Monday, December 22, 2014

Re: NYPD Shootings: Cuomo Should Sign "Prisoner Mental Health Discharge Bill" Today

Even after mentally ill ex-prisoner Ismaaiyl Brinsley who shot New York Police Department officers Liu Wenjin and Raphael Ramosa, New York State Governor Cuomo is refusing to sign a bill (S7818) that passed both houses and is on his desk right now. 

The “Prisoners Mental Health Discharge Planning Bill”  would require prison officials to make sure prisoners with mental illness who are being released are 
  • given a discharge plan, 
  • an appointment with a community program, 
  • and enough medications to last until the appointment. 
  • It also adds parole officials to the list of people who can refer someone with a mental illness to a hospital for evaluation. 
Ismaaiyl Brinsley was reported by his mom to be mentally ill, and reported to have been previously institutionalized and incarcerated. While Brinsley was not released from a New York prison, this bill would help improve care and prevent violence by those with mental illness who are. Cuomo should sign it today. 

Supporters
NYS Association of Chiefs of Police 
National Alliance on Mental Illness of NYS  

Sponsors 
Senator Catharine Young (Senator representing Kendra Webdale’s parents district in Buffalo)  
Assemblyman Danny O’Donnell (NYC)  

We also note that Mayor DeBlasio's Task Force on Mentally Ill at Riker's failed to include expansion of Kendra's Law in their recommendations. Kendra's Law reduces homelessness, arrest, violence and incarceration by the mentally ill prisoners who are enrolled by keeping them in mandated and monitored community treatment.

In both Albany and NY officials are ignoring the most seriously ill. 

Finally, we thank Rep. Tim Murphy (R.PA) for introducing HR 3717, The Helping Families in Mental Health Crisis Act which addresses serious mental illness rather than ignoring it.

(This was written quickly. Sorry for any typos). 


Visit http://mentalillnesspolicy.org for science based info on serious mental illness intersecting with violence.








Monday, November 17, 2014

Mental Health Advocates versus Mental Illness Advocates


Excerpts from Speech to NAMI/NYS Convention
By DJ Jaffe
Exec. Dir. Mental Illness Policy Org.
November 15, 2013

I am supposed to talk on legislation here and in Washington, and I would be glad to talk about that. But before beginning I want to make clear that like most of you, I am not a mental health advocate. 

Like most of you, I am a mental illness advocate.  I think we need less mental health spending and more mental illness spending.  It is the most seriously ill not the worried-well, who disproportionately become homeless, commit crime, become violent, get arrested incarcerated or hospitalized. 360,000 are behind bars and 200,000 homeless because we are now focused on improving mental health, rather than treating serious mental illness.

My number one message is that we have to stop ignoring the most seriously ill. Send them to the front of the line for services rather than jails shelters prisons and morgues.  I’ll talk about how mental health advocates ignore the seriously ill, followed by how the debate between mental health and mental illness is being reflected in legislation in Washington and Albany.

Now before beginning, I admit the boundary between mental health and mental illness is debatable, but the extremities are clear. 100% of the population can have their mental health improved. 20% have some sort of illness that can be found in DSM, mainly minor illnesses like anxiety. And most of the illnesses in DSM are minor. But only 4.2% have a serious mental illness like schizophrenia, treatment resistant bipolar, major severe depression or another illness that prevents them from functioning.

Historically, people with serious mental illness were a priority because our budget was spent on the hospitalized. But mental health advocates have changed our focus. The federal government spends $130 billion mental health dollars, much on improving the mental health of all Americans-or as former NYS OMH Commissioner Michael Hogan argued, “to create hope filled environments where people can grow”

I say we stop ignoring the seriously mentally ill.

That distinction between mental health and mental illness is the main debate going on today around the country and is certainly at the core of the two bills Congress is now considering and was at the core of some bills being considered in New York like the SAFE Gun Control Legislation.  NAMI/NYS is one of the few groups doing both.  They have always done a stellar job at trying to improve the mental health of the 20% and they also advocate for the 4%. So if someone asks me, “Where do I stand” it is with NAMI/NYS. Although I should add, my comments today are mine, not theirs. 

Let me talk about how mental health advocates drive care away from the most seriously ill. 

Mental "health" advocates claim everyone is well enough to volunteer for treatment. That is simply not true. As Congressman Murphy-who is also a psychologist, mentioned last night, some have anosognosia: They are so sick, they don’t know they are sick because the brain is impaired so insight is lacking. When you see someone walking down the street screaming they are the Messiah it is not because they think they are the Messiah. They know it. Their illness tells them it is so.

