BACKGROUND PAPER
June 2016
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SUMMARY
Violent behavior by individuals with untreated serious mental illness is a source of significant and growing public and policy concern. Most people with disorders such as schizophrenia and bipolar disorder are not violent, and most violent acts are not committed by individuals with psychiatric disease. Nonetheless, serious mental illness, primarily when untreated, is a well-documented risk factor for violence, including suicide, homicide and mass homicide. To reduce the risk of violence and the high-profile tragedies and stigma associated with it, the search to identify interventions that improve outcomes for the most severe and persistent mental illnesses and, specifically, to reduce the risk of violence has intensified in recent years.
Assisted outpatient treatment (AOT) is one such intervention. AOT is the practice of delivering outpatient treatment under court order to adults with severe mental illness who meet specific criteria, such as a prior history of repeated hospitalizations or arrest. In the process, the treatment system is committed to the patient at the same time the patient is committed to treatment. The Department of Justice, Office of Justice Programs, has deemed AOT to be an evidence-based practice for reducing crime and violence, and the International Association of Chiefs of Police and National Sheriffs’ Association have endorsed its use. Also known as “involuntary outpatient commitment,” “mandated outpatient treatment” and by other terms, AOT is authorized by statute in 46 states and the District of Columbia.
EVIDENCE-BASED PRACTICE
The role of AOT in reducing violence associated with untreated mental illness has been the subject of study since the 1990s. Findings include the following.
- AOT resulted in a 36% decrease in violent behavior after one year.
In North Carolina, 262 individuals “with psychotic or major mood disorders” were randomly assigned to AOT or to outpatient care without a court order. Violent behavior defined as fights involving physical contact, physical assault or a threat of assault with a weapon was assessed every four months. For participants engaged in AOT at least 12 months, “the results were striking. The extended [AOT] group had a significantly lower incidence of violence during the year: 26.7% v. 41.6% . . . p=0.025.” - AOT resulted in a 47% decrease in violent behavior (physically harming others) after six months.
In New York, outcomes involving 2,745 individuals who participated in AOT (known in New York as “Kendra’s Law”) between 1999 and 2004 were analyzed. Among participants, 84% were diagnosed with schizophrenia or bipolar disorder, and 52% had a co-occurring substance abuse disorder. The following data were reported for the six-month period before receiving AOT and the first 6-month period participating in court-ordered outpatient treatment.
Before AOT (6 months) During AOT (6 months) Reduction in Violent Behavior Physically harming others 15% 8% 47% Threatening physical harm 28% 16% 43% Damaging or destroying property 13% 7% 46% - AOT resulted in a 66% decrease in “serious violent behavior” after 1 year.
In New York, 76 New York City AOT patients were compared with a control group of 108 patients recently discharged from psychiatric hospitalization who were enrolled in the same clinics but did not meet criteria for Kendra’s Law. Schizophrenia, schizoaffective disorder or bipolar disorder was the diagnosis for 84% of the AOT group and 90% of the non-AOT group. All individuals were assessed every three months for whether they had “kicked, beaten or choked anyone; hit anyone with a fist or beaten up anyone; tried to physically force anyone to have sex against his or her will; threatened anyone with a knife, gun or other weapon; or fired a gun at someone or used a knife or a weapon on him or her.” Despite being more violent than the control group historically, the AOT/Kendra’s Law participants were four times less likely than control group patients to commit acts of serious violence while engaged in AOT. - AOT reduced the chances of being arrested for a violent offense by 88%.
In New York, arrest records were analyzed for 86 AOT participants, including five years prior to being placed on AOT and up to three years after being placed on AOT. Within the group, 75% were diagnosed with psychotic disorders. The records were searched for arrests for violent offenses including “murder, non-negligent manslaughter, forcible rape, robbery and aggravated assault.” The risk of arrest for a violent offense was found to be 8.6 times higher in the prior to AOT participation than during the period of AOT involvement and the six months following discharge from the program. - Conditional release resulted in an 80% decrease in violent behavior after two years.
Conditional release is similar to AOT except that legal authority to re-hospitalize the patient is vested in the director of the state psychiatric hospital, not the court. Thus patients on conditional release can remain in the community only as long as they follow their treatment plans. In New Hampshire, 26 patients–all previously hospitalized for self-harm or harm to others and “certified as severely and persistently mentally ill”–were released conditionally and followed for two years. Episodes of violence were coded on a seven-point scale and rated monthly for the first two years on conditional release, then compared with episodes of violence for the one year prior to their hospitalization. Compared with the year prior to hospitalization, violent behavior was reduced by 57% (5.6 to 2.4) in the first year and 80% (5.6 to 1.1) in the second year on conditional release.