Last month, the Department of Health and Human Services announced the Crisis Solutions Initiative, a new state effort aimed at addressing the failures of Gov. Easley’s 2001 mental health reforms. Following the announcement, the Civitas Institute called on the McCrory administration to get serious about severe mental illness. The first meeting of the Crisis Solutions Initiative was held this week. As coalition partners consider myriad issues in the mental health system, it’s time for some innovative responses.
North Carolina’s mental health system is strained to its breaking point. Inpatient resources for people in crisis are so scarce that it takes an average of three-and-a-half days to get admitted to a psychiatric facility. But the outpatient system is even worse: Few patients follow through with treatment after they are discharged from psychiatric hospitals. The result is a system that is constantly in a state of crisis. Scarce resources are wasted as people with severe mental illnesses are trapped in a destructive “revolving door” of hospitalization, discharge, regression, and hospitalization.
If the Crisis Solutions Coalition is serious about addressing this “revolving door,” they should start by looking at assisted outpatient treatment. Assisted outpatient treatment (AOT) is a court-ordered process used to prevent deterioration in someone who might become dangerous to themselves or others if untreated.
AOT works to interrupt the “revolving door” by directing care at individuals who repeatedly end up in the hospital, but refuse to adhere to treatment in an outpatient setting. This is quite common among people with severe mental illness: Approximately half of people with schizophrenia or bipolar disorder believe that they are not sick. To be clear, not all of these people are necessarily good candidates for assisted outpatient treatment. But when other forms of intervention fail, assisted outpatient treatment can provide a badly-needed safety net for the worst-off people.
Studies from Duke University and Columbia University (see sources below) have shown conclusively that assisted outpatient treatment is an evidence-based practice that improves outcomes, both for participants and for the public at large. AOT participants are less likely to be victims of crime. They are less likely to be violent. They are less likely to be incarcerated or hospitalized. At the same time, they are more likely to take their medication and more likely to be actively involved in the community.
Assisted outpatient treatment also saves taxpayers a great deal of money. A study of assisted outpatient treatment in New York found that
… the average annual cost per person declined substantially and consistently … In the New York City sample, average costs declined 50%, from about $105,000 to about $53,000 per person, and in the five-county sample, average costs declined 62%, from about $104,000 to about $39,000 per person.[i]
The evidence shows that assisted outpatient treatment can interrupt the “revolving door.” By ensuring continuous care after discharge from a hospital, people who previously would have slipped through the system are able to remain integrated in the community. Nonetheless, AOT has fierce critics. Opponents of assisted outpatient treatment argue that involuntary treatment is a violation of civil liberties. They argue that patients should be free to make decisions for themselves about their treatment. And in most cases, this is true. But in some cases, it is not at all clear that psychotic or delusional patients are in the best position to make those decisions. Michael Biasotti, a New York police chief and a staunch advocate of AOT, asked: “We’re so concerned about someone’s civil liberties – which, I agree – but at what point? At what point are you denying them their civil liberties by not bringing them back to reality?”
So-called “patient advocates” say that they want mentally ill people to have “self-determination” and receive treatment in the “least restrictive setting.” But as E. Fuller Torrey, a prominent schizophrenia researcher, has warned, this is not always possible:
“Self-determination” often means merely that the person has a choice of soup kitchens. The “least restrictive setting” frequently turns out to be a cardboard box, a jail cell, or a terror-filled existence plagued by both real and imaginary enemies.
For family members who watch their loved ones consumed by untreated mental illness, lofty talk of civil liberties rings hollow.
The arguments against assisted outpatient treatment are well-intentioned, but often they ignore the facts. Assisted outpatient treatment is an evidence-based practice that can save lives in North Carolina. It can serve as a badly-needed safety net in the state mental health system. Finally, it can reduce the strain on families, law enforcement, and the public health system.
If the administration is truly earnest about this new Crisis Solutions Initiative, they should start by taking a close look at assisted outpatient treatment.
Swanson, J.W., Van Dorn, R.A., Swartz, M.S., Robbins, P.C., Steadman, H.J., McGuire, T.G. & Monahan, J.T. (2013). The cost of assisted outpatient treatment: can it save states money? American Journal of Psychiatry 170, 1423-1432.
Van Dorn, R.A., Desmarais, S.L., Petrila, J., Haynes, D. & Singh, J.P. (2013). Effects of outpatient treatment on risk of arrest of adults with serious mental illness and associated costs. Psychiatric Services 64, 856-62.
Van Dorn, R.A., Swanson, J.W., Swartz, M.S., Wilder, C.M., Moser, L.L. Gilbert, A.R.,…Robbins, P.C. (2010). Continuing medication and hospitalization outcomes after assisted outpatient treatment in New York. Psychiatric Services 61, 982-7.
Gilbert, A.R., Moser, L.L., Van Dorn, R.A., Swanson, J.W., Wilder, C.M., Robbins, P.C.,…Swartz, M.S. (2010). Reductions in arrest under assisted outpatient treatment in New York. Psychiatric Services 61, 996-999.
Swartz, M.S., Swanson, J.W., Hiday, V.A., Wagner, H.R., Burns, B.J., Borum, R. (2001). A randomized controlled trial of outpatient commitment in North Carolina. Psychiatric Services 52, 325-329.
Swartz, M.S., Wilder, C.M., Swanson, J.W., Van Dorn, R.A., Robbins, P.C., Steadman, H.J.,…Monahan, J. (2010). Assessing outcomes for consumers in New York’s assisted outpatient treatment program. Psychiatric Services 61, 976-981.
New York State Office of Mental Health. (2005). Kendra’s law: final report on the status of assisted outpatient treatment.