The clinical effectiveness of AOT has been clearly established. Multiple studies have shown that it dramatically decreases the number of psychiatric admissions, hospital days, arrests, incarcerations, days of homelessness, and alcohol and drug abuse. People on AOT are more adherent to medication and, probably associated with this, are victimized less often.2 Four studies have also reported a decrease in violent behavior associated with the use of AOT (Table 2).3-6
Those who deny the effectiveness of AOT have offered 2 arguments. First, they claim that AOT’s effectiveness is based mostly on before-and-after studies of patients placed on AOT, rather than by studies that randomly assign patients to AOT or a control. But it can be argued that random assignment would be both unethical and legally impossible, as individuals eligible for AOT have already met criteria evidencing either dangerousness or need for treatment and a history of being unable to participate in such care voluntarily. Second, they claim that studies in other countries have not shown community treatment orders to be effective. However, community treatment orders are dissimilar to AOT because they fail to utilize a court order and thus cannot benefit from a judge’s authority—often deemed the “black robe effect.” The design of community treatment order studies themselves has also been subject to criticism.
These academic arguments diminish as data on AOT’s effectiveness accumulate. For example, in San Francisco where AOT was implemented in 2015 after 4 years of debate, the first-year report noted that almost everyone who met AOT criteria accepted voluntary treatment, leading to fewer emergency department visits and “a small but helpful step toward addressing” the problem of homelessness.
As impressive as the clinical effectiveness of AOT—and likely more salient to policymakers—is its demonstrated cost-effectiveness. In North Carolina, according to the researchers, “outpatient commitment [AOT] of six months or more, combined with provision of outpatient services, appeared to result in cost savings of 40%.”7 In New York, in the first year after AOT was implemented, costs declined 43% in New York City and 49% in 5 counties, and even more in the second year.8
In a study in Summit County, Ohio, “annualized aggregate costs per participant in AOT were found by researchers to have declined 50% in the period before and after participation.”9 In a small study in Nevada County, California, the cost reduction for each AOT participant the first year was 80%—$1.81 saved for every $1.00 invested in the program.10
Much of these cost savings come from improved medication adherence and decreased hospitalizations. In a separate study, researchers estimated that improved medication adherence for individuals with schizophrenia could save Medicaid $1580 per patient, or $3.3 billion per year.11
Given the clearly established benefits of AOT, why has it taken so long for the program to gain mainstream acceptance? In some states, AOT statutes are poorly written or contain illogical criteria. In Pennsylvania, for example, eligibility criteria for AOT mirror the inpatient standard, requiring a judge to determine a person to be both a “clear and present danger” and eligible for community treatment.
In other communities, a lack of understanding may hinder its use. Judges are often surprised that AOT statutes do not allow for incarceration or direct placement into inpatient care as a noncompliance sanction. In many communities, the delay in adoption reflects the realities of a struggling mental health system, in which providers are reluctant or unable to address the upfront costs of program implementation, despite evidence that AOT saves money over time.
Dr. Torrey is a research psychiatrist who specializes in schizophrenia and bipolar disorder. He is Founder of the Treatment Advocacy Center and Associate Director of the Stanley Medical Research Institute, and he is Professor of Psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, MD. Mr. Snook is Executive Director of the Treatment Advocacy Center.
The authors report no conflicts of interest concerning the subject matter of this article.
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