Ask your state mental health director to apply for these federal funds to expand Assisted Outpatient Treatment (AOT)

(June/July 2015)

Thanks to Rep. Tim Murphy, there is new federal funding available that can be used to expand access to assisted outpatient treatment. Following is the draft of a letter you should send your state mental health director, local mental health director and share with anyone who is operating an AOT program in your state encouraging them to apply for the funds.

Name of Mental Health Director

Title

Name of Dept

Street

City, State, Zip

Re: Apply for Federal Certified Community Behavioral Health Clinic Funding and use it expand availability of Assisted Outpatient Treatment

Dear name of state mental health director:

The “Protecting Access to Medicare Act of 2014” (H.R. 4302, 2013-2014) established funding for eight states to create two-year Demonstration Projects allowing Certified Community Behavioral Health Clinics (CCBHCs) to be reimbursed prospectively to help people with serious mental illness. As the result of action by Rep. Tim Murphy, Section 223(d)(4(iii) of the law (P.L. 113-93) states that “preference should be given to those (Demonstration Project applicants) that “will improve availability of, access to, and participation in Assisted Outpatient mental health treatment in the State.” The bill is at http://www.gpo.gov/fdsys/pkg/PLAW-113publ93/pdf/PLAW-113publ93.pdf 

On June 8, SAMHSA is hosting a pre-application webinar to inform you how to apply for funding for the Demonstration Programs. See  http://www.samhsa.gov/sites/default/files/sm-16-001-webinar-notification_0.pdf. Your application must be submitted by August 5, 2015. Comprehensive information on all of this is at http://www.samhsa.gov/grants/grant-announcements/sm-16-001.

We strongly urge you to apply for these funds and to specifically use them to increase the availability of Assisted Outpatient Treatment (AOT) in (name of state).  

Thank you very much.

Name

Cc: Local Mental Health Director

       Local Programs with AOT program

Bills to Help People with Mental Illness in California Pass Mental Health Committee

(April 14, 2015) Several California bills proposed by Assemblymembers Eggman, Waldron and Brown passed the mental health committee today and go to other committees. The first two improve Laura's Law, California's Assisted Outpatient Treatment (AOT) program. It allows courts to order  noncompliant persons with mental illness who have already become violent or needlessly hospitalized as a result of going off treatment, to stay in six months of mandated and monitored treatment while they live in the community. It's been very successful in counties and states that use it. The following summaries are based on bills before they were amended by the committees, so this may not be entirely accurate. Check the actual bills.

• AB1193 (Eggman) eliminates the requirement that counties vote to implement Laura's Law and eliminates the requirement that counties certify that voluntary programs are not being cut. Counties that don’t want Laura’s Law have to vote not to have it, rather than to have it as before. It also allows superior court judges to request a Laura’s Law petition be filed for individuals who come before the court. It extends Laura's Law until 2022. 
• AB 59 (Waldron) supposedly complements AB 1193. I believe it removes the sunset (whereas AB 1193 moved it until 2022, but maybe that was one of the provisions removed during the meeting.) It also removes the requirement that counties certify that no voluntary programs are cut before implementing Laura's Law. That certification requirement basically required counties to maintain failed programs before they could implement Laura's Law. The bill originally would have authorized the court to order a person to obtain assisted outpatient treatment for up to 12 months, rather than 6 months as is now the case. But that provision was removed at last minute. It allows hospitals to petition for AOT for people who are involuntarily committed to inpatient care (5150) and who are being released. That is a good idea as there are people who are involuntarily committed who could leave the hospital if Laura's Law was available to them.

Two other bills, not related to Laura's Law, but that help the seriously ill also passed the mental health committee and move to other committees.

• AB1194 (Eggman) allows courts to consider past history when deciding when to 5150 (involuntarily commit) someone. Past history is best predictor of future behavior (l,e someone who went off meds in past, and became violent is more likely to become violent again if they again go off meds). AB1194 now goes to appropriations.  
• AB 1237 (Brown) passed mental health committee and goes to next committee. It requires state hospital system to create pool of psychiatrists to evaluate people who are found mentally incompetent to stand trial or who has been found to be insane at the time he or she committed the crime. 

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.

Research showing AOT (Kendra's Law) in New York works

Research showing AOT (Laura's Law) in California works is here

Footnotes 

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 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.” “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.

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[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.

Nordentoft, M. (2007). Prevention of suicide and attempted suicide in Denmark. Epidemiological studies of suicide and intervention studies in selected risk groups. Danish Medical Bulletin, 54(4),306-69.

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.