We have to stop ignoring the seriously ill  

Other mental "health" advocates claim mental illness affects everyone and claim all mental illness is serious. They are wrong. All mental illness is not serious. Many people I worked with including myself, have had or have depression, anxiety, have trouble sleeping, take Zoloft or Prozac, or nothing and do quite well.  We don’t need funds diverted from the seriously ill to the highest functioning.

Mental "health" advocates claim everyone recovers. That is False. Some do not. They actually hide those who don’t recover. You won’t see the homeless and psychotic in their Mental Health Awareness Week PSAs because they want everyone to believe all mentally ill are high functioning. Trying to gain sympathy for mental illness by only showing the high functioning is like trying to end hunger in Africa, by only showing the well-fed.

We have to stop ignoring the seriously ill

There are two trade associations here in Albany that do some good work for the high functioning, but claim to speak for those with serious mental illness. They want OMH to close hospitals that serve the seriously ill and turn the money over to them.  That would be wrong. We are short 95000 hospital beds, nationwide and 4000 in NY, even if we had perfect community services.  When hospitals go down incarceration goes up. There are so few hospitals, today it’s harder to get into Bellevue than Harvard and once in you’ll be discharged sicker and quicker. Here in Albany last week Desmond Wyatt was released from the Capital District Psychiatric Center and killed his mother the next day.  His brother told police Desmond was hearing voices but that didn’t stop the hospital from releasing him.
We have to stop ignoring the seriously ill.
Mental health advocates work to convince the public that violence is not associated with mental illness. That may be true for the high functioning but violence is clearly associated with untreated serious mental illness. To convince the public mentally ill are not more violent, mental health advocates quote studies of the treated. Those studies prove treatment works, not that the untreated are not more violent than others. Or they quote studies of the 20% with any mental illness not the 4% with serious mental illness. Their studies are of those in the community and therefore exclude the violent: those in jails, in prisons, involuntarily committed, or have completed suicide.

They argue even talking about violence causes stigma. Talking about violence is a prerequisite to reducing it. It is violence by the small minority that tars the non-violent majority. Their failure to admit to violence is preventing us from implementing policies to reduce it.

We have to stop ignoring the seriously ill.

Current laws prevent people from getting treatment until after they become danger to self or others. That’s ludicrous. Laws should prevent violence not require it. Think seatbelts. But mental "health" advocates want civil commitment to be even more difficult. They argue involuntary treatment is bad without recognizing jail and prison are worse. They argue against medications and restraint and as the NY Times pointed out on Monday that is causing hospitals to become dangerous places. Patients can’t be restrained so hospitals call police. Mental health advocacy is causing seriously mentally ill patients into prisoners.

We have to stop ignoring the seriously ill.

Mental Health Advocates are working to stop Assisted Outpatient Treatment (Kendra’s Law). AOT is the most successful treatment for the small group of the most seriously ill who already accumulated multiple incidents of violence, arrest, incarceration, or needless hospitalization because of their refusal, actually their inability, to be well enough to volunteer for treatment. Kendra’s allows courts to order six months of mandated and monitored community treatment.  It is less restrictive than the alternatives: inpatient commitment and incarceration. It reduces arrest, suicide, hospitalization and violence among people with serious mental illness over 70% each and cut costs in half creating more funds for services for all.

Peer support may do something. But it is not proven to do anything like what Kendra’s Law does. But mental health advocates want to replace Kendra’s Law with peer support.

We have to stop ignoring the seriously ill

Mental "health"  advocates encourage government to spend more on prediction and prevention. As we heard in multiple sessions yesterday, we don’t know how to predict or prevent serious mental illness because we don’t know what causes it.  They argue we should focus our spending on children because half of all mental illness begins before age 14.  But the statement is only true if you include substance abuse. The study the claim is based on actually EXCLUDED serious mental illnesses like schizophrenia and bipolar. Serious mental illness begins in late teens and early twenties and continues after that. That’s where we have to focus our attention.

Mental "health" advocates argue mental illness is associated with bad grades, poverty, single parent households, and their latest cause, bullying and cyberbullying so we should divert funds meant to help the seriously ill to improve grades, end poverty, improve marriages and address cyberbullying.  Those are worthy social services issues but are not mental illnesses. Spending mental health funds on those diverts attention from mental illness.   Mental "health" advocates claim trauma is a mental illness. Trauma is not a mental illness. PTSD is. It can be extreme or mild.

Stop Diverting the Money!

