AOT patients benefit from agency collaboration

In Summit County, Ohio thousands of seriously mentally ill people have benefited from court ordered outpatient treatment. The effectiveness of assisted outpatient treatment (AOT) in decreasing hospital admissions in Summit County was clearly established over a decade ago, when they documented a decrease from 1.5 to 0.4 per year before and after AOT (Munetz et al. 1996). AOT also increased patients’ compliance with outpatient psychiatric appointments from 5.7 to 13.0 per year and with attendance at day treatment sessions from 23 to 60 per year (Munetz et al. 1996).

I recently joined a team of Treatment Advocacy Center representatives who traveled to Akron, Ohio to learn more about this highly successful program. During our two day visit, we interviewed representatives from many different agencies and heard from people who depend upon services from Summit County for treatment of their mental illnesses.

Over 15 years ago, mental health officials in Summit County established a new framework for continuing court supervision of mentally ill people once they were released from inpatient care. While well designed on paper, the ultimate success of this program comes from the way that all of the participating agencies work together to uphold the program’s purpose. Assisted Outpatient Treatment thrives in Summit County because judges, lawyers, mental health professionals, caseworkers, and law enforcement officers all recognize the benefits of AOT as a legal mechanism and also share the same strong desire to see seriously mentally ill people stay well.

The outpatient commitment process in Summit County begins with the release of a person from inpatient care. The judges of the Summit County probate court reasonably interpret Ohio’s commitment laws as allowing outpatient care for patients who are released from hospitalization but who still need court ordered treatment to avoid rapid deterioration. Taking into account all relevant circumstances, the courts carefully balance the patient’s need for continued supervised treatment against their ultimate right to return to the community without restrictions.

In turn, county case workers who assist these seriously ill patients in the community readily acknowledge that this continuation of court ordered treatment greatly increases treatment compliance and decreases practical problems for patients. The understanding that he or she is subject to an ongoing court order and may be ordered back for further evaluation is a sufficient inducement for most patients to comply with their treatment plans.

How families feel about AOT

The Otago community treatment order study has provided us with valuable information on how AOT has been working in New Zealand. There, researchers examining the views of participants concluded that, “the usefulness of community treatment orders is accepted by most patients under them in New Zealand, as well as by most physicians.” Their most recent study, “Family perspective on community treatment orders: a New Zealand study” carries this research over to consumers’ families, a group whose experiences and views of their family members have been little studied.

When politics corrupts science

We expect reputable institutions to conduct honest scientific inquiry. However, a recently published British "review" of the literature on assisted outpatient treatment demonstrates how science can be so easily corrupted by politics. The report evidences a clear bias against AOT and serves up a full menu of platitudes that can be used by individuals and organizations that oppose AOT. But, before opponents use this report to try to discredit AOT, they should be prepared to apply the same analysis standards to the alternative treatments they propose.

The review discounts all evidence except randomized control trials and does not even consider secondary analysis for such trials, at the same time acknowledging the practical and legal challenges to conducting such studies of AOT. The Cochrane Reviews use a similar approach to declare the following treatments/practices for schizophrenia to be unsupported by the data, some of which are specifically designated "evidence based practices" by the Center for Mental Health Services:

· case management
· cognitive rehabilitation therapy
· compliance therapy
· family intervention
· psychodynamic psychotherapy techniques
· life skills training
· integrated substance abuse treatment
· supported housing

Those who dare to use the British review to oppose AOT had better be prepared to abandon these services as well as the current "transformation to recovery" for which not a single randomized control study proving its efficacy can be found.

Psychiatric illnesses are extremely complex. A more thoughtful consideration of evidence of benefit for a variety of options, including AOT is a morally and intellectually sound approach. Simplistic, knee jerk analyses based on political pandering do a disservice to those who are suffering.

Overhyping a coercion controversy?

Two international studies recently examined consumers and other stakeholders’ experiences with AOT in long-standing programs in Canada and New Zealand.

Their findings echo what we hear over and over from families and consumers who’ve actually participated – AOT works and the controversy surrounding its use is much more attenuated than those who oppose it would have you believe.

As the Canadian researchers explain, “[O]ur findings were similar to those of researchers in New Zealand who noted that the actual experience of coercion by the majority of patients was much less than the strident policy debates… sometimes suggest.”

Australian researchers on AOT's value

A new study of AOT in Victoria, Australia looked at almost 1,200 individuals over nine years. The results, recently published in the journal Social Work in Health Care, echo other published studies of AOT.

Individuals in the Australian study receiving extended outpatient commitment experienced significant decreases in hospitalization (from an average 56.3 days per year before extended AOT to only 19.6 days per year after) and a third more service utilization than in the period before AOT.

Researchers also found that neither AOT nor community services alone accounted for the reduction in inpatient bed use – in fact, either service alone was actually associated with increased inpatient utilization. Their analysis demonstrated that “it is the combination of community services enabled by outpatient commitment that facilitates the reduction in hospital utilization…” This further shatters the myth that enhanced services alone are enough for this population.

The researchers explain that “outpatient commitment is perhaps best conceived as a delivery mechanism rather than a treatment in and of itself” that serves as a “way of delivering services to a population that cannot or will not accept such services voluntarily.” AOT’s role is “to raise the level of outpatient commitment to that provided to the treatment compliant comparison sample.”

In other words, the goal of AOT is to allow individuals whose illnesses cause them to refuse care the opportunity to access the same services as other individuals with mental illnesses. AOT is simply a means of ensuring that everyone has the same opportunity to recover from their illness.