How effective are court-mandated outpatient treatment programs for people with “serious mental illness”? Evidence from a recently completed study suggests that such programs can be quite effective, helping individuals achieve key clinical and social-functioning outcomes, although the wide range of circumstances and rules under which these programs are administered can often make a big difference in specific cases.

“Assisted Outpatient Treatment,” or AOT, is authorized in all U.S. states except Connecticut and Massachusetts. To be considered eligible, an individual typically must be 18 or older, be diagnosed with a “serious mental illness”—usually, persistent psychosis or a severe mood disorder that limits “insight” into their condition and the need for help—and must be deemed by a court to be able to live safely in the community with supports provided by a local AOT program.

Researchers conducting an assessment of AOT, led by Kiersten L. Johnson, Ph.D., of the North Carolina-based research firm RTI International, and including senior members Jeffrey W. Swanson Ph.D., a 2013 BBRF Distinguished Investigator, and Marvin S. Swartz, M.D., both of Duke University School of Medicine, note that “no two implementations of AOT in the U.S. look exactly alike.” Some AOT programs take a “step-up” approach, with a court mandating outpatient treatment for a person already living in the community, and others a “step-down” approach that amounts to a conditional release from inpatient psychiatric care into an AOT program within the community.

“In recognition that AOT’s effectiveness will likely vary depending on the ways in which it is implemented,” the team notes, there have been calls for studies drawing on data from multiple sites where AOT is being administered, and assessing effectiveness using a wide range of factors bearing on individual outcomes.

In 2014, an occasion for such a study was provided when Congress authorized new funding for AOT programs. The federal government’s Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Institute of Mental Health (NIMH) supported an evaluation of SAMHSA’s 4-year pilot program funding new AOT support, part of a bill signed by then-President Obama designed to “protect access to Medicare.” RTI International, in partnership with Duke University and Policy Research Associates, were authorized to conduct an in-depth evaluation of 6 of the 18 SAMHSA-funded AOT sites.

The study reporting the results of that evaluation recently appeared in the journal Psychiatric Research and Clinical Practice. Data used in the analysis were collected between 2017 and 2021, from 392 people receiving AOT at 6 sites. The cohort was identified as 39% female, 39% Black, 53% White, average age about 40. Nearly 60% had graduated high school, 14% were currently employed, 27% had a prior arrest, 17% were homeless, and about 69% adhered to prescribed medicines and psychiatric appointments when their AOT began. About 62% had at been psychiatric inpatients within the 6-month period prior to their AOT order.

The researchers found that AOT was “associated with improvements in treatment adherence, clinical functioning, and social functioning outcomes,” measured from 6 months prior to an AOT order to 6 and 12 months following the initiation of an AOT order. The average order in this cohort was about 7 months in duration, though this varied widely. During and after AOT, participants adhered more often to medications and therapy appointments. There was also an improvement in participants’ perceptions of their own mental health, and in their reports on “life satisfaction.” Study participants, on average, reported improvements in their working alliance with therapists and were less inclined to exhibit violent or suicidal behaviors while in AOT care and after the order expired. There was a substantial reduction in the number of inpatient psychiatric hospitalizations and days spent in hospital during and after AOT.

Researchers also found evidence of improved social functioning, including reductions in arrests and drug use that persisted post-AOT. Reductions in homelessness were also observed at 6 months, though effects diminished by the 12-month follow-up. “There was decisive [statistical] evidence of improvements in nearly all of the client-level outcomes assessed,” the team wrote.

Importantly, the researchers noted that AOT “does not purport to deliver ‘better’ outcomes, but rather to increase engagement in the treatment needed to obtain such outcomes.” Thus, they ask, “the question remains as to whether these AOT clients [in the study] would have seen the same improvements without the court order” that mandated their involvement.

While a definitive determination, especially one that might apply to AOT programs generally, is difficult to make, the team’s data did suggest several factors that appeared to affect the impact of AOT on those mandated to receive it. One was the length of time covered by the court order. “Spending at least 6 months on an AOT order [compared with less than 6 months of mandated treatment] was associated with a reduced likelihood of violent behavior, fewer suicidal thoughts, fewer nights spent in a psychiatric inpatient facility, and a reduced likelihood of homelessness.” Further, those who successfully completed AOT orders showed better improvement in symptoms and in reduced homelessness.

Another “moderator” of results noted by the team was involvement in the criminal justice system at the time the AOT order was issued. Such involvement was associated with subsequently greater reductions (post-AOT) in violent behavior and arrests, although the reasons for this were not possible to determine based on data collected in the study.

In this study no significant difference in outcomes was noted among those participants who went into AOT from the community (“step-up”) vs. from an inpatient hospitalization or jail stay (“step-down”).

“Our findings point to significant improvements across a range of client outcomes,” the team concluded. These included, in those who had an AOT order of greater than 6 months, compared with those with shorter orders, comparatively greater reductions in the likelihood of violence (24.5% vs. 14.7%), suicidal ideation (27.4% vs. 21.4%) and inpatient hospital nights (14.5 fewer nights vs. 8.3 nights).