Mental  "health" advocates blame police when something goes wrong, and want more CIT training as do I. But police only step in when one condition has been met: The mental health system failed. And mental health advocates fail to recognize that as their diverting funds to the tangential rather than the consequential is largely responsible for the system failing. As mental 'health" advocates abandoned advocating for the seriously ill, criminal justice has stepped up: Largely thanks to Chief Biasotti, the International and NYS Associations of Chiefs of Police, Dept. of Justice, National Sheriffs Association, and others have become the leading voices on how to improve care for the seriously ill.

Now I’d like to turn to how this debate between mental health and serious mental illness is playing out in New York and Washington.

What is interesting to me, is that generally it is Republicans, not Democrats who are helping the seriously ill.  I am a left wing Democrat so it pains me to say, but my party is generally oblivious to the fact that throwing more money at mental health does not improve treatment for people with serious mental illness. Democrats have been captured by mental health advocates and therefore ignore unpleasant truths like not everyone recovers, sometimes hospitals are needed; and left untreated a small subset of the most seriously ill do become violent.  
For example, in NY, when Governor Cuomo said he was going to pass legislation requiring therapists to report potentially dangerous mentally ill to criminal justice so they could be banned from owning firearms, there was no way to stop it. But Republicans inserted provisions requiring the reports to go through county mental health directors rather than directly from therapist to criminal justice. Why? Because that was a way to force county mental health departments to become aware of seriously mentally ill who live in their counties. The hope was they would offer treatment not just take guns away.  Directors fought the provision, preferring to keep their heads in the sand.  They called it an ‘unfunded mandate’. Helping the seriously ill is not an unfunded mandate, it is their mandate.

Much of the rest of the speech was dedicated to explaining the provisions of the Helping Families in Mental Health Crisis Act (HR 3717), why a competing bill doesn't help, and myths raised by mental health advocates about it. 
To improve care for people with serious mental illness money is not missing, leadership is. We have to stop listening to mental health advocates and start listening to mental illness advocates. We need to replace mission creep with mission control. As Police Chief Biasotti, testified to Congress,

We have two mental health systems today, serving two mutually exclusive populations: Community programs serve those who seek and accept treatment. Those who refuse, or are too sick to seek treatment voluntarily, become a law enforcement responsibility. …(M)ental health officials seem unwilling to recognize or take responsibility for this second more symptomatic group.”

We have to stop ignoring the seriously ill.

Thank you.

Friday, October 31, 2014

Research Shows Assisted Outpatient Treatment (AOT) Works


AOT allows courts to order six months of mandated and monitored treatment in the community for a very small group of people with very serious mental illness who have previously become arrested, incarcerated, violent, homeless or hospitalized multiple times as a result of their failure to comply with treatment, often because they are so ill they don't know they are ill ("anosognosia").

More than two decades of research and practice show it works. AOT reduced hospitalizations[i], arrests[ii], incarcerations, crime[iii], victimization[iv] and violence[v] and improved treatment adherence[vi] The Department of Justice deemed AOT to be an effective evidence-based program for reducing crime and violence[vii]; AOT also produces significant taxpayer/system cost savings. New York’s program achieved savings of 50% in the first year and an additional 13% in the second year. A study in North Carolina reported similar cost savings of 40%[viii]. These savings free up mental health funds to treat more people or provide better treatment.

Footnotes 

Wednesday, October 29, 2014

Biggest Police Group Endorses Greater Use of Assisted Outpatient Treatment (AOT)


“AOT helps prevent mental health officials from offloading 
the most seriously mentally ill to jails, shelters, prisons and morgues.” 

(Oct. 29, 2014) The International Association of Chiefs of Police (IACP) took steps to improve care for people with serious mental illness and protect the safety of officers by endorsing greater use of Assisted Outpatient Treatment (AOT) at their 2014 annual meeting in Orlando, FL. Research collected by Mental Illness Policy Org shows AOT reduces arrest, suicide, hospitalization and violence by people with the most serious mental illnesses over 70% each. By replacing more expensive and liberty-depriving inpatient commitment and incarceration with less expensive outpatient treatment, AOT cut taxpayers’ costs in half. DJ Jaffe, Executive Director of Mental Illness Policy Org. said “Police step in when one condition has been met: the mental health system failed. This resolution will encourage mental health departments to do the right thing. If implemented it will save the lives of patients and police.”

