Assisted Outpatient Treatment Expands Options for People with Severe Mental Illness

People with severe mental illness (SMI)—severe bipolar disorder, schizophrenia spectrum disorders, and major depression with psychotic features – can be caught in a cycle of repeat hospitalizations, homelessness, and incarcerations. While state psychiatric hospitals provide a critical service for people with SMI, the number of state hospital beds has been declining and has reached an historic low.

In many states, these psychiatric hospital beds are used primarily for acute care and for people accused of crimes and found to be incompetent to stand trial or found not guilty by reason of insanity (known as “forensic patients”). This leaves others with SMI—who need long-term, hospital-level care, and who have no criminal behavior—with few options for treatment.

Treatment Advocacy Center (TAC) is a national non-profit organization working to change that paradigm. TAC was established in 1998 to eliminate barriers to timely and effective treatment of SMI through advocacy, public education, and support for individuals and families affected by SMI.

According to TAC, barriers to care for people with SMI come in a variety of forms. For example, many states have passed laws making it difficult to access treatment at a time when it is most likely to be of maximum benefit. Or they make it so difficult to meet criteria that people with SMI are routinely driven into the criminal legal system. Funding decisions that lead to the loss of already-scarce treatment beds compound the issue, as does lack of research investment to find better medications and treatments.

Another barrier to care is anosognosia, a neurological condition in which a person with SMI is unaware of their neurological deficit or psychiatric condition. Because those with anosognosia don’t believe they have a mental illness, they are less likely to adhere to prescribed medications and treatment protocols.

To help overcome obstacles to mental health care for people with SMI, most states and many jurisdictions have adopted a model of care called assisted outpatient treatment (AOT), also referred to as outpatient civil commitment. TAC provides training and assistance to community collaborators interested in implementing AOT and works to build interest and momentum for implementation.

“AOT prioritizes the most vulnerable patients for mental health services,” said Amy Lukes, LICSW, Director of AOT Implementation, TAC. “It reduces expensive and often unavailable inpatient care with outpatient care and helps to reduce costly emergency department visits and hospitalizations.”

What is AOT?

AOT is the practice of providing community-based mental health treatment under civil court orders. It is designed to motivate those with an SMI and who struggle with voluntary treatment adherence to engage fully with their treatment plan. It also focuses treatment providers on the need to work diligently to keep the person engaged in effective treatment.

AOT programs are organized, systematic efforts within communities to ensure that AOT will be made available to those who need it to live safely in the community. Essential elements of AOT programs include:

• Identifying individuals who appear to be persistently non-adherent with needed treatment for their mental illness and who meet criteria for AOT under state law.

• Ensuring that whenever such individuals are identified, the mental health system itself takes the initiative to gather the required evidence and petition the court for AOT, rather than relying on community members to do so.

• Safeguarding the due process rights of participants at all stages of AOT proceedings.

• Maintaining clear lines of communication between the court and the treatment team, so the court receives the clinical information it needs to exercise its authority appropriately and the treatment team can leverage the court’s powers as needed.

• Providing evidence-based treatment services focused on engagement and helping the participant maintain stability and safety in the community.

• Continually evaluating the appropriateness of the participant’s treatment plan throughout the AOT period and making adjustments as warranted.

• Employing specific protocols to respond if an AOT participant falters in maintaining treatment engagement.

• Evaluating each AOT participant at the end of the commitment period to determine whether it is appropriate to seek renewal of the commitment or if the participant can transition to voluntary care.

• Ensuring that upon transitioning out of the program, each participant remains connected to the treatment services they continue to need to maintain stability and safety.

According to Lukes, a judge usually orders AOT upon discharge from a hospital or jail but can also order it for individuals living in the community if they have a recent history of cycling in and out of the hospital or jail. The AOT participant is court-ordered to follow their treatment plan, and if they do not adhere to treatment, the court may modify the treatment plan, order the participant to appear in court, or order the participant to be evaluated for possible hospitalization.

“AOT is not a punitive approach to care,” Lukes said. “Rather it provides increased support for people who need extra motivation and assistance engaging in treatment and ensures the mental health system is attentive to their needs.”

Mental Health Benefits of AOT

Studies show that AOT can dramatically improve treatment outcomes and substantially reduce the likelihood of repeat hospitalizations and criminal justice involvement.

• AOT reduced hospitalizations in New York by 77%2

• AOT reduced the length of hospital stays in Florida by 43%3

• AOT reduced violent behavior in New York by 47%4

• AOT reduced illegal substance use nationwide5

“AOT works best when the individual enters the program immediately upon discharge from the hospital,” Lukes said. “The longer a person’s psychosis goes untreated, or the greater number of psychotic episodes a person undergoes, the more damage to the brain and the greater the accumulation of disability. AOT helps to stop that.”

Lukes pointed out that while AOT has an “endpoint” – the active engagement in treatment that leads to the dissolution of the court order, typically after at least six months – any positive progress the individual makes should be celebrated as a success. At the same time, any relapse in disease or any subsequent hospitalization should not be considered a failure. Importantly, the end of the court order does not mean the end of treatment, although some individuals go on to lower levels of care.

“It is incumbent upon AOT treatment teams to do the hard work of helping the individual meet their goals, or at least make progress toward their goals,” she said. “For example, we find that when AOT participants engage in the process and adhere to their medication protocols – which is not an easy task, especially when anosognosia is involved – they discover the benefits of reducing their time in the hospital, maintaining a job, and getting along better with their family.”

The Future of AOT

According to Lukes, AOT initiatives are very young – “we’re like toddlers” – and prevalence of AOT implementation varies across states and jurisdictions. The biggest barrier is the lack of staffing to provide the services needed. TAC actively advocates for more resources to be devoted to the AOT model, more research to prove its effectiveness, and more communities to work collaboratively to implement it.

“People with severe mental illness not only need medications but also need the type of case management support system inherent in AOT to live successfully in their community,” she said. “Case managers are critical for helping them apply for benefits like food stamps and Medicaid. Use of evidence-based treatment, including assertive community treatment, cognitive behavioral therapy and first episode psychosis, is also relatively limited. These restrictions are a pennywise but pound-foolish approach to mental illness, especially when you consider that AOT does not require a huge outpouring of resources to implement.”

Editor’s Note: HealthWell offers a Schizophrenia – Medicare Access Fund that provides up to $4,000 in medication copayment or insurance premium (Medicare Part B only) assistance for prescription drugs and biologics used in the treatment of schizophrenia.

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