Assisted Outpatient Treatment: APA’s Position Statement

In December the Board of Trustees approved a position statement that directs our ongoing advocacy efforts on involuntary outpatient commitment (IOC)/assisted outpatient treatment (AOT). The APA position is that IOC/AOT can be a useful intervention for patients with severe mental illness and documented histories of poor compliance leading to repeated relapses and rehospitalizations. It can be effective when accompanied by adequate resources and intensive, individualized outpatient services and when the initial commitment period is 180 days.

The position statement and an accompanying resource document were developed by a work group led by Dr. Marvin Swartz, one of the leading researchers in this area, under the auspices of the Council on Psychiatry and Law in consultation with the Committee on Ethics.

It is important to have a position statement because IOC/AOT is one of the more debated aspects of the mental health bills that are now in Congress (for example, here and here). It is controversial among members of some advocacy groups, some consumer groups, and some of our members. Even the name is controversial. In the congressional bills and in some states, such as New York and California, the term AOT is used, but some opponents of AOT feel that “assisted outpatient treatment” is a euphemism. They argue that we are talking about involuntary outpatient commitment involving a court order, and the title should reflect that reality. We used both titles in the position statement. In this column, I will use the term “AOT” because that is the terminology that is used most prominently in Congress, and I will review some of the most significant controversies about AOT.

• Does AOT work? Research has generally shown positive outcomes with AOT under certain circumstances. The problem with measuring the impact of AOT is that a court order alone will not fix underfunded systems of care. Effectiveness is largely a function of systematic implementation, the availability of intensive community-based services, and the duration of the court order. When all of these elements are insufficient, results of research will not show effectiveness.

Many of the available studies have been criticized for their methodology and patient selection. There have only been three randomized, controlled studies of AOT: one in New York, one in North Carolina, and one in the United Kingdom. The New York and British studies said that AOT did not work, and the North Carolina study said that AOT led to a decrease in hospital days if the court order lasted for 180 days. Other nonrandomized, controlled studies have shown that AOT reduces overall service costs, reduces hospitalizations and length of stay, increases use of psychotropic medications and intensive case management services, and leads to greater engagement in outpatient services.

When AOT works, this is likely due to a combination of access to intensive services and a team of mental health professionals working together to help the patient. The court order commits the mental health system to the patient as well as the patient to the mental health system. Some studies also refer to the “black robe effect” of having a judge order participation in treatment.

• Is AOT ethical? Some opponents of AOT feel that it is unethical to force patients into treatment except for emergency treatment, that is, when a patient is a danger to self, a danger to others, or unable to care for basic needs. They argue that AOT goes against the principles of autonomy and right to self-determination.

Opponents contend that even if someone has a chronic mental illness and has a history of hospitalization or incarceration, they still have the right to decide if they want to comply with treatment, barring an emergency. AOT supporters argue that AOT is consistent with the principle of beneficence and tries to intervene before someone meets the criteria for involuntary hospitalization to prevent deterioration based on past history. After reviewing the arguments on both sides, the APA position statement supports the use of AOT and opines that it is ethical when used appropriately.

• Is AOT racially discriminatory? Some opponents to AOT argue that African Americans and other minorities are overrepresented in AOT programs, such as the one in New York. Since 1999, 34 percent of AOT recipients have been African American—a demographic that comprises only 17 percent of the New York state population and 25 percent of the population of New York City, where AOT is predominantly used. Others dispute this concern about racial bias based on the data that the number of minorities on AOT is proportional to the percentage of minorities who are eligible for AOT, that is, African Americans are overrepresented in the eligible population of patients who have had multiple hospitalizations in the public facilities.

The APA position statement and resource document conclude that the use of AOT is not racially discriminatory and that there is no current evidence that AOT is applied disproportionally to minority populations. Nevertheless, there should be independent evaluations of AOT programs to ensure that they are being used appropriately. Outcomes such as disproportionate use among minority groups or inadequate due process protections must be followed by corrective action.

In summary, APA has undergone a very careful review of the literature and research to come up with a reasonable and evidence-based statement in support of AOT that is accompanied by appropriate resources. My opinion is that this is a useful intervention under certain circumstances. It should be part of the toolbox of our profession. With that said, voluntary treatment without coercion and with adequate access and resources will always be the preferable method of care for our patients. ■