After lounging on the doorstep of respectability for the past decade, assisted outpatient treatment (AOT) has finally entered the mainstream.
In September, the Substance Abuse and Mental Health Services Administration (SAMHSA) announced more than $13 million in federal funding for AOT demonstration grants (Table 1). Three months later, as part of the 21st Century Cures Act, Congress extended the AOT grant program until 2022, increased the funding, and made AOT programs eligible for Department of Justice funding. This was part of a larger recognition by Congress that the US mental health system was in dire need of reform, led by Congressman Tim Murphy (R-PA) and Senator John Cornyn (R-TX). Thus, AOT has now been officially endorsed by SAMHSA and Congress, joining such groups as the National Sheriffs’ Association, the International Association of Chiefs of Police, the National Alliance on Mental Illness, and the American Psychiatric Association.
AOT is court-supervised treatment of severe mental illness within the community. It is a 2-way commitment that requires mental health systems to serve participants at the same time it commits participants to adhere to their treatment plans. It is similar in intent to conditional release, mental health courts, and conservatorship—all of which seek to improve the person’s adherence to a treatment plan and quality of life.
The specific procedures vary by state, but generally, to be a candidate for AOT, a person must meet clinical and legal criteria, such as a history of repeated hospitalizations or arrest resulting from nonadherence to treatment. For example, in New York the person must, among other factors, have a history of treatment nonadherence that has led to 2 or more psychiatric hospitalizations or incarcerations within the past 3 years or 1 or more acts of serious violence in the past 4 years; be unlikely to voluntarily participate in outpatient treatment; and be in need of treatment to prevent a relapse that would likely result in serious harm to self or others. Court petitions for AOT are usually filed by the county mental health department, which also arranges for development of a treatment plan and delivery of services (Figure).
Joy Torres illustrates the life-changing capabilities of AOT. Plagued by delusions and auditory hallucinations for years, she refused care, was hospitalized multiple times, jailed once, and lost her job and children. She recalls being “handcuffed and shackled on the cold, wet cement of a tiny (jail) cell with only a tin can for a bathroom,” “running around naked,” “sleeping in dumpsters to avoid being raped,” and “being treated like an animal because no one is willing to help you when you are too ill to help yourself.” Finally, she was court-ordered to adhere to a treatment plan under Laura’s Law—California’s AOT program. She says this gave her the right to “sleep on a bed, go to school, make friends, love my family, and to get and stay well.” She added, “Should I ever become sick again, please give me Laura’s Law.”1
AOT was reportedly first used in 1972 at St. Elizabeth’s Hospital in Washington, DC, by an agreement between Dr. Roger Peele, a psychiatrist, and Harry Fulton, the chief public defender. A patient was ready for discharge but still needed medication supervision, so they decided to commit her to outpatient treatment in place of additional inpatient treatment. This was consistent with a previous court ruling that mandated patient placement in the “least restrictive alternative.” By 1984, AOT had been used at the hospital on 293 patients with very favorable results and had spread to a few other states. However, it was not widely known until 1999 when New York passed an AOT law called Kendra’s Law, named after Kendra Webdale, a young woman pushed under a subway train by a man with grossly undertreated schizophrenia.
AOT has spread in recent years but is still underutilized. New York, and more recently New Jersey, are using it most extensively. Ohio has excellent programs in Butler and Summit Counties and is extending it to other counties. In California, Laura’s Law was pioneered in Nevada County and has now been implemented in counties covering two-thirds of the state’s 38 million population. Seminole County in Florida and Oakland County in Michigan also have excellent programs. All states have laws permitting AOT except for Massachusetts, Connecticut, Maryland, and Tennessee, but in at least 15 states it is virtually never used.
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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