Program Profile: Assisted Outpatient Treatment (AOT)

This is a court-ordered treatment program for individuals with mental illness who have a history of multiple hospitalizations or have exhibited violence toward themselves or others. The program is rated Promising. Participants who received treatment had a statistically significant reduction in risk for arrests of any offense, compared with the comparison group. However, there was no statistically significant difference found between the groups in risk of arrests for violent offenses.

A Promising rating implies that implementing the program may result in the intended outcome(s).

Program Goals

In 1999, Kendra’s Law, a statutory framework passed in New York State, established the court-ordered Assisted Outpatient Treatment (AOT), also known as outpatient commitment (OPC). AOT is mental health intervention that provides community-based services to individuals diagnosed with a mental illness and have a history of multiple hospitalizations or have exhibited violence toward themselves or others. The goal of AOT is to reduce arrests for any offense and especially violent offenses.

Target Population

In New York State, AOT targets individuals (18 and older) diagnosed with a mental illness, who are capable of living in the community with the help of family, friends, and mental health professionals. However, without routine care and treatment, these individuals may relapse and become violent or suicidal or require hospitalization (New York State Office of Mental Health 2005). In order for the court to mandate AOT, the petitioners must establish that the individuals meet specific legal and clinical eligibility criteria, including having 1) a history of treatment noncompliance, whereby they are considered unlikely to voluntarily adhere to treatment; and 2) a high likelihood of benefiting from the mandated treatment, especially if they are at risk for relapse or deterioration that would result in physical harm to themselves or others and are unable to take responsibility for their own care (New York State Office of Mental Health 2005).

Program Components

Kendra’s Law established mechanisms so that local mental health systems give individuals entering AOT priority access to case management and enhanced services (including housing and vocational services) that are essential to treating an individual’s mental illness, avoiding relapse that would lead to harm or re-hospitalization, and helping the individual live in the community.

Mandatory treatment plans are developed and implemented to ensure comprehensive, community-based services are provided to AOT recipients. There is a wide range of services provided, including case management, medication management, individual or group therapy, day programs, substance abuse services, housing or housing support services, and urine or blood toxicology tests (to ensure adherence to medication).

No court order goes into effect unless a treatment plan has been submitted to the court. The court cannot add anything to the proposed treatment plan but can reduce or eliminate treatment mandates. The length of the court order can vary by individual. Some court orders last 6 months or less, while others are in place for longer than 6 months. When the court order expires, individuals are moved to a voluntary agreement when they transition from AOT, maintaining the same level of enhanced services for 6 months. Afterwards, they are moved out of the formal AOT program, although they may continue to receive services as needed. Although Kendra’s Law does not include specific enforcement provisions, noncompliance with an AOT court order can be a factor in a physician’s consideration of an evaluation for involuntary hospitalization (New York State Office of Mental Health 2005; Gilbert et al. 2010).

Study 1

An evaluation of New York State?s Assisted Outpatient Treatment (AOT) by Gilbert and colleagues (2010) examined whether individuals had lower arrest rates when receiving AOT or voluntary enhanced services than before initiating either one. Study participants were sampled from AOT program rosters of mental health service recipients in six New York counties. Based on structured interviews, 181 individuals who had either received court-mandated AOT (n=139) or had signed a voluntary service agreement (n=42) at some point during the study period were identified for the study. The sample was 60 percent male, with an average age of about 34. The sample was approximately 46 percent white, 35 percent African American, 11 percent Hispanic, and 7 percent Asian/Pacific Islander or other. There were no significant differences between the groups on age, gender, race or ethnicity, and education. Individuals with voluntary agreements were more likely to have a primary diagnosis of major depressive disorder (17 percent), compared with individuals who received AOT (4 percent), and were also more likely to reside in regions outside New York City (98 percent of the voluntary agreement group, compared with 60 percent of the AOT group).

