RESEARCH WEEKLY: Assisted outpatient treatment versus mental health courts

(July 3, 2018) Assisted outpatient treatment (AOT) and mental health courts have many similarities, but also many important differences and distinctions, including the people they serve and their previous engagement with treatment, new research shows.

AOT and mental health courts are both legal mechanisms to get individuals with serious mental illness engaged into treatment services. Both utilize court processes to mandate treatment for individuals in the community in order to increase treatment engagement for individuals who do not otherwise adhere to treatment. The goals of both programs are to prevent adverse outcomes due to lack of treatment and allow the individual live successfully in their community.

Key differences between the two programs are the court where the processes occur and who the programs serve.

Mental health courts occur in a criminal court and serve criminal justice-involved clients and often are used as an alternative to incarceration for individuals with severe mental illness. In addition, although mental health courts mandate treatment and have increased enforcement mechanisms for participants that do not adhere to their treatment plan, participation in the program is voluntary.

AOT, by contrast, is a civil court proceeding and serves individuals who meet certain criteria, often times those with multiple recent psychiatric hospitalizations. AOT has less enforcement power for non-adherence but is an involuntary process. Participation in AOT does not necessitate that an individual be arrested or otherwise involved in the criminal justice system.

New research published last month in Psychiatric Services by Natalie Bonfine, PhD, and colleagues from the North East Ohio Medical University and funded by the Stanley Medical Research Institute, the supporting organization to the Treatment Advocacy Center, reports that individuals served by mental health courts and assisted outpatient treatment programs have clear differences in characteristics and prior treatment histories, suggesting a more tailored approach is needed in each program to address the specific needs of the individual.

“Because of a reduction in available mental health services, including hospital beds, and a lack of training or other options among first responders, a person with symptomatic mental illness may end up in jail instead of in a crisis center or a hospital,” Bonafine writes. “Where such individuals end up might depend on circumstances other than the nature of the person’s behavior. If the individual is incarcerated, he or she might be a candidate for mental health court. If, however, the individual is hospitalized, he or she might be a candidate for AOT. Some individuals may be admitted to either program at different times or to both programs at the same time. However, the extent to which there is overlap among users of these programs is unknown.”

Study findings
The authors examined 261 people who had participated in an AOT program or mental health court in Summit County, Ohio over a seven-year period between 2001 and 2007. The found only 8 individuals, or 3% of the study population, participated in both programs during the study period, suggesting little overlap between the two programs.

Individuals in AOT were significantly more likely to have schizophrenia compared to bipolar disorder, and had significantly higher rates of crisis service utilization and psychiatric hospitalization prior to enrollment than those served in a mental health court.

Despite the non-criminal nature of AOT, 39% of program participants had a previous incarceration. The authors argue that this high-rate of criminal justice involvement but lack of participation in mental health courts suggest that the voluntary participation of mental health courts may be limiting, because “agreeing to participate in mental health court requires a willingness to engage in extended treatment rather than face what could be a short jail sentence. It is possible that individuals with more antisocial attitudes and beliefs (criminogenic needs) are more likely to refuse mental health court.”

More attention to the specific needs of the individuals served by these programs are needed by program staff in order to reduce adverse outcomes such as incarceration or hospitalization, the authors conclude. There is substantial evidence to show that AOT and mental health courts are effective in increasing treatment engagement and reducing incarceration, however more specific tailoring is needed to address specific needs of the population each program serves.

References:
Bonafine, N. et al. (June 2018). A comparison of participants in two community-based programs: Assisted outpatient treatment and mental health court. Psychiatric Services.