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AOT cost-effectiveness study stirs national debate (Part 2)
The anti-AOT perspective
While people like Ronald Honberg of NAMI represent the “gray area” in the middle of the Assisted Outpatient Treatment (AOT) debate amd well-known psychiatrists E. Fuller Torrey, M.D. and acolyte D.J. Jaffee anchor the "pro" side, Harvey Rosenthal, executive director of the New York Association of Psychiatric Rehabilitation Services, has spent decades fighting against outpatient commitment.
Studies, including the Bellevue pilot in 1999, show that engagement in treatment, not forced treatment, is what works, Rosenthal says. “I think it’s unconscionable to replace a funded system with a reliance on court orders and injections,” he says. “You wouldn’t do that with any other population – forcing a needle into you.” For example, what public policy would require obese patients who refuse to diet to take appetite suppressants?
Swanson and his colleagues were looking at “the question of the day” – which is what saves money and improves care at the same time, says Rosenthal. “But if you want to look at what saves Medicaid dollars, look at peer support, not outpatient commitment,” he says, calling AOT “the lazy man’s way to say you have a functioning mental health system.”
Interestingly, managed care companies may be more motivated to encourage this engagement than public payers have been, notes Rosenthal. The Swanson study of AOT in New York only proves that recovery saves money. “There’s no question that recovery is good business for a managed care company, and a good financial plan for New York’s Medicaid program,” he says.
As part of Medicaid “redesign” in New York, Gov. Andrew Cuomo is focusing on cutting hospital readmissions across the board, and boosting treatment in the community. As a result, Medicaid officials are finally interested in and knowledgeable about the importance of housing for the mentally ill, says Rosenthal.
Rosenthal, who was hospitalized with a mental illness when he was 19 in 1970, takes medication. “But it’s my choice,” he says. Most of the AOT court orders do require medication. However, medication may not be forcibly administered to any AOT patient.
Rosenthal cites a Pathways to Housing study which offered housing and support to people in their 30s with severe mental illness, mostly with co-occurring substance abuse, and a history of incarceration and hospitalizations. “They did not require medication compliance or abstinence,” said Rosenthal. “But they had an 85-percent retention rate, because they started where the person was. It could very well be that afterward, people voluntarily agreed to take medication.”
In the Bellevue study, both the control group (not under AOT) and the study group were getting a very intensive level of services – so intensive, in fact, that the those under orders may not have experienced the treatment as coercive.
In the past, when people didn’t show up for treatment and were difficult to engage in treatment, they were called non-compliant, says Rosenthal. That is no longer acceptable, he said. “You have to leave the office, hit the street, and use new tools, sometimes using peers,” to find the patients, he said.
And Rosenthal is hopeful for more patient empowerment, that comes with more funding of treatment in the community. “The stars are lined up in a way they never have been before, because when you tie the money to the outcomes, things can change,” he says.
The debate
But will the debate over AOT ever have a compromise solution? The controversy over outpatient commitment pits opponents, who say someone in the community with mental illness who is legally competent and not criminally accused cannot be forced to get treatment, against proponents who say that people have a history of revolving door hospitalizations due to the fact that they can’t or won’t comply with medication. These are two arguments on the extreme, and they don’t ever seem to have any way to debate the issue. “The two arguments pass each other in space,” Swanson says. In the most stark analogy some advocates call outpatient commitment “leash laws.”
“There’s a disconnect,” says Swartz. “One is the symbolism of it, that it’s an intrusion into the lives of people who have broken no law,” he said.
But the arguments are simplistic, because the long-term consequence of outpatient treatment is that it allows people to have a better quality of life, said Swanson. “Having a severe mental illness is a deprivation of the ability to act freely in the community,” he says.
But policymakers should know that only people for whom AOT works are likely to thank them for it. “We asked people in North Carolina who have been on outpatient commitment,” says Swanson. “Only a minority endorsed it.” But when the people were divided into two groups – one that had successful outcomes and one that didn’t – the one with the good outcomes was significantly more likely to endorse AOT, he says.
It’s true that by statute people can’t be forcibly medicated in the outpatient setting, but, says Swanson, people act on the basis of what they believe is true. “In another study we did here, people under outpatient commitment orders said it was their perception that the order required them to take their medication.”
In another study, Swanson found that people with AOT felt more coerced, and had a lower subjective quality of life, than people not on AOT. At the same time, increasing the services resulted in a positive effect on quality of life. “The tradeoff was the benefit of being in the community instead of in the hospital,” said Swanson.
“We’ve said this repeatedly in our work – you need to have a mental health system that has the capacity to respond to people with mental illness,” said Swartz. Having court orders are useless if there’s not treatment. “In fact, if people get AOT without intensive services, not only does it not work, but it could be counterproductive,” he said.
“In a perfect world, no one would play the violence card to draw people’s attention to AOT statutes,” said Swartz. “Unfortunately, too many people evaluate the quality of a mental health system not as a public health system, but a public safety system.”
