International Association of Chiefs Urges Mental Health Departments to use Assisted Outpatient Treatment (AOT) to keep patients and police safer.
Resolution adopted by IACP
October 28, 2014
WHEREAS, law enforcement officers are often the first responders to individuals in mental health crisis; and
WHEREAS, law enforcement officers continue to experience an increase in interactions with people with severe mental illness[i]; and
WHEREAS, such interactions consume a disproportionate amount of limited law enforcement resources[ii]; and
WHEREAS, approximately forty percent of individuals with severe mental illness are not receiving treatment, primarily because the illness affects their ability to voluntarily participate in needed care[iii]; and
WHEREAS, noncompliance with treatment, specifically non-adherence to medication, is strongly associated with hospitalization,[iv] suicide,[v] victimization,[vi] violence[vii] and relapse;[viii] and
WHEREAS, noncompliance with treatment is also strongly associated with arrest and incarceration,[ix] resulting in a disproportionate representation of individuals with severe mental illness in the criminal justice system; and
WHEREAS, a 2014 report found that 10 times more mentally ill persons are in prisons and jails than are receiving treatment in state psychiatric hospitals[x]; and
WHEREAS, Assisted Outpatient Treatment (AOT) provides court-ordered treatment in the community for high-risk individuals with severe mental illness and a history of treatment noncompliance, as a less restrictive alternative to inpatient hospitalization; and
WHEREAS, more than two decades of research and practice document AOT as an effective tool to improve outcomes for this focus population, including reduced hospitalizations[xi], arrests[xii], incarcerations, crime[xiii], victimization[xiv] and violence[xv] while increasing treatment adherence[xvi] and substance abuse treatment outcomes; and
WHEREAS, numerous state and local law enforcement associations support and have championed the passage and implementation of AOT programs; and
WHEREAS, the Department of Justice deemed AOT to be an effective evidence-based program for reducing crime and violence[xvii]; and
WHEREAS, studies amply demonstrate AOT’s effectiveness in reducing arrests and incarcerations, e.g., a recent study of New York State’s signature AOT program (“Kendra’s Law”) concluded that the “odds of arrest in any given month for participants who were currently receiving AOT were nearly two-thirds lower” than those not receiving AOT[xviii]; and
WHEREAS, AOT also produces significant taxpayer/system cost savings, ultimately increasing overall service capacity and leading to greater access for both voluntary and involuntary recipients. A cost-impact study in New York City found net cost savings of 50% in the first year and an additional 13% in the second year; a study in North Carolina reported similar cost savings of 40%[xix]; now, therefore be it
RESOLVED, that the International Association of Chiefs of Police (IACP) recommends the authorization, implementation, appropriate funding, and consistent use of Assisted Outpatient Treatment (AOT) laws to ensure treatment in the least restrictive setting possible for individuals whose illness prevents them from otherwise accessing such care voluntarily.
[i] Biasotti, Michael C. Management of the severely mentally ill and its effects on homeland security. Naval Postgraduate School Monterey Ca. Dept. of National Security Affairs, 2011.
[ii] Biasotti, Michael C. Management of the severely mentally ill and its effects on homeland security. Naval Postgraduate School Monterey Ca. Dept. of National Security Affairs, 2011.
[iii] Substance Abuse and Mental Health Services Administration. (2013). Results from the 2012 National Survey on Drug Use and Health: Mental Health Findings. NSDUH Series H-47, HHS Publication No. (SMA) 13-4805.
[iv] Valenstein, M., Copeland, L., Blow, F., et al. (2002). Pharmacy data identify poorly adherent patients with schizophrenia at increased risk for admission. Med Care 40:630–639.
Weiden, P., Kozma, C., Grogg, A., et al. (2004). Partial compliance and risk of rehospitalization among California Medicaid patients with schizophrenia. Psychiatric Services 55:886–891.
Gilmer, T., Dolder, C., Lacro, J., et al. (2004). Adherence to treatment with antipsychotic medication and health care costs among Medicaid beneficiaries with schizophrenia. American Journal of Psychiatry 161:692–699.
