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Assisted Outpatient Treatment: Can it Reduce Criminal Justice Involvement of Persons with Severe Mental Illness? Marvin S. Swartz, M.D. Duke University Medical Center Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013

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Page 1: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

Assisted Outpatient Treatment: Can it Reduce

Criminal Justice Involvement of Persons with

Severe Mental Illness?

Marvin S. Swartz, M.D.

Duke University Medical Center

Saks Institute for Mental Health Law, Policy and Ethics

Spring Symposium, 2013

Page 2: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

Collaborators

• Jeffrey Swanson

• Barbara Burns

• John Monahan

• Henry Steadman

• Pamela Robbins

• Richard Van Dorn

• Tom McGuire

• Support from NIMH

• Support from the

MacArthur Research

Network on Mandated

Community Treatment

Page 3: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

Questions

• Can Assisted Outpatient Treatment (AOT)*

be effective ?

– Under what conditions?

– Can it reduce arrests and criminal justice

involvement?

– Is it fair?

• Is AOT cost effective?

*AOