Views on assisted outpatient treatment: Steven K. Hoge, M.D.

Steven K. Hoge, M.D., chair of the Council on Psychiatry and Law of the American Psychiatric Association (APA), ran the forensic of division of Bellevue Hospital in New York City, which oversaw the provision of AOT in Manhattan and Rikers Island jail. While the APA doesn’t have a formal position statement on AOT or mandatory outpatient treatment, there is a resource document that says it can be useful. It dates from 1999 and can be found PDF format here.

 It supports mandatory outpatient treatment as a tool, but recommends more than just getting medication. That’s because often the people who are alienated from treatment systems are alienated from family as well, says Hoge. The treatment plans under Kendra’s Law are “incredibly comprehensive,” he adds. “They’re soup to nuts.” But he stresses that people who are “hard-core refusers of services aren’t going to do well under mandatory outpatient treatment, either.”

Many of the patients Hoge has seen will not comply with treatment if left to their own devices. “They’re too disorganized,” he says. It could be that patients comply because of legal sanctions. “There are going to be many many different stories under the umbrella of outpatient treatment. he notes “We tried to expand our services at Rikers for AOT, and it’s very difficult. Many wouldn’t comply, and would disappear. You can go across the river to New Jersey, and they don’t care what the New York courts say.”

However, for a significant number of patients, a court order and a structure facilitates compliance. “It’s probably not coincidental that some of that mandatory treatment involves having a day program,” said Hoge. The last thing many patients want is to live in a psychiatrically supervised residence.

At Bellevue, every few years certain individuals would be arrested and brought to the emergency department, where they would get started on treatment, said Hoge. Then, they would drop out.

However, Hoge reports that most of the people treated in AOT in New York complied and were satisfied.

The medication does make some people feel better, said Hoge. But forgetting about involuntary treatment, the long-term studies of individuals with schizophrenia show that “a huge number” are noncompliant with medication, and are readmitted. In fact, readmissions are almost entirely because of noncompliance. Why didn’t they take their medication? Some thought they didn’t need it – they thought they could do well without it, said Hoge. Sometimes they complain of side effects, like weight gain and sexual problems. Or sometimes it may be that they become “a little bit psychotic,” and rather than get an adjustment to their medication, their psychosis makes them think they are okay.”

Hoge warns against using violence as a way to get more resources for treatment. “You hear people who want to use any opportunity to get more funding, but that’s a bargain with the devil,” he said. “We continue to try to educate people about facts: that the mentally ill represent a very small proportion of the people who commit violence.”.

The key point about mandatory outpatient services is that they need to be funded, said Hoge. “It’s one thing to have a law on the books, but if there’s no money for it, there’s no way of implementing it and it doesn’t do anyone any good.

Read the pros and cons of AOT in the two-part series starting with part one by clicking here.