AOT allows judges to order a small group of the most seriously ill to stay in six months of mandated and monitored treatment while they live in the community. It is limited to those who have already accumulated multiple episodes of homelessness, hospitalization, violence, arrest or incarceration associated with going off treatment. Representative Tim Murphy (R. PA) included funding for AOT in the Helping Families in Mental Health Crisis Act (HR 3717). AOT is known as “Kendra’s Law” in New York and “Laura’s Law” in California after two women who were killed by persons with untreated serious mental illness. Families of the seriously ill in those states had been arguing for AOT to help their ill family members get treatment, but could not get mental health departments to listen to them until after the tragedies.

As the result of the mental health system’s refusal to deliver services to the most seriously ill, and preferring to treat the highest functioning, there are now ten times as many mentally ill incarcerated as hospitalized according to the Treatment Advocacy Center. New Windsor, NY Police Chief Michael Biasotti conducted a survey of 2400 senior law enforcement officers and recently told CongressWe have two mental health systems today, serving two mutually exclusive populations: Community programs serve those who seek and accept treatment. Those who refuse, or are too sick to seek treatment voluntarily, become a law enforcement responsibility.” “AOT will help return care and treatment of the seriously mentally ill back to the mental health system where it belongs” said Jaffe. The National Sheriff’s Association and Department of Justice previously endorsed AOT as has almost every major organization concerned about care and treatment of the most seriously ill. Chief Michael Biasotti and outgoing IACP President Yost Zakhary were responsible for obtaining the IACP endorsement. Mental Illness Policy Org urges local chiefs to encourage their mental health departments and legislatures to make greater use of it.

A copy of the IACP Resolution follows or get PDF version to share with local law enforcement and mental health officials. Learn about AOT in New York (Kendra's Law) and about AOT in California (Laura's Law)

Mental Illness Policy Org. is an independent science based think tank on serious mental illness (not mental health) @MentalIllPolicy

IACP Endorses Assisted Outpatient Treatment 
Resolution adopted by IACP October 28, 2014
PDF VERSION

WHEREAS, law enforcement officers are often the first responders to individuals in mental health crisis; and
WHEREAS, law enforcement officers continue to experience an increase in interactions with people with severe mental illness[1]; and
WHEREAS, such interactions consume a disproportionate amount of limited law enforcement resources[2]; and
WHEREAS, approximately forty percent of individuals with severe mental illness are not receiving treatment, primarily because the illness affects their ability to voluntarily participate in needed care[3]; and
WHEREAS, noncompliance with treatment, specifically non-adherence to medication, is strongly associated with hospitalization,[4] suicide,[5] victimization,[6] violence[7] and relapse;[8] and
WHEREAS, noncompliance with treatment is also strongly associated with arrest and incarceration,[9] resulting in a disproportionate representation of individuals with severe mental illness in the criminal justice system; and
WHEREAS, a 2014 report found that 10 times more mentally ill persons are in prisons and jails than are receiving treatment in state psychiatric hospitals[10]; and
WHEREAS, Assisted Outpatient Treatment (AOT) provides court-ordered treatment in the community for high-risk individuals with severe mental illness and a history of treatment noncompliance, as a less restrictive alternative to inpatient hospitalization; and
WHEREAS, more than two decades of research and practice document AOT as an effective tool to improve outcomes for this focus population, including reduced hospitalizations[11], arrests[12], incarcerations, crime[13], victimization[14] and violence[15] while increasing treatment adherence[16] and substance abuse treatment outcomes; and
WHEREAS, numerous state and local law enforcement associations support and have championed the passage and implementation of AOT programs; and
WHEREAS, the Department of Justice deemed AOT to be an effective evidence-based program for reducing crime and violence[17]; and
WHEREAS, studies amply demonstrate AOT’s effectiveness in reducing arrests and incarcerations, e.g., a recent study of New York State’s signature AOT program (“Kendra’s Law”) concluded that the “odds of arrest in any given month for participants who were currently receiving AOT were nearly two-thirds lower” than those not receiving AOT[18]; and
WHEREAS, AOT also produces significant taxpayer/system cost savings, ultimately increasing overall service capacity and leading to greater access for both voluntary and involuntary recipients. A cost-impact study in New York City found net cost savings of 50% in the first year and an additional 13% in the second year; a study in North Carolina reported similar cost savings of 40%[19]; now, therefore be it
RESOLVED, that the International Association of Chiefs of Police (IACP) recommends the authorization, implementation, appropriate funding, and consistent use of Assisted Outpatient Treatment (AOT) laws to ensure treatment in the least restrictive setting possible for individuals whose illness prevents them from otherwise accessing such care voluntarily.



