AOT and Long-Term Use of Antipsychotics

TO THE EDITOR: It was with considerable disappointment that we read the Open Forum by Barnes and Badre (1). The core premise—that long-term antipsychotic medication is a “key treatment modality” in assisted outpatient treatment (AOT) that is administered forcibly over a long period of time—is not based on the evidence in the statutes of the 46 states and District of Columbia where AOT is authorized and is inaccurate (2). To the contrary, the laws make clear that AOT is a short-term intervention that leaves medication decisions to the supervising clinician and patient. No state allows medication over the patient’s objection or defaults to automatic hospitalization.

Beyond the legal technicalities, however, is the vast body of positive outcome data about AOT that the American Psychiatric Association (APA) has found compelling and evidence based (3). In New York, where AOT is called “Kendra’s Law” and is subject to mandated outcome reporting, the treatment option was found, in 2005, to have produced reductions among participants of 87% in incarceration, 83% in arrests, 77% in psychiatric hospitalization, and 74% in homelessness, along with dramatic increases in participation in critical services, such as case management (4). Subsequent studies in New York and independent research in multiple other states have found that AOT reduces violence, including victimization and suicide attempts, and improves substance abuse treatment outcomes (5). The scant negative outcome data regarding New York’s experience comes from an early pilot program in the state that was replaced by “Kendra’s Law” (6).

When the APA Board of Trustees in December 2015 approved a position statement finding AOT to be a “useful tool to promote recovery” (2), the APA joined a host of government agencies and mental health organizations that have examined the evidence and deemed court-ordered treatment in the community to be “part of a solution” for a “very narrow segment of the patient population” at risk of criminalization and other poor outcomes because they are “unlikely to seek or voluntarily adhere to needed treatment” for serious mental illness. Among others, these entities include the Substance Abuse and Mental Health Services Administration, Department of Justice Office of Justice Programs, National Alliance on Mental Illness, International Association of Chiefs of Police, and U.S. Congress, which created a national demonstration project of the practice and funded it in 2015.

The evidence is strong and clear that AOT—and the short-term use of medication in that context—is effective, the unsupported mischaracterizations notwithstanding.