About Assisted Outpatient Treatment (AOT)

Assisted Outpatient Treatment (AOT) is for a very small group of the most seriously mentally ill who already accumulated multiple incidents of hospitalization arrest or incarceration associated with their failing to stay in voluntary treatment. AOT allows judges, after full due process to require certain mentally ill to accept six months of mandated and monitored treatment as a condition for living in the community. It provides an off ramp before incarceration. As Linda Dunn said, Assisted Outpatient Treatment is like putting a fence by the edge of the cliff rather than an ambulance at the bottom. (Barnidge 2014)

The research on AOT is extensive and positive. (Mental Illness Policy Org 2013). Six months of mandated and monitored treatment has been shown to reduce homelessness 74%; hospitalization 77%; arrest 83%; incarceration 87%, physical harm to others 47%; property destruction 46%; suicide attempts 55%; and substance abuse (48%). By replacing expensive incarceration and hospitalization with less expensive community care Assisted Outpatient Treatment cuts costs to taxpayers in half. (Swanson, et al. 2013). AOT also reduces victimization. (V.A. Hiday 2002). These results are particularly outstanding because AOT is limited to the most seriously ill, often a very hard to treat population.

New Report: California Mental Health Services Act Fails Seriously Mentally Ill

California Mental Health Services Act Oversight Commissioners (MHSOAC) just issued a press release saying Prevention and Early Intervention (PEI) programs (20% of total MHSA Funds) are working. 

http://www.mhsoac.ca.gov/MHSOAC_Publications/docs/PressReleases/2014/PR_Programs-Work_080514.pdf

However, they didn't even study adults with serious mental illness.

NAMI/National less than honest with members

Call 202 224 3121 or go here and urge your U.S. Representative to co-sponsor HR 3717, the Helping Families in Mental Health Crisis Act.

NAMI State and local chapters do brilliant work trying to improve care for people with the most serious mental illnesses and provide comfort to them and their families. NAMI/National is ignoring the most seriously ill in order to be politically correct.

Representative Tim Murphy (R. PA) has proposed HR3717 the “Helping Families in Mental Health Crisis” that does much of what NAMI local and state members have been begging for.

SAMHSA FAILS SERIOUSLY MENTALLY ILL

A bill in Congress (HR3717, the Helping Families in Mental Health Crisis Act) would change SAMHSA and some wonder why change is needed. SAMHSA (Substance Abuse and Mental Health Services Administration) was created by Congress to “reduce the impact of…mental illness on America’s communities” and “target … mental health services to the people most in need”. SAMHSA has failed to do either. SAMHSA refuses to require its funds reach the most seriously ill and enacts policies to see they don't.

SAMHSA largely ignores the most significant impacts of mental illness on the communities, specifically violence, incarceration, hospitalization, homlessness and suicide. Instead, SAMHSA focuses on improving metrics like 'feeling of empowerment' 'hopefullness' and other softer outcomes.

Info on mental illness related violence in PA

Facts about Pennsylvania Mental Health System and Violence

List of Acts of violence by untreated mentally ill in PA

http://mentalillnesspolicy.org/states/Pennsylvania/preventabletragediesPA.pdf

Pennyslvania needs 3800 more psychiatric beds for the most seriously ill assuming they had perfect services

Chart two at http://mentalillnesspolicy.org/imd/shortage-hosp-beds.pdf

Pennsylvanians are 2X as likely to be incarcerated for mental illness as hospitalized

http://mentalillnesspolicy.org/NGRI/jails-vs-hospitals.html

Statement/Facts on Laura's Law vote in Los Angeles, CA

If You Don't Ask Your US Rep to Cosponsor Helping Families in Mental Health Crisis Act, You are Part of Problem.

