Is forced treatment in our outpatients’ best interests?

He was careful to note that one of the major issues with AOT is that not only does it obligate the patient to obtain treatment, but it obligates the state to provide care. Those in the system in New York and North Carolina, where follow-up studies have been conducted, receive case management services, housing, and access to treatment and medications, accommodations that many patients with severe psychiatric disorders are unable to access.

Outpatient commitment’s efficacy

So does AOT work? And what does it mean to even ask that? A pilot study done at Bellevue did not show efficacy. "The treatments they were getting weren’t working very well, and overall the evidence is mixed," Dr. Swanson said. The so-called Duke study (Am. J. Psychiatry 1999;156:1968-75) and the New York AOT studies (Psychiatr. Serv. 2010;61967-9 and Am. J. Psychiatry 2013;170:1423-32), revealed that the successes of forced outpatient treatment are dependent on an investment in effective implementation, the availability of intensive community services, and the duration of treatment – with a notable decrease in hospital readmission rates for those treated for more than 180 days.

The Duke study showed that the control group had a 48% rehospitalization rate, with an average of 27.9 days hospitalized; those assigned to AOT for less than 180 days had a 50% rehospitalization rate, with an average of 37.7 days; and those assigned to AOT for more than 180 days had a 32% rehospitalization rate, with an average of 7.51 days. In fact, those assigned to AOT for less than 6 months appeared to do worse than the controls. The study did show that people receiving AOT were less likely to have violent behaviors and were less likely to be the victims of violence; however, the study included all aggressive behaviors, including shoving and acts that resulted in no injury. Obviously, these studies said nothing about the likelihood that AOT would decrease the probability that someone with a major mental illness would murder a stranger.

And what about the patients: Did they feel helped by forced treatment? This is an issue of key concern to me, because I remain perplexed at the idea that people are not grateful to be returned to a state of mental well-being, and I don’t believe that their concerns about their treatment should be dismissed with the idea that they simply lack insight. Of the patients, only 27% endorsed forced treatment after the fact, while the rest did not. On a measure of "quality of life," there were improvements for those in AOT for more than 12 months but not for those treated for 6 months.

Dr. Swanson concluded his talk by saying that the added benefits of housing and intensive services may have been instrumental in causing some of the positive change that is captured with ongoing AOT. He showed a final slide:

Outpatient commitment is neither a cure-all nor a catastrophe. It brings neither an end to violence nor an end to civil rights. It does not affect the majority of people with some form of psychiatric illness. It cannot fix a fiscal crisis of the state in which resources for mental health services continue to shrink. But it may be a reasonable and measured policy that can make effective treatment much more consistently available to those few among us who are in most need of treatment in the community, who at times may actually want it, but in the real word may not get it any other way.

My conclusion

I’ll leave Dr. Swanson out of it from here, but it’s funny that we started with Newtown, and not one of the many laws that have been passed since that tragic day have done anything to address the spiral that led to that senseless massacre. Today, the shooter’s mother would still be able to purchase guns for his use, and nothing about his story as publicized leads us to believe that he would now be entered into a public database or forced to go to a treatment program.

We’ve started with a problem, and created what we hope might be answers to a whole different set of issues. Perhaps those answers are benign or beneficial, but perhaps they will further antagonize those who most need our help. If the issue is finances and decreasing hospital stays, it’s unclear why we target the mentally ill while leaving those with diabetes and heart disease to drink soda, and those with lung disease to smoke cigarettes. What, no discussion of tobacco and sugar registries?