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