Call your US Rep to ask them to co-sponsor HR-3717, the Helping Families in Mental Health Crisis Act for the 6 reasons below:
Background

Five percent of Americans have serious mental illness (i.e., schizophrenia, severe bipolar). Twenty percent have “any” mental illness (i.e., some form of depression, stress, anxiety, social phobia, etc.).  It is the 5% who are most likely to become homeless, suicidal, criminal, arrested, incarcerated and violent. Up to 40% of the most seriously ill are so ill they do not know they are ill (“anosognosia”). While most mentally ill are not violent, that does not hold true for the untreated seriously mentally ill with anosognosia. We can not ignore them. Following are provisions in HR3717 that most directly improve care for the seriously ill and reduce the chance of violence, homelessness, suicide:

Does Assisted Outpatient Treatment Violate Civil Liberties

Does Assisted Outpatient Treatment violate civil liberties of persons with mental illness?  Courts say no, and courts are the arbiters. Courts have decided that since AOT is limited to such a small group (those with a past history of arrest, violence, needless hospitalizations) that AOT is an appropriate use of police power (to protect citizenry) and parens patraie powers (to help those who can't help themselves). 

Another way to look at it is that AOT generally does not affect persons with mental illness. Having a mental illness is not enough to qualify someone for AOT. At most, 123,000 people would be eligible for AOT and research shows that even when AOT is funded, only roughly one-third of those eligible will ever be put on it (41,000 individuals). There are 58 million people who had  a mental illness diagnosis in past year. Therefore the maximum number of people it will affect, is .07% of individuals with mental illness.  

Clearly, not all people with mental illness are being put "at risk". It does not result in the massive depravation of rights claimed by opponents.

The upside is AOT has been proven to work. AOT reduces homelessness, arrest, violence, incarceration over 70% among those enrolled. It is constitutional, does not violate civil liberties; keeps patients public and police safer, is racially neutral, has support from consumers who actually experienced it, and cuts costs to taxpayers in half. 

AOT is smart policy to help deliver treatment to a very small group of the most symptomatic. 

Assisted Outpatient Treatment Pilot Program Grants Passed by Congress

On Monday, March 31, 2014, the Senate passed H.R.4302 which included $60 million for Assisted Outpatient Treatment Pilot Programs. Following is the text of the legislation (Followed by the text of the Excellence in Mental Health Act which was also included in HR 4302) 

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SEC. 224. ASSISTED OUTPATIENT TREATMENT GRANT PROGRAM FOR INDIVIDUALS WITH SERIOUS MENTAL ILLNESS.

(a) In General- The Secretary shall establish a 4-year pilot program to award not more than 50 grants each year to eligible entities for assisted outpatient treatment programs for individuals with serious mental illness.

Treatment of violent mentally ill lowers rates of reoffending. New Study

Important new study: Researchers followed violent offenders (sentenced to 2 years or more) for an average of 10 months following their release and ascertained the rate of violent re-offending. The study included 742 individuals without psychosis; 94 with schizophrenia; 29 with delusional disorder; and 102 with drug-induced psychosis. It also assessed whether the individual’s mental illness was treated in prison, after leaving prison, or not at all.

Is Assisted Outpatient Treatment (Laura's Law, Kendra's Law) "Forced Treatment"?

Someone suggested Assisted Outpatient Treatment (AOT) is "Forced" Treatment (and therefore presumably bad).

1. Describing AOT as "forced treatment" demonstrates a misunderstanding. AOT, by definition, is only used after voluntary treatment fails. They serve mutually exclusive populations. For those individuals who won't access voluntary treatment, perhaps because they are too psychotic or have anosognosia, AOT is a way to reduce forced treatment. It is the last off ramp before patients are put into locked into involuntary commitment wards or put behind locked cell doors. Involuntary commitment to a locked hospital ward or a jail cell is a genuine use of force. The AOT research clearly states AOT reduces the use of those forms of forced treatment.

Affordable Care Act/ACA Fails Seriously Mentally Ill

Many 'mental health' advocates claim that the Affordable Care Act (ACA, a/k/a "Obamacare") combined with "mental health parity" will ensure people with mental health issues get care. The ability to keep a child on your insurance until age 26 will likely help many, since serious mental illness affects people in their late teens, early twenties. Maybe other provisions will help the higher functioning. But as the analysis below shows, overall, it makes things worse for the most seriously ill: those who need long term hospitalization.  Unfortunately, the impact of ACA on the most seriously mentally ill has been largely ignored by 'mental health' advocates.

What is serious mental illness in adults and what is not?

Serious mental illnesses are a small subset of the 300 mental illnesses that are in DSM. While it is fair to debate where the line between serious mental illness (SMI) and poor mental health is, the extremities are clear. The Center for Mental Health Services defined SMI as

mental illnesses listed in DSM that “resulted in functional impairment which substantially interferes with or limits one or more major life activities.” (CMHS 1999)

 By all accounts, serious mental illnesses include “schizophrenia-spectrum disorders,” “severe bipolar disorder,” and “severe major depression” as specifically and narrowly defined in DSM. People with those disorders comprise the bulk of those with serious mental illness. However, when other mental illnesses cause significant functional impairment they also count as a serious mental illness.  

According to the National Institute of Mental Health, serious mental illness is relatively rare, affecting only 5% of the population over 18. Serious mental illness includes schizophrenia; the subset of major depression called “severe, major depression”; the subset of bipolar disorder classified as “severe” and a few other disorders.

Schizophrenia (NIMH defines all schizophrenia as “severe”):  1.1% of the population (FN 1)
The subset of bipolar disorder classified as “severe”:  2.2% of the population (FN 2)
The subset of major depression called “severe, major depression”:  2.0% of the population (FN 3)

Therefore total “severe” mental illness in adults by diagnosis: 5.3% of the population (FN 4)

US mental health spending and mental health non-profits focus almost exclusively on people who do not have serious mental illness, rather than those who do. This is the single major problem with the US mental health system. Money is not lacking. Prioritization is.

Please send letter in Support of Helping Families in Mental Health Crisis Act

If you are part of any organization (state or local NAMI, MHA, Prison Reform, Consumer Group, etc) that wants to help persons with serious mental illness, please send a letter on your letterhead, to Rep. Tim Murphy urging passage of Helping Families in Mental Health Crisis Act (HR 3717). They want as many letters of support from organizations as possible.

You can see the NAMI/NYS letter below and use it as a model. You can see other letters (ex. NAMI National, American Psychiatric Assoc., etc) at http://murphy.house.gov/helpingfamiliesinmentalhealthcrisisact#Letters%20of%20Support

Darrell Steinberg asks Californians to pay twice for same program. Fails Mentally Ill

On December 19, California Senate President pro Tem Darrell Steinberg asked for more money for Mentally Ill Offender Crime Reduction Grants.

If Prop 63/MHSA funds were spent as legislatively required, no new funds would be needed. MHSA already specifically earmarked funds for this. MHSA Sec. 5813.5 (f) says:

Here's what's in the new "Helping Families in Mental Health Crisis" Act

(Left-Representatives Leonard Lance of New Jersey,  Bill Cassidy of Louisiana, a medical doctor, and Congressman Tim Murphy (Psychologist)  introduce the "Helping Families in Mental Health Crisis Act" HR 3717 12/12/13). 

Call your Representative and ask him/her to support HR 3717. To find your Rep phone number, enter your zip code at http://www.opencongress.org/people/zipcodelookup 

BACKGROUND

SPENDING AND SCOPE OF PROBLEM

In 2014, the U.S. will spend $203 billion on mental health. Due to mission-creep, the funds are now spent ‘improving mental health’ rather than treating those with serious mental illness. Moms who have children known to be seriously mentally ill are virtually powerless to see they receive care. While the public becomes aware of the failure of the mental health system after high-profile rare acts of violence, the everyday tragedies faced by people with serious mental illness and their families go unnoticed.

Wellness Recovery Action Plan (WRAP) Lacks Independent Verification and is not Evidence Based

WRAP labeled as 'evidence based' by SAMHSA. 

But is it?

When we ask “is a program evidence-based’, at Mental Illness Policy Org we break that question down into three components:

1.  Does it help people with serious mental illness (ex. schizophrenia, bipolar, major depressive disorders) or is it a program designed to improve the mental health of anyone who feels their mental health can be improved. 
2. Does the program improve a meaningful outcome? To be evidence based, we require it to improve a meaningful independent measure such as reducing suicide, homelessness, hospitalization, violence, substance abuse, arrest, incarceration, etc. Self reports of greatier happiness (“improved mental health”) are not sufficient or unique to WRAP
3. What is the quality and independence of the research.

WRAP (Wellness Recovery Action Plan) has been certified by SAMHSA National Registry of Evidence Based Practices and Programs (NREPP) as an evidence-based intervention. This certification encourages states to implement it. But the evidence is not clear that WRAP improves any meaningful measure like decreasing hospital days, decreasing incarceration, decreasing homelessness or that it is for people with serious mental illness. The certification of unproven programs leads states to waste money.

New NAMI Needed: National Alliance on SERIOUS Mental Illness (NASMI)

I think there needs to be a National Membership Org that focuses exclusively on Serious Mental Illness including important politically incorrect issues that NAMI refuses to address like preservation of enough psychiatric hospital beds, expansion of Assisted Outpatient Treatment (AOT), and relaxation of civil commitment laws.

One way to get it going would be to get former NAMI National Board Members to lend their name, form a nucleus. Perhaps call the new organization the National Alliance on Serious Mental Illness (NASMI)

State and local organizations can eventually make a decision as to whether they prefer to be part of the existing NAMI, or the one that makes serious mental illness their number one priority.

I believe the following former National NAMI Board Members might be willing to help: Eleanor Owen, Bernie Schell, Gerald Tarutis, Carla Jacobs, perhaps Fred Frese, Richard Lamb,and moi. If you know of more names, add them to this post.

Here is the National Alliance on Serious Mental Illness Facebook Page where you can discuss the idea https://www.facebook.com/seriousmentalillness

Obama Mental Illness Parity Regulations Fail to Help the Most Seriously Mentally ill

The Obama administration announced new regulations requiring private insurers to do what the federal government wont: provide health care coverage for mental illnesses equal to that provided for other physical illnesses. The new regulations will help many, but only few of the most seriously mentally ill. And while requiring private insurers to end discrimination against mental illness is to be lauded, it is unconscionable, dangerous and expensive to allow the federal government to continue its own discrimination.

President Obama should focus any incremental social service and health care programs on those who need it most, rather than the higher functioning.

NYC Mental Health Dept. must Prioritize Serious Mental Illness Rather than Mental Health

Testimony by DJ Jaffe, to NYC Dept of Health and Mental HealthNov. 1, 2013

My name is DJ Jaffe. I am Executive Director of Mental Illness Policy Org.

NYC and State used to focus all their resources on people with serious mental illness, but both are engaged in massive mission-creep that now leaves the most seriously ill to fend for themselves. Bullying is the newest cause celebre used by NYC to justify ignoring serious mental illness[1]. The fact that bullying isn’t a mental illness matters not a whit when it comes to spending money. Peer support-in spite of lack of evidence that it reduces violence, arrest, homelessness, suicide and incarceration is flooded with money while Kendra’s Law proven to help the most seriously ill is largely ignored.

NYC has largely abandoned efforts at symptom amelioration for the most seriously ill and instead focuses on ‘recovery’ and ‘wellness’ services for those who are higher functioning. The mental health system, which used to be a mental illness system, has offloaded the most seriously ill to the shelters, prisons, jails and morgues. As a result Riker’s Island is now the primary provider of services to the seriously ill in NYC. There is no known way to prevent mental illness, but ‘prevention’ ranks high in the department’s activities. “Early Identification” is the  new buzz word, when those identified can’t get treatment. Mission-creep and ignoring the elephant in the room: untreated serious mental illness has become policy.

We would ask that NYC stop shunning the seriously mentally ill, end mission creep and return to making serious mental illnesses like schizophrenia and treatment resistant bipolar disorder a department priority.

Here is how NYC can help people with serious mental illness 

Julius Graham, and Riverside Park Stabbings

Ray Kelly says the person Julius Graham, the homeless man who allegedly stabbed multiple individuals in Manhattan today (10/1/13) appears to be 'emotionally disturbed'. Following is info for those who want to understand why the NYS mental health system does such a poor job of preventing violence by persons with serious mental ilness. It is not lack of funding. It is lack of leadership.

NY has a “Tragedy Before Treatment” Mental Ilness Policy. We need a “Treatment Before Tragedy”  System.

In NY hearing voices and being delusional is, not enough to get someone treatment if they don’t recognize they are ill. For that to happen, they have to force the issue by bringing on a tragedy. Rather than prevent violence, NY laws require it.

 About 16% of all the people in Office of Mental Health psychiatric hospitals are forensic patients, who gained admission only after a tragedy occurred and a court process forced the state to admit them.

New York went from 600 beds per 100,000 population in the mid-1950s to fewer than 27 today. As a result, Rikers Island is New York’s largest psychiatric institution, holding more mentally ill people than all Office of Mental Health hospitals combined.

State mental health officials are proposing to close more psychiatric hospital beds, thereby making hospitalization even more difficult. They claim few of the existing beds are used, but that is only because the Office of Mental Health discharges patients “sicker and quicker” to artificially reduce the count. Experts say, to meet minimum standards, NYS needs 4300 more beds to serve those with serious mental illness. Here's what we need to do.

Mental Health First Aid Unproven & Should Not Be Funded

• Mental Health First Aid (MHFA) lacks sufficient proof it helps people with serious mental illness. 
• The venders of the program and those who want to purchase it, have convinced Congress to introduce a bill to have taxpayers pay for it. 
• Those funds would be better used on programs proven to help people with serious mental illness.

(Note: If anyone has research contrary to that which we discuss, please post it in comments section. Our goal is to make sure our information and conclusions are accurate. Thank you)

Background: Mental Health First Aid (MHFA) is a commercially available training program created in Australia and now sold by the National Council for Community Behavioral Healthcare, the Maryland Department of Health and Mental Hygiene, and the Missouri Department of Mental Health to non-profits in the United States. The training program purports to teach people to identify the symptoms of mental illness in others and connect them to help. They also license others to be trainers for a fee. Participants get a certificate saying they received the training.

As part of his “Now is the Time” initiative in response to the shootings at Newtown, President Obama announced support  for  Mental Health First Aid. The organizations above, plus NAMI, MHA and others are now lobbying Congress to spend $20 million dollars for passage of The Mental Health First Aid Act of 2013 (S. 153/H.R. 274). The program is shown to make those who receive and give the training feel better, but has not been shown to have an impact on those they are supposed to be helping: people with serious mental illness.

Congress should not fund MHFA, and instead use the funds for programs that work. (Read more)

Rep. Tim Murphy Announces Important Mental Health Legislation

This is big news.

Rep Tim Murphy (R. PA) is a former child psychologist, and head of the Mental "Health" Caucus. In spite of that,  he totally gets serious mental "illness" in adults and what the important versus tangential issues are.  He is as good as a Wellstone or a Domenici, and better than a Kennedy (who tended to focus on mental 'health' versus mental 'illness')

Rep. Tim Murphy has held extensive hearings where he listened to others focused on the most seriously ill including Dr. E. Fuller Torrey, Sally Satel, Joe Bruce , Ed Kelly. He also received extensive input from consumers around the country who contacted him. He  announced the results of his hearings today and the legislation he intends proposing.  It includes preserving hospitals, AOT (a/k/a Kendra's Law), revising HIPPA Handcuffs ( so families can get the info they need to help mentally ill loved ones), reigning in SAMHSA's anti-treatment activities , increasing police training, increasing NIMH budget for serious mental illness, and other key issues. I am very excited. 

 I am no Washington Insider, so I have no knowledge if it will fly or not. But at least someone is focused on right issues, not just PC tangential ones. Please support these efforts. He is totally on the right track. His press release and link to the floor speech follows: (Read more)

Tell Governor Brown to Sign SB 585 to allow MHSA Funds for Laura's Law

(Updated 9/3/13)

Urgent: Contact Governor Jerry Brown immediately (Sept. 2013) and URGE HIM TO SIGN SB 585 which will help clarify that Mental Health Services Act (Prop 63) funds may be used to fund Laura's Law.  Phone: (916) 445-2841.  Fax: (916) 558-3160 and use his online contact form.

