Introduction

The delivery of mental health care is often fraught with ethical and political dilemmas. Concern for consent and personal liberty are often in contention with interests in public health and safety. Assisted Outpatient Treatment (AOT) is one approach to balancing the diverse needs of Mental Health and Substance Abuse (MHSA) patients and their communities.

Background

Historically, mentally ill individuals were often involuntarily institutionalized in order to remove them from society.[1] Over time it became clear that widespread institutionalization brought with it abuse and civil liberties violations, and beginning in the late 1960s, American mental health care began moving towards more individualized, community-based care.[2]

AOT is considered a compromise position between involuntary institutionalization and allowing mentally ill individuals to remain untreated in the community. Involuntary commitment requires mentally ill individuals to present an imminent danger to themselves or others, but an AOT mandate requires only that the involuntary treatment would prevent relapse or deterioration of a severe mental illness, which would likely result in harm to self or others.

For purposes of most AOT laws, severe mental illness is defined as a severe mental disorder that interferes substantially with the primary activities of daily living.[3] Those disorders include (but are not limited to) schizophrenia, bipolar disorders, paranoid and psychotic disorders, major depressive disorders, schizoaffective disorders, pervasive developmental disorders, obsessive-compulsive disorders, childhood depression, panic disorders, post-traumatic stress disorders, bulimia nervosa, and anorexia nervosa.[4]

AOT explicitly comes with limits on the patient’s ability to travel and make other personal life decisions while under court order. Failure to comply with the order could result in 72 hour hospitalization to establish evidence for involuntary commitment, or incarceration.[5]

AOT Demonstrations

States with AOT programs have shown promising results. Forty-four states have AOT laws in place, but only New York has implemented an AOT state-wide.[6] The U.S Department of Justice has established through studies of the various AOT programs that these laws reduce crime and violence, and decrease the risk of hospitalization, arrest, incarceration, and victimization.[7] Reports have shown that AOT patients have 76 percent reduced incidences of homelessness during treatment, 55 percent reduced risk of suicide, and a 48 percent reduction in substance abuse compared with those who fail to receive treatment.[8] Furthermore, there is evidence that AOT lasting six months or longer leads to savings in the patient’s overall cost of health care.[9]

One judge who utilizes the option to remand individuals to AOT has noted that “[AOT] has provided life-saving services to individuals suffering from mental illness […] and has reduced the need for action by law enforcement, medical emergency personnel, and the Courts, and lessens the trauma and anguish of family and friends.”[10]

Conclusion

The ethics of using the legal system to force treatment on an individual who would otherwise refuse consent is a debate that will continue among policymakers, individuals, and families impacted by mental illness. However, the empirical evidence is clear that targeted AOT laws contribute to better long-term outcomes for patients and their communities. State-level AOT laws have proven successful in limiting violence and negative health impacts while generating long-term health care savings. Federal policymakers considering nationwide AOT legislation should look to those state programs for evidence of success, and lessons learned.