[1] Biasotti, Michael C. Management of the severely mentally ill and its effects on homeland security. Naval Postgraduate School Monterey Ca. Dept. of National Security Affairs, 2011.
[2] Biasotti, Michael C. Management of the severely mentally ill and its effects on homeland security. Naval Postgraduate School Monterey Ca. Dept. of National Security Affairs, 2011.
[3] Substance Abuse and Mental Health Services Administration. (2013). Results from the 2012 National Survey on Drug Use and Health: Mental Health Findings. NSDUH Series H-47, HHS Publication No. (SMA) 13-4805.
[4] Valenstein, M., Copeland, L., Blow, F., et al. (2002). Pharmacy data identify poorly adherent patients with schizophrenia at increased risk for admission. Med Care 40:630–639.
Weiden, P., Kozma, C., Grogg, A., et al. (2004). Partial compliance and risk of rehospitalization among California Medicaid patients with schizophrenia. Psychiatric Services 55:886–891.
Gilmer, T., Dolder, C., Lacro, J., et al. (2004). Adherence to treatment with antipsychotic medication and health care costs among Medicaid beneficiaries with schizophrenia. American Journal of Psychiatry 161:692–699.
Ascher-Svanum, H., Faries, D., Zhu, B., et al. (2006). Medication adherence and long-term functional outcomes in the treatment of schizophrenia in usual care. Journal of Clinical Psychiatry 67:453–460.
Velligan, D., Weiden, P., Sajatovic, M., Scott, J., Carpenter, D., Ross, R., Docherty, J., (2009). The expert consensus guideline series: adherence problems in patients with serious and persistent mental illness. Journal of Clinical Psychiatry. 70 Suppl 4:1-46; quiz 47-8.
[5] Muller-Oerlinghausen, B., Muser-Causemann, B. & Volk, J. (1992). Suicides and parasuicides in a high-risk patient group on and off lithium long-term medication. Journal of Affective Disorders, 25(4),261-269.
Leucht S., Heres S. (2006). Epidemiology, clinical consequences, and psychosocial treatment of nonadherence in schizophrenia. Journal of  Clinical Psychiatry, 67(Suppl. 5), 3–8.
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Chapman, S.C., Horne, R. (2013). Medication nonadherence and psychiatry. Current Opinion in Psychiatry, 26(5),446-552.
[6] Hiday, V., et al. (1999). Criminal Victimization of Persons with Severe Mental Illness. Psychiatric Services, 50, 62-68.*
*Individuals with severe psychiatric disorders who were not taking medication were found to be 2.7 times more likely to be the victim of a violent crime (assault, rape, or mugging) than the general population.
[7] Swartz, M., Swanson, J., Hiday, V., Borum, R., Wagner, H., Burns, B. (1998). Violence and severe mental illness: The effects of substance abuse and nonadherence to medication. American Journal of Psychiatry, 155, 226-31.
Substance abuse, medication non-compliance and low insight into illness operate together to increase violence risk. Van Dorn, R., Volavka, J., Johnson, N. (2011). Mental disorder and violence: is there a relationship beyond substance use? Social Psychiatry and  Psychiatric Epidemiology.
Witt, K., Van Dorn, R., Fazel, S. (2013). Risk factors for violence in psychosis: Systematic review and metaregression analysis of 110 studies. PLOS  ONE, 8, e55942.
Belli, H., Ozcetin, A., Erteum, U., et al. (2010). Perpetrators of homicide with schizophrenia: sociodemographic characteristics and clinical factors in the eastern region of Turkey. Comprehensive Psychiatry, 51,135-41.
Alia-Klein, N., O’Rourke, T., Goldstein, R., et al. (2007). Insight into illness and adherence to psychotropic medications are separately associated with violence severity in a forensic sample. Aggressive Behavior, 33, 86–96.
Elbogen, E., Van Dorn, A., Swanson JW, et al. (2006). Treatment engagement and violence risk in mental disorders. British Journal of Psychiatry, 189,354–360.
Swanson, J., Swartz, M., Essock, S., et al. (2002). The social-environmental context of violent behavior in persons treated for severe mental illness. American Journal of Public Health, 92, 1523–1531.
Bartels, J., Drake, R., Wallach, M., et al. (1991). Characteristic hostility in schizophrenic outpatients.  Schizophrenia Bulletin, 17, 163–171.
[8] Robinson, D. (2010). First-episode schizophrenia. CNS Spectrum, 15 (Supplement 6), 4-7.
