Assessing Outcomes for Consumers in New York's Assisted Outpatient Treatment Program
This study examined whether New York State's assisted outpatient treatment (AOT) program, a form of involuntary outpatient commitment, improves a range of policy-relevant outcomes for court-ordered individuals. Administrative data from New York State's Office of Mental Health and Medicaid claims between 1999 and 2007 were linked to examine whether consumers under a court order for AOT experienced reduced rates of hospitalization, shorter hospital stays, and improvements in other outcomes. Multivariable analyses controlling for relevant covariates were used to examine the likelihood that AOT produced these effects. On the basis of Medicaid claims and state reports for 3,576 AOT consumers, the likelihood of psychiatric hospital admission was significantly reduced by approximately 25% during the initial six-month court order (odds ratio [OR]=.77, 95% confidence interval [CI]=.72-.82) and by over one-third during a subsequent six-month renewal of the order (OR=.59, CI=.54-.65) compared with the period before initiation of the court order. Similar significant reductions in days of hospitalization were evident during initial court orders and subsequent renewals (OR=.80, CI=.78-.82, and OR=.84, CI=.81-.86, respectively). Improvements were also evident in receipt of psychotropic medications and intensive case management services. Analysis of data from case manager reports showed similar reductions in hospital admissions and improved engagement in services. Consumers who received court orders for AOT appeared to experience a number of improved outcomes: reduced hospitalization and length of stay, increased receipt of psychotropic medication and intensive case management services, and greater engagement in outpatient services.
[Show abstract] [Hide abstract] ABSTRACT: Since 2009, 14 assertive community treatment (ACT) teams have started up in Norway. Over 30 % of the patients treated by the ACT teams were subject to community treatment orders (CTOs) at intake. CTOs are legal mechanisms to secure treatment adherence for patients with severe mental illness. Little is known about patients’ views and experiences of CTOs within an ACT context. The study was based on qualitative in depth interviews with 15 patients that were followed up by ACT teams and that were currently subjected to CTOs. The data were analyzed by using a modified grounded theory approach. While some participants experienced the CTO as a security net and as an important factor for staying well, others described the CTO as a social control mechanism and as a violation of their autonomy. Although experiencing difficulties and tensions, many participants described the ACT team as a different mental health arena from what they had known before, with another frame of interaction. Despite being legally compelled to receive treatment, many participants talked about how the ACT teams focused on addressing unmet needs, the management of future crises, and finding solutions to daily life problems. Assistance with housing and finances, reduced social isolation, and being able to seek help voluntarily were positive outcomes emphasized by many patients. The participants had different views of being on a CTO within an ACT setting. While some remained clearly negative to the CTO, others described a gradual transition toward regarding the CTO as an acceptablesolution as they gained experience of ACT. Many of the participants valued the supportive relationship withthe ACT team, and communication with the care providers and the care providers’ attitudes could make a significant difference. The study shows that the perception of coercion is context dependent, and that the relationship between care providers and patients is of importance to how patients interpret the providers’ behavior and the restrictive interventions. Although some patients focused on loss of autonomy and being compelled to take medications, other patients emphasised the supportive relationships they had with the ACT teams and that they had received help with housing, finances, and other daily life problems. Thus, being on mandated community treatment could be acceptable in the opinion of several of the patients, provided that they received other services that they found beneficial.0Comments 2Citations
- "The low case load and the shared responsibility within the teams imply that assertive outreach workers have more time, and more opportunities to monitor medication use and to more actively involve patients in treatment planning decisions [53, 54]. Some studies have shown that when CTOs were combined with intensive services (ACT) for more than six months, there was a substantial decrease in hospital admissions rates, total days hospitalized, and improved rates of psychotropic medication use [22, 55]. Our study is in line with other studies that show that patients' lives seem modestly improved under ACT  and that being coerced does not necessarily negatively influence patients satisfaction with treatment [57, 58]. "
[Show abstract] [Hide abstract] ABSTRACT: Background Coercion has always existed in psychiatry and is increasingly debated. The ‘move into the community’ in many countries over recent decades and the evolution of community services have substantially altered the locus of coercion. In many countries psychiatric services remain poorly funded and patchy. Substantial differences between regions and countries in the provision of services, the role of the family, and the wider economic and political climate are likely to lead to different sources and experiences of coercion. Discussion This paper explores a number of factors that may affect the prevalence and type of coercion in psychiatric services and in society and their impact upon those with severe mental illnesses. Differences in service provision are explored and wider societal issues that may impact are considered along with relevant evidence. Conclusions Coercion is commonly experienced by those with severe mental illnesses but is poorly understood. The vast majority of research relates to High Income Group countries with developed community services and formal mental health legislation that adopt the so-called ‘medical model’. Further research and collaboration is urgently required to increase our understanding of these issues, which are difficult to define and measure. An evidence base that is relevant worldwide, not just to a small group of countries, is needed to inform training and the care of all patients. A particular focus must be expanding our knowledge and understanding of coercion in cultures outside those where such research has traditionally taken place to date.0Comments 3Citations
- "The former has typically examined the effects upon outcome in terms of symptoms, functioning, and hospital use (Swartz et al., 2001) whereas the last two have tended to focus on civil liberties, the role of the state and arguments for and against coercive intervention (Eastman, 1997). Recently there have been attempts to take interdisciplinary approaches to the subject (Kallert et al., 2005; Swartz et al., 2010). While there is relatively little empirical research published, there is no shortage of opinion and comment. "
[Show abstract] [Hide abstract] ABSTRACT: The evidence regarding community treatment order effectiveness has been conflicting. This systematic review aims to bring up to date the review performed by Churchill and colleagues in 2005 by assessing and interpreting evidence of CTO effectiveness defined by admission rates, number of inpatient days, community service use, and medication adherence published since 2006. Databases were searched to obtain relevant studies published from January 2006 to March 2013. 18 studies including one randomised controlled trial were included. There remains lack of evidence from randomised and non-randomised studies that CTOs are associated with or affected by admission rates, number of inpatient days or community service use. The most recent and largest RCT is included in this review and found no significant impact on admission rate (RR = 1.0, 95 % CI 0.75-1.33) or number of days in hospital (IR = 0.90, 95 % CI 0.65-1.26). Results from the two largest longitudinal datasets included in this review do not concur. Studies using the New York dataset found that CTOs were associated with reduced admission rates and inpatient days, while studies using the Victoria dataset generally found that they were associated with increased admission rates and inpatient days. There is now robust evidence in the literature that CTOs have no significant effects on hospitalisation and other service use outcomes. Non-randomised studies continue to report conflicting results. Distinguishing between CTO recall and revocation and different patterns of community contact is needed in future research to ensure differentiation between CTO process and outcome.0Comments 24Citations
- "The three studies that investigated medication adherence all reported that CTO use was associated with increased rates of adherence202122. All three based their analysis on the New York dataset and used a proxy measure for adherence called the medication possession ratio (MPR). "