry 143:1255–58
(1986).
8 Policy
Research Associates, Inc. Research study of the New York City involuntary outpatient
commitment pilot program. (December 1998).
9
Swanson, J.W, R. Borum, M.S. Swartz, et al. Can involuntary outpatient commitment reduce
arrests among persons with severe mental illness? Criminal Justice and Behavior 28:
156 (2001).
10
Swanson, J.W., M.S. Swartz, R. Borum, et al. Involuntary outpatient commitment and
reduction of violent behaviour in persons with severe mental illness. British Journal
of Psychiatry, 176: 224–31 (2000).
11 Hiday
V.A., M.S. Swartz, J.W. Swanson, R. Borum, and H.R. Wagner. Impact of outpatient
commitment on victimization of people with severe mental illness. Am J Psychiatry 159:1403-1411,
2002.
12
Hiday, V.A. and T.L. Scheid-Cook. The North Carolina experience with outpatient
commitment: A critical appraisal. International Journal of Law and Psychiatry 10:215–32
(1987).
13 Van
Putten, R.A., J.M. Santiago, and M.R. Berren. Involuntary outpatient commitment in
Arizona: A retrospective study. Hospital and Community Psychiatry 39:953–8
(1988).
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