Background:

Laura's Law allows courts to order a small group of people who have serious mental illness and a history of dangerousness to stay in treatment as a condition of living in the community. It has reduced arrest, incarceration, hospitalization and length of hospitalization in the two counties that use Laura's Law.

Two Reasons Counties Haven't Implemented Laura's Law:

There are two reasons more counties don't implement Laura's Law. Three million dollars in Mental Health Services Act (MHSA) funds are going to Disability Rights California and they are using those funds to threaten to sue counties that use any MHSA funds to implement Laura's Law even though such expenditure is clearly allowed. Laura's Law requires county boards of supervisors to vote to implement Laura's Law and simultaneously certify that no voluntary programs will be cut to do it.

Steinberg initially promised to help:

 In reaction to widespread outrage that people were being denied access to MHSA funded programs merely because they were so sick they were eligible for Laura's Law, Senator Steinberg introduced SB 585 in early April. The ostensible purpose was to clarify that MHSA funds could be used for people in Laura's Law.  But Steinberg  weakened his own bill. He added back a requirement that other bills by other legislators would have removed. Specifically, he added back a requirement that boards of supervisors vote (directly or through the budget process) to implement Laura's Law. And he added back a requirement that counties certify no voluntary programs will get cut to implement Laura's Law.

Unfortunately, SB 585 is the only bill Steinberg would let pass. And since it does somewhat clarify that MHSA funds can be used for Laura's Law, we are supporting it. Contact Governor Jerry Brown immediately (Sept. 2013) and urge him to sign SB 585 which will help clarify that Mental Health Services Act (Prop 63) funds may be used to fund Laura's Law. Phone: (916) 445-2841 Fax: (916) 558-3160 and use his  online contact form. 

California's Prop 63/Mental Health Services Act Fails Seriously Mentally Ill

In 2004, Californians altruistically passed a 1% tax on millionaires specifically to fund services for people with serious mental illness. As a result of reports that the funds were not reaching people with serious mental illness Mental Illness Policy Org. conducted a study and found many of the complaints to be true. Below is a summary of our report released August 15, 2013. The full report is here Our op-ed in San Diego Union Tribune is here. We shared our concerns with the California State Auditor.

California’s Mental Health Service Act:   A Ten Year $10 Billion Bait and Switch 

An investigation by Mental Illness Policy Org and Individual Californians

August 15, 2013 

Background

In November, 2004 California voters enacted a 1% tax on millionaires (Prop 63) to establish the Mental Health Services Act (MHSA) fund solely to help people with serious mental illnesses.[1] $10 billion has been raised since inception. Voters also created a Mental Health Services Oversight and Accountability Commission (MHSOAC a/k/a “Oversight Commission”) to see the program stuck to its purpose of helping people with serious mental illness.

Primary Findings

Many people with serious mental illness are receiving critical treatment as a result of Prop 63 but billions are being diverted to other purposes:

•  $1-2 Billion of Prevention and Early Intervention (PEI) Funds was intentionally diverted to social service programs masquerading as mental illness programs or falsely claim they prevent serious mental illness.
• ·$2.5 billion of the “Full Service Partnership (FSP) funds were spent without oversight of whether the recipients had schizophrenia, bipolar disorder, or the other serious mental illnesses that made them eligible for MHSA funds.
•  $23 million went to organizations directly associated with Oversight Commissioners.
• $11 million is going to PR firms that make the Oversight Commissioners look good and hide the failure of MHSA to accomplish its mission
• $9 million is going to organizations working prevent the seriously ill from receiving treatment until after they become violent.
• ·Up to $32 million was diverted to TV shows, radio shows, PSAs and other initiatives designed to reach the public without mental illness. Some feature the Senate President Pro Tem Darrell Steinberg

Additional Findings