Ascher-Svanum, H., Faries, D., Zhu, B., et al. (2006). Medication adherence and long-term functional outcomes in the treatment of schizophrenia in usual care. Journal of Clinical Psychiatry 67:453–460.
Velligan, D., Weiden, P., Sajatovic, M., Scott, J., Carpenter, D., Ross, R., Docherty, J., (2009). The expert consensus guideline series: adherence problems in patients with serious and persistent mental illness. Journal of Clinical Psychiatry. 70 Suppl 4:1-46; quiz 47-8.
[v] Muller-Oerlinghausen, B., Muser-Causemann, B. & Volk, J. (1992). Suicides and parasuicides in a high-risk patient group on and off lithium long-term medication. Journal of Affective Disorders, 25(4),261-269.
Leucht S., Heres S. (2006). Epidemiology, clinical consequences, and psychosocial treatment of nonadherence in schizophrenia. Journal of Clinical Psychiatry, 67(Suppl. 5), 3–8.
Nordentoft, M. (2007). Prevention of suicide and attempted suicide in Denmark. Epidemiological studies of suicide and intervention studies in selected risk groups. Danish Medical Bulletin, 54(4),306-69.
Chapman, S.C., Horne, R. (2013). Medication nonadherence and psychiatry. Current Opinion in Psychiatry, 26(5),446-552.
[vi] Hiday, V., et al. (1999). Criminal Victimization of Persons with Severe Mental Illness. Psychiatric Services, 50, 62-68.*
*Individuals with severe psychiatric disorders who were not taking medication were found to be 2.7 times more likely to be the victim of a violent crime (assault, rape, or mugging) than the general population.
[vii] Swartz, M., Swanson, J., Hiday, V., Borum, R., Wagner, H., Burns, B. (1998). Violence and severe mental illness: The effects of substance abuse and nonadherence to medication. American Journal of Psychiatry, 155, 226-31.
Substance abuse, medication non-compliance and low insight into illness operate together to increase violence risk. Van Dorn, R., Volavka, J., Johnson, N. (2011). Mental disorder and violence: is there a relationship beyond substance use? Social Psychiatry and Psychiatric Epidemiology.
Witt, K., Van Dorn, R., Fazel, S. (2013). Risk factors for violence in psychosis: Systematic review and metaregression analysis of 110 studies. PLOS ONE, 8, e55942.
Belli, H., Ozcetin, A., Erteum, U., et al. (2010). Perpetrators of homicide with schizophrenia: sociodemographic characteristics and clinical factors in the eastern region of Turkey. Comprehensive Psychiatry, 51,135-41.
Alia-Klein, N., O’Rourke, T., Goldstein, R., et al. (2007). Insight into illness and adherence to psychotropic medications are separately associated with violence severity in a forensic sample. Aggressive Behavior, 33, 86–96.
Elbogen, E., Van Dorn, A., Swanson JW, et al. (2006). Treatment engagement and violence risk in mental disorders. British Journal of Psychiatry, 189,354–360.
Swanson, J., Swartz, M., Essock, S., et al. (2002). The social-environmental context of violent behavior in persons treated for severe mental illness. American Journal of Public Health, 92, 1523–1531.
Bartels, J., Drake, R., Wallach, M., et al. (1991). Characteristic hostility in schizophrenic outpatients. Schizophrenia Bulletin, 17, 163–171.
[viii] Robinson, D. (2010). First-episode schizophrenia. CNS Spectrum, 15 (Supplement 6), 4-7.
Ayuso-Gutierrez, J., Del Rio, V. (1997). Factors influencing relapse in the long-term course of schizophrenia. Schizophrenic Research, 28, 199-206.
Morken, G., Widen, J., Grawe, R. (2008). Non-adherence to antipsychotic medication, relapse and rehospitalisation in recent-onset schizophrenia. BMC Psychiatry, 8,32-8.
Suppes, T., Baldessarini, R., Faedda, G., Tohen, M. (1991). Risk of recurrence following discontinuation of lithium treatment in bipolar disorder. Archives of General Psychology, 48(12),1082-1088.
Franks, M., Macritchie, K., Mahmood, T., Young, A. (2008) Bouncing back: is the bipolar rebound phenomenon peculiar to lithium? A retrospective naturalistic study. Journal of Psychopharmacology, 22(4), 452-456.
[ix] Munetz, M.R., Grande, T.P., & Chambers, M.R. (2001). The incarceration of individuals with severe mental disorders. Community Mental Health, 34:361-71.* * Nearly 90 percent of a sample of individuals with severe mental illness in a local jail were partially or completely non-complaint with medication in the year before they were incarcerated.
Lattimore, P. K., Broner, N., Sherman, R., Frisman, L., & Shafer, M. S. (2003). A comparison of prebooking and postbooking diversion programs for mentally ill substance-using individuals with justice involvement. Journal of Contemporary Criminal Justice, 19(1), 30-64.* *Individuals with co-occurring mental illness and substance abuse who are noncompliant with medication have a threefold increase in risk for arrest and are significantly more likely to be at risk for violent behavior.
Ascher-Svanum, H., Nyhuis, A.W., Faries, D.E., Ball D.E., & Kinon B.J. (2010). Involvement in the US criminal justice system and cost implications for persons treated for schizophrenia. BMC Psychiatry, 10:11.
Shelton, D., Ehret, M. J., Wakai, S., Kapetanovic, T., & Moran, M. (2010). Psychotropic medication adherence in correctional facilities: A review of the literature. Journal of Psychiatric and Mental Health Nursing, 17(7), 603-613.
[x] Torrey, EF, Zdanowicz, MT, Kennard, AD, et al. The treatment of persons with mental illness in prisons and jails: a state survey. Treatment Advocacy Center and National Sheriff’s Association, April 8, 2014.
[xi] Swartz, M., Swanson, J., Wagner, H., Burns, B., Hiday, V., & Borum, R. (1999). Can involuntary outpatient commitment reduce hospital recidivism: Findings from a randomized trial with severely mentally ill individuals. American Journal of Psychiatry 156: 1968-1975.
Swartz, M., Swanson, J., Steadman, H., Robbins, P., & Monahan J. (2009). New York state assisted outpatient treatment program evaluation. Duke University School of Medicine.
[xii]Gilbert, A., Moser, L., Van Dorn, R., Swanson, J., Wilder, C., Robbins, P., Keator, K., Steadman, H., & Swartz, M. (2010). Reductions in arrest under assisted outpatient treatment in New York. Psychiatric Services 61: 996-999.
[xiii] New York State Office of Mental Health. 2005. Kendra’s Law: Final Report on the Status of Assisted Outpatient Treatment.
[xiv] Hiday, V., Swartz, M., Swanson, J., Borum, R., & Wagner, R. (2002). Impact of outpatient commitment on victimization of people with severe mental illness. American Journal of Psychiatry, 159: 1403-1411
[xv] Phelan, J., Sinkewicz, M., Castille, D., Huz, St., & Link, B. (2010). Effectiveness and outcome of assisted outpatient treatment in New York state. Psychiatric Services 61: 137-143.
[xvi] New York State Office of Mental Health. 2005. Kendra’s Law: Final Report on the Status of Assisted Outpatient Treatment.
[xvii] National Institute of Justice, Program Profile Assisted Outpatient Treatment (AOT). Retrieved August 27, 2014, from http://www.crimesolutions.gov/ProgramDetails.aspx?ID=228
[xviii] Gilbert, A., Moser, L., Van Dorn, R., Swanson, J., Wilder, C., Robbins, P., Keator, K., Steadman, H., & Swartz, M. (2010). Reductions in arrest under assisted outpatient treatment in New York. Psychiatric Services 61: 996-999.
[xix] Swanson, J., Van Dorn, R., Swartz, M., Robbins, P., Steadman, H., McGuire, T., & Monahan, J. (2013). The cost of assisted outpatient treatment: Can it save states money? American Journal of Psychiatry 170:1423-1432.