Ayuso-Gutierrez, J., Del Rio, V. (1997). Factors influencing relapse in the long-term course of schizophrenia. Schizophrenic Research, 28, 199-206.
Morken, G., Widen, J., Grawe, R. (2008). Non-adherence to antipsychotic medication, relapse and rehospitalisation in recent-onset schizophrenia. BMC Psychiatry, 8,32-8.
Suppes, T., Baldessarini, R., Faedda, G., Tohen, M. (1991). Risk of recurrence following discontinuation of lithium treatment in bipolar disorder.  Archives of General Psychology, 48(12),1082-1088.
Franks, M., Macritchie, K., Mahmood, T., Young, A. (2008) Bouncing back: is the bipolar rebound phenomenon peculiar to lithium? A retrospective naturalistic study. Journal of Psychopharmacology, 22(4), 452-456.
[9] Munetz, M.R., Grande, T.P., & Chambers, M.R. (2001). The incarceration of individuals with severe mental disorders. Community Mental Health, 34:361-71.* * Nearly 90 percent of a sample of individuals with severe mental illness in a local jail were partially or completely non-complaint with medication in the year before they were incarcerated.
Lattimore, P. K., Broner, N., Sherman, R., Frisman, L., & Shafer, M. S. (2003). A comparison of prebooking and postbooking diversion programs for mentally ill substance-using individuals with justice involvement. Journal of Contemporary Criminal Justice, 19(1), 30-64.* *Individuals with co-occurring mental illness and substance abuse who are noncompliant with medication have a threefold increase in risk for arrest and are significantly more likely to be at risk for violent behavior.
Ascher-Svanum, H., Nyhuis, A.W., Faries, D.E., Ball D.E., & Kinon B.J. (2010). Involvement in the US criminal justice system and cost implications for persons treated for schizophrenia. BMC Psychiatry, 10:11.
Shelton, D., Ehret, M. J., Wakai, S., Kapetanovic, T., & Moran, M. (2010). Psychotropic medication adherence in correctional facilities: A review of the literature. Journal of Psychiatric and Mental Health Nursing, 17(7), 603-613.
[10] Torrey, EF, Zdanowicz, MT, Kennard, AD, et al. The treatment of persons with mental illness in prisons and jails: a state survey. Treatment  Advocacy Center and National Sheriff’s Association, April 8, 2014.
[11] Swartz, M., Swanson, J., Wagner, H., Burns, B., Hiday, V., & Borum, R. (1999). Can involuntary outpatient commitment reduce hospital recidivism: Findings from a randomized trial with severely mentally ill individuals. American Journal of Psychiatry 156: 1968-1975.
Swartz, M., Swanson, J., Steadman, H., Robbins, P., & Monahan J. (2009).  New York state assisted outpatient treatment program evaluation. Duke University School of Medicine.
[12]Gilbert, A., Moser, L., Van Dorn, R., Swanson, J., Wilder, C., Robbins, P., Keator, K., Steadman, H., & Swartz, M. (2010). Reductions in arrest under assisted outpatient treatment in New York. Psychiatric Services 61: 996-999.
[13] New York State Office of Mental Health. 2005. Kendra’s Law: Final Report on the Status of Assisted Outpatient Treatment.
[14] Hiday, V., Swartz, M., Swanson, J., Borum, R., & Wagner, R. (2002). Impact of outpatient commitment on victimization of people with severe mental illness.  American Journal of Psychiatry, 159: 1403-1411.
[15] Phelan, J., Sinkewicz, M., Castille, D., Huz, St., & Link, B. (2010). Effectiveness and outcome of assisted outpatient treatment in New York state. Psychiatric Services 61: 137-143.
[16] New York State Office of Mental Health. 2005. Kendra’s Law: Final Report on the Status of Assisted Outpatient Treatment.
[17] National Institute of Justice, Program Profile Assisted Outpatient Treatment (AOT). Retrieved August 27, 2014, from  http://www.crimesolutions.gov/ProgramDetails.aspx?ID=228
[18] Gilbert, A., Moser, L., Van Dorn, R., Swanson, J., Wilder, C., Robbins, P., Keator, K., Steadman, H., & Swartz, M. (2010). Reductions in arrest under assisted outpatient treatment in New York. Psychiatric Services 61: 996-999.
[19] Swanson, J., Van Dorn, R.,  Swartz, M., Robbins, P., Steadman, H., McGuire, T., & Monahan, J. (2013). The cost of assisted outpatient treatment: Can it save states money? American Journal of Psychiatry 170:1423-1432.