Critical Gaps in Assisted Outpatient Treatment Research in the United States

One of the most important factors to consider in a mental health intervention is its ability to improve outcomes for participants. There is a wealth of evidence supporting the effectiveness of AOT programs across a variety of outcomes, including improving treatment adherence and the ability to care for oneself, while reducing hospitalization episodes, days hospitalized, arrests, victimization, and violence against self or others (Swanson et al., 2000; Swanson et al., 2001; Hiday et al., 2002; Esposito et al., 2008; Swartz et al., 2009; Gilbert et al., 2010; Phelan et al., 2010; Azar et al., 2018). However, this evidence comes from data that were collected more than a decade ago and are predominantly from New York State, making it difficult to determine if these results would be replicated in or applicable to the diverse variety of AOT programs implemented throughout the United States today.

There is also evidence that increased mental health treatment engagement may provide other health benefits for AOT participants, including earlier identification of physical health conditions (Segal et al., 2018). New research measuring individual-level outcomes should expand to include wellness and recovery-oriented outcomes, such as quality-of-life, perceived coercion, and feelings of empowerment, along with other outcomes identified and defined through community-based participatory research methods that include AOT participants in the design and development of research projects. New research should additionally determine if improvements are sustained following the completion of the AOT program.

However, it is not enough to demonstrate that AOT is effective at improving outcomes for participants. Court-ordered treatments like AOT should only be used for the subset of people with serious mental illness who may need them when voluntary treatment has failed. While there is evidence to suggest AOT participants have better outcomes than those in comparable voluntary services, this evidence is outdated (Swartz et al., 1999; Swartz et al., 2009; Busch et al., 2010; Gilbert et al., 2010).

There are also little data comparing the effectiveness of AOT among diverse populations. Data from New York showed that Black and Hispanic participants had worse outcomes following completion of AOT than white participants, including being more likely to be readmitted to a hospital (Van Dorn et al., 2010). Research into racial disparities in AOT is especially important given the overrepresentation of marginalized groups in involuntary treatment and AOT-eligible populations. Further, research into the effectiveness of AOT for special populations, such as those with criminal legal involvement, may also be relevant given recent proposals to utilize AOT as a diversion strategy. Additional populations of interest may include people with co-morbid substance use disorders, people experiencing chronic homelessness, and people who have been referred to AOT from different sources (e.g., clinicians, family members, etc.).

While outcomes research conducted within an AOT program can indicate whether the program is working, research comparing outcomes across different types of programs is also needed to determine best practices for program implementation.

Judicial involvement is one element of AOT that varies substantially across programs. Some programs have limited judicial involvement whereas others use an “active court” model, which involves regular “check-ins” between participants, their treatment team, and the judge or magistrate. While the positive impact of compassionate judicial involvement,sometimes referred to as the “black robe effect,” is thought to be a part of what makes AOT programs effective (Munetz et al., 2014), there is no existing research that empirically examines this phenomenon. It is important to carefully examine how the level of judicial involvement impacts the efficacy of AOT programs and for which populations.

It is presumed that AOT is effective not only because it keeps an individual accountable to their treatment team, but also because it keeps the treatment system accountable to the individuals to whom they provide services. Therefore, it may be the case that AOT works because treatment teams are required to ensure that program participants do not “fall through the cracks” while in the program. However, systems of accountability, such as employing an AOT monitor or requiring meetings between the treatment team and the court, can vary from program to program, and no research has yet investigated which mechanisms are most effective. Future research is needed in this area to understand best practices for program implementation and which different system accountability mechanisms are the most successful at improving participant and program outcomes.

AOT has also been thought to decrease the public cost of serious mental illness through decreasing the need for inpatient hospitalization and/or diverting individuals away from the criminal legal system into treatment. Prior research has shown that among individuals with a history of criminal legal system involvement, AOT can reduce arrests by nearly two-thirds in any given month and reduce the chance of being arrested for a violent offense by 88% (Gilbert et al., 2010; Link et al., 2011). In addition, AOT has been shown to reduce hospitalizations by up to 85% and reduce days spent in the hospital by 44% (Esposito et al., 2008; Swartz et al., 2009; Azar et al., 2018). The positive impacts of these reductions may extend to entire systems of care, such as through improved, targeted allocation of available public hospital beds to those most in need. However, as with other gaps in our knowledge of AOT, most of this research comes out of New York State and further research is needed to see if this effect can be generalized to AOT programs nationwide. Additionally, there is limited research examining how community and mental health system contextual factors such as the availability of intensive outpatient services or behavioral workforce shortages may impact the effectiveness or implementation of AOT programs. Multi-site or multi-state program comparison research examining the community-impact of AOT programs is needed to further understand the community and system impacts of AOT programs.