Requiring people with mental illness to get treatment by court order can result in significant cost savings to Medicaid by reducing repeat hospitalizations, according to a study conducted in New York City and published in the August issue of the American Journal of Psychiatry. But court-ordered outpatient treatment, called assisted outpatient treatment (AOT), is highly a controversial intervention, opposed by some patient advocates as a violation of civil rights. Behavioral Healthcare interviewed two authors of the study, as well as patient advocates.
It’s important to note that the study was conducted in New York, where Kendra’s Law, which was enacted in 1999 to authorize AOT, also provides for additional funding for outpatient treatment. The study does not show that simply relying on AOT will be effective in other states which may lack treatment benefits in the community.
The study, “The Cost of Assisted Outpatient Treatment: Can it Save States Money?” is by Jeffrey W. Swanson, Ph.D., who is with the Department of Psychiatry and Behavioral Sciences at Duke University School of Medicine, and colleagues. The researchers found that net costs went down 50 percent in the first year after AOT began in the New York City sample, and an additional 13 percent in the second year. The authors concluded that even after a substantial investment of state resources in treatment, including psychotropic medication, overall costs for people with serious mental illness (SMI) went down.
AOT is NOT violence prevention
The political, but not the scientific, rationale for passing Kendra’s Law was violence. Andrew Goldstein, a mentally ill man who was seeking treatment, pushed Kendra Webdale to her death in front of a subway train in New York City in 1999. At the time, Swanson and Marvin S. Swartz, M.D., also from Duke and a co-author on the article, were involved in a Bellevue AOT pilot study comparing patients on AOT and patients not on AOT. There were no differences in outcome in the two groups, but that may have been because both groups got intensive services. “There were methodology issues, and you’d never look at that work and say let’s expand this” on the basis of the Bellevue study alone, said Swanson. “What changed the game was Kendra Webdale being pushed in front of the train,” he says. “But people who understand what outpatient commitment is would never say this is a violence prevention strategy.”
In New York, where money was made available for treatment, there was a case to be made for AOT, says Swanson. “But outpatient commitment isn’t going to prevent mass shootings.”
“Let them eat AOT” is a phrase that Swartz uses to describe the attitudes of some proponents of outpatient commitment; in other words, like Marie Antoinette, these people say that if the mentally ill don’t have adequate treatment, they can just be forced to get whatever kind of treatment there is – mainly, medication. But for treatment to be effective, there has to be more than medication; as in New York, case management and other services are essential. “AOT is a tool to use within a well-functioning mental health system,” Swartz says.
“Those people who are interested in promoting outpatient commitment and rolling back civil commitment reforms have focused on the violence issue because that is what moves public opinion,” says Swanson. And they are playing into the beliefs of people who don’t care much about mental illness, but who are concerned about public safety.
While it is a true that the majority of people with mental illness who need treatment are not violent, the same truth is seen — and played differently — by others. In a recent National Review blog, the Treatment Advocacy Center’s D.J. Jaffe cited an Australian study finding that people with schizophrenia were about 2.5 times more likely to be convicted of a violent crime than a control group, a probability that “soared” when schizophrenia and substance abuse were co-occurring. He condemned “the non-profit mental-health industry” for its “head-in-the-sand approach,” which he said “vigorously denies a relationship between violence and untreated serious mental illness for fear of causing stigma.” This approach, he said, “has prevented widespread implementation of programs that can reduce the violence.”
Sad to say, the political reality behind the legislation that drove AOT’s “success” in New York was not an expressed need for better mental health treatment, but the spectre of an innocent Kendra being pushed off that platform — and the need to prevent such violence in the future.
Coercion all in the mind?
Ronald S. Honberg, national director for policy and legal affairs at the National Alliance on Mental Illness (NAMI), says AOT has always been controversial because it involves involuntary treatment. “We all recognize that it’s far more preferable for people to make their own decisions,” says Honberg. “At the same time we recognize that some people suffer horribly as a consequence of not getting treatment, and some people, perhaps because of the severity of their symptoms, are not in a position to make an informed decision about what’s best for them in terms of treatment.”
There is disagreement even within NAMI about AOT, says Honberg, who chose his words carefully so he would be representing the viewpoint of the organization. “The people who cycle in and out of homelessness, jails, prisons, and hospitals are the ones who cost the system the most, and who suffer the most,” he says. “Many of them, for whatever reason, will not take medication, and will not participate in treatment.”
Honberg laments the “divisive rhetoric” coming from both sides of the debate, because this precludes the community from coming up with a reasonable solution to this problem. And he commended Swanson and his colleagues as a “who’s who of leading mental health service researchers who don’t have any preconceived ideological position.”
More than medication
For someone with SMI, treatment isn’t just medication, and it isn’t just medication and therapy, said Honberg. “There needs to be an array of services, with case management, integrated mental health and substance abuse, housing, supports,” he said. “People have to navigate a maze in order to get access to the services they need.” For example, one of the benefits of AOT in New York City is that recipients are put on the top of the list for housing.
Kendra’s law is different from outpatient commitment laws in other states. As much as it’s been criticized, it was a well-conceived law, says Honberg. It authorized outpatient commitment, but it also put in resources to provide services for people under these orders. In many of the states that have laws authorizing AOT, it’s not even being used because there is no funding to pay for the treatment that is being required, he says.
Professionals who work well with patients with SMI are able to persuade them to take medication, in a process that is not perceived as coercive, says Honberg. “If AOT is seen as forcibly medicating someone, it will be seen as coercive,” he says. “But if it’s seen as trying to engage people, and to engage people over time, then it might be experienced as not coercive.”
There are people with SMI who can be engaged by a professional who “creates a relationship with them, who makes them feel that you’re listening to them,” says Honberg. “But thinking back to my own clinical days as a social worker, there were some people who, no matter what you did, nothing helped, because they didn’t believe they were sick.” This condition, called anosognosia, afflicts people in the throes of very serious delusions. “You thought that if only this person would take medication long enough to get stabilized, then they would be in a position where they could exercise personal choice.”
Too many patients have had negative treatment experiences even on a voluntary basis, and this just reinforces their resistance to further treatment and makes AOT more frightening than helpful, says Honberg. “I don’t want to attack the treatment system,” he says.
“We do not believe that AOT is the solution to the problems of the mental health system, to the sad reality that there are so many people who are falling through the cracks,” concludes NAMI’s Honberg. “On the other hand, as a last resort, we do think it can be helpful with certain individuals.”