The primary outcome of interest was arrest rates. Arrest records for the 181 participants from Nov. 1, 1999, to Feb. 28, 2008, were obtained from the New York State Division of Criminal Justice Services. Demographic information was collected during the interviews, and diagnostic data was extracted from matched Medicaid claims files. The primary diagnosis was classified into four categories: schizophrenia, bipolar disorder, major depressive disorder, and other.

A dummy variable was created to indicate whether the study participants had been arrested during any given month. Analytic comparison groups of person-month observations were constructed to reflect status in regard to AOT or a voluntary service agreement. A single category of observations (pre?AOT and prevoluntary service agreement) was used as the reference group for comparison. This category included all person-months before an individual either received AOT or signed a voluntary agreement. This created five groups of observations that were compared: 1) pre?AOT and prevoluntary agreement, 2) current AOT, 3) current voluntary agreement, 4) post?AOT, and 5) postvoluntary agreement.

The data was structured as one unit of observation per person, per month, over the 100-month study period. There were 9,229 person-months available for analysis: pre?AOT and prevoluntary agreement (n=7,097), current AOT (n=1,094), current voluntary agreement (n=468), post?AOT (n=361), and postvoluntary agreement (n=209).

Data was examined using estimated repeated-measures, multivariable logistic regression models to predict the odds of arrest by AOT and voluntary agreement status, with the models controlling for time and nonindependence of observations. The multivariate analysis also controlled for region, race and ethnicity, age, and sex.

Limitations of the study include a small sample size and nonrandomized study groups.

Study 2

Link and colleagues (2011) conducted a quasi-experimental study that examined the impact of the Assisted Outpatient Treatment (AOT) intervention, established in New York State in 1999 through ?Kendra?s Law.? Eligibility for the court- mandated AOT intervention was based on the following legal criteria: 1) the individual had a history of treatment noncompliance, whereby the individual is considered unlikely to voluntarily adhere to treatment; and 2) the individual has a high likelihood of benefiting from the mandated treatment. The New York State Office of Mental Health records were used to accurately identify periods in which individuals were assigned to AOT. Participants were recruited from outpatient clinics in the New York City boroughs of the Bronx and Queens (n = 183).

Of the 183 participants, 86 were assigned to the treatment group (individuals who had at some point in their lives received AOT), and 97 were assigned to the comparison group (individuals who had never received AOT at any point). Sixty percent of the total sample population was male, with an average age of 37 years. Of these participants, 54 percent were African American, 29 percent were Hispanic, and 18 percent were white or other. Patient data reported that 70 percent of the total sample had a psychotic disorder diagnosis, 25 percent had a mood disorder diagnosis, and 5 percent had an ?other? diagnosis. There were no statistically significant differences between the groups at baseline, except that there were more men in the AOT group than in the comparison group (67 percent versus 54 percent, respectively). Adjustments were made using fixed-effects logistic regression, which removed between-person variance and allowed within-person variance, thus controlling the effects of individual differences (such as age, gender, race-ethnicity, and education attainment), whether measured or not.

Outcomes of interest included all arrests (for any offense) and arrests for violent offenses. Official arrest data were retrieved from the New York State Department of Criminal Justice Services (DCJS) for each participant, from the date the participant turned 18 until January 1, 2007; however, the study included extended arrest records for up to 60 months prior to study recruitment, as study researchers had to verify that participants were New York residents at the time of the interview. Specifically, data records included the date of each offense and the associated charge.

A between-group analysis comparing those who had never been assigned to AOT with those who were ever assigned to AOT, at three time periods,: 1) before AOT, 2) during and 6 months after AOT, and 3) more than 6 months after AOT ended. The CrimeSolutions review of the study focused on the comparison between those never assigned to AOT and those who were currently receiving, or within the last 6 months had received, AOT. Logistic regression estimated through generalized estimating equations (GEE) was used in the between-group analysis that compared the likelihood of all arrests and arrests for violent offenses, between the AOT and comparison groups, at 6 months after AOT. The study authors did not conduct subgroup analyses.

Study 3

Swanson and colleagues (2000) employed a 1-year randomized trial to examine the effectiveness of involuntary outpatient commitment (OPC) combined with case management to reduce the incidence of violence among people with severe mental illness in North Carolina. Study participants were screened from a population of involuntarily hospitalized patients who had been court-ordered to undergo a period of OPC upon discharge.

Upon discharge from the hospital, 262 patients were randomly assigned to release or court-ordered treatment. Study participants in the experimental group received an initial period of OPC no longer than 90 days. After that, commitment orders could be renewed for up to 180 days if a psychiatrist and the court determined that the patient continued to meet the legal criteria for OPC. Participants in the control group received immunity from any OPC during the year of the study. All study participants received case management and other outpatient treatment at mental health programs in the area. An exception to the randomization procedures was made in cases where patients had a history of serious assault involving weapon use or physical injury to another person within the past year. This group (the seriously violent group) was required to undergo at least the initial period of OPC as ordered, but they were not randomly assigned to the group.

Of the 262 patients, 102 were randomly assigned to the OPC group, 114 were randomly assigned to the control group, and 46 were assigned to the seriously violent group. A little more than half of the study participants (53.4 percent) were male and 18?39 years old (52.7 percent). The majority of participants (66 percent) were African American, while the rest were non-Hispanic white (33 percent) or other (1 percent). Most of the sample had diagnoses of psychotic disorder (68 percent), 28 percent had bipolar disorder, and 4 percent had recurrent major depression. There were no significant differences between the groups on demographics and other characteristics.

Data was collected from structured interviews with study participants as well as family members, others who knew the participant well, and case managers. Data was also obtained from hospital records and outpatient service records. The outcome measures of interest included violence, psychiatric symptoms, functional impairment, insight, social support, substance use and misuse, medication adherence, and outpatient services utilization. Violent incidences included whether study participants had been picked up by police or arrested for physical assault on another person, had been in fights involving physical contact, or had threatened someone with a weapon.

Logistic regression was used to examine the relative impact of sustained OPC and outpatient services utilization on the incidence of violent behavior, controlling for baseline violence history and relevant covariates.

There were some limitations to the study. The study design deviated from a strict randomized controlled trial in two ways. First, the sample included a subgroup of study participants with a recent history of seriously violent behavior who could not be randomly assigned to the control group. Second, the amount of time on OPC was neither random nor controlled experimentally. The amount of time a study participant remained in OPC following the required 90 days of treatment varied depending on how the clinicians applied the legal criteria for renewal of OPC orders.

Under Kendra’s Law, local Assisted Outpatient Treatment (AOT) programs were created to monitor and oversee the implementation of AOT requirements for New York City and for each New York State county. These local AOT programs accept and investigate reports of individuals who may require AOT; prepare and file petitions for AOT in local supreme or county courts; and prepare and approve proposed AOT treatment plans. The local programs are also responsible for oversight and monitoring of service providers, including case management services or Assertive Community Treatment (ACT) team services. The case managers and ACT team members are in charge of directly monitoring an AOT recipient’s level of compliance and delivery of services by other providers pursuant to the court order. Case managers and ACT team members report to local AOT program directors on an individual’s treatment status (New York State Office of Mental Health 2005).

The Treatment Advocacy Center (TAC) provides information on AOT. Additional information is available at https://www.treatmentadvocacycenter.org/.

Re-review

In 2014, Assisted Outpatient Treatment (AOT) received a final program rating of Effective based on a review of a studies by Swanson and colleagues (2000), Gilbert and colleagues (2010), and Link and colleagues (2011).

In 2020, a re-review of the same studies, using the updated CrimeSolutions Program Scoring Instrument, resulted in a new final rating of Promising. Studies that are rated as Promising have some evidence to indicate they achieve their intended outcomes.

These sources were used in the development of the program profile:

These sources were used in the development of the program profile: