Assisted Outpatient Treatment Research (AOT, a/k/a Involuntary Outpatient Commitment) on Important Outcomes

SUMMARY OF ASSISTED OUTPATIENT TREATMENT RESEARCH: Forty-four states permit the use of assisted outpatient treatment, also called outpatient commitment. However, having a law on the books does not mean the state uses the law. Many states do not. The six states that do not have AOT are Connecticut, Maryland, Massachusetts, New Mexico, Nevada, and Tennessee. Assisted outpatient treatment is a form of treatment limited to those individuals who have a history of dangerousness or multiple rehospitalizations associated with medication noncompliance. Assisted Outpatient Treatment (AOT) is a court-order to accept treatment as a condition of remaining in the community. The court may order an individual to accept medication, and that is usually enough to ensure compliance.

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. Violation of the court-ordered conditions can result in the individual being hospitalized for evaluation to see if inpatient treatment or a modification of the court order is needed.

Assisted outpatient treatment (AOT) 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

In a small AOT program in Florida, AOT reduced hospital days from 64 to 37 days per patient over 18 months. The savings in hospital costs averaged $14,463 per patient.

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 non-adherence 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, non-adherence 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 (AOT) reduces homelessness

A tragic consequence for many individuals with untreated mental illnesses is mentally ill 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.1

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.1
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

In the Florida study, AOT reduced days spent in jail among participants from 16.1 to 4.5 days, a 72 percent reduction.

Assisted outpatient treatment (AOT) 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.1

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 (AOT) 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 (AOT) 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).1

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.4
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.”5

Assisted outpatient treatment (AOT) 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).

Consensus statement

In 2007, then leaders of American psychiatry published a consensus statement. It said: —Involuntary outpatient treatment is an underused strategy for violent patients. . . . Broader use of mandatory treatment after [hospital] release—as the newer generation of outpatient commitment statutes enables—should be helpful for involuntary patients who are unlikely to adhere to treatment and likely as a result to present a substantial violence risk.?16

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).