Treatment providers face off against patient advocates over AOT: Part 2

Court-ordered treatment means that people who get into legal trouble – and many people with mental illness do get picked up by the police and taken to emergency departments – could be required by a court order to take medication. If they don’t, they could be picked up by the police and institutionalized.

Kendra’s Law in New York, allows AOT but is backed up by intensive support services. A recent study by researchers closely involved with the law shows that affected patients are less likely to be re-arrested or re-hospitalized, and that AOT in combination with the supports cut Medicaid mental health costs in half. (See AOT cost-effectiveness study stirs national debate.

But the Bazelon Center and others say that AOT eviscerates the civil rights of people with mental illness, and undermines trust between patient and treatment provider.

At the April 3 hearing on H.R. 3717, the president of the National Alliance on Mental Illness, Sylvia Thompson, testified in support of the bill, which has little chance of passing.

H.R. 4302, the Access to Medicare Act which was signed by President Obama April 1, specifically includes two provisions from H.R. 3717: AOT grant programs for local jurisdictions, and a demonstration program to improve access to community-based mental health services.

Brian Altman, legislative affairs director for the Substance Abuse and Mental Health Services Administration (SAMHSA), spoke to Behavioral Healthcare about H.R. 3717 and AOT. “Our role is not to specifically support or oppose any legislation,” he said. “But we do say, ‘Here are some of the issues that may be of concern.’” SAMHSA provides what is called “technical assistance” to legislators and staff, he added. So far, no such technical assistance has been given in terms of H.R. 3717, Altman said. “We’re developing it, but it’s all internal at this point.”

When SAMHSA does provide the information to legislators, it doesn’t necessarily publicize it, added Altman.

As for defunding SAMHSA’s unauthorized programs – some of which come in for criticism by Rep. Murphy (R-Pa.) and by Fuller Torrey, M.D., founder of the Treatment Advocacy Center and a proponent of AOT-- Altman said that various programs are not specifically authorized. He cited the suicide prevention lifeline and the minority fellowship programs. “These and other programs are not specifically authorized, but are funded because Congress sees a need for them,” he said. “We’ve been able to provide technical assistance to the best of our understanding on the programs that have not been specifically authorized at SAMHSA.”

To the charges that SAMHSA doesn’t treat people with serious mental illness adequately, Altman said, “Fully 68 percent of SAMHSA’s budget is directed at substance abuse prevention and treatment,” he said. “Right out of the gate–most SAMHSA money is for substance abuse.” Congress directs other funding for people with mental illness, and Medicaid pays for most of it, he said. In fiscal year 2014, 77 percent of the SAMHSA mental health budget supports people with serious mental illness and children with serious emotional disturbance, he said. And not only is Medicaid and private insurance the largest payers for mental illness treatment, but they will be even more important under health care reform. “But it seems that no matter how many times we provide the pure raw data, it doesn’t change” the minds of SAMHSA’s critics, said Altman. “SAMHSA’s budget as it relates to mental health services in America is not the largest source of funding by any means. “

On December 2, 2013, SAMHSA hosted a seminar on AOT, with presentations by Jeffrey Swanson, Ph.D. and Marvin Swartz, M.D., the Duke University researchers who studied the impact of Kendra’s Law. (For the video of the four-hour seminar, go to https://www.wciconferences.com/aott/archives.html). “We hosted that event to continue and advance the conversation at large,” said Altman. “A lot of folks have said AOT is the next greatest thing since the iPad, and other folks say it should never be used. SAMHSA wanted to put out multiple perspectives and engage people in an actual dialogue.” The panel also included an AOT opponent.

Whether AOT is useful only in states that have full community supports is still a question for some people, said Altman. “AOT can be an option, if folks who are committed to outpatient treatment have services and supports available,” he said.

A version of the AOT grant program went through the Medicare bill, but there is no funding attached to it, Altman pointed out. The Medicare bill authorized $15 million each year for AOT for fiscal years 2015 through 2018. “People who are supportive of that will have to go to the appropriators and ask for it to be funded,” he said. “Our position has been if Congress authorizes and appropriates it, SAMHSA will implement and evaluate it so people can understand what works and what might not.”

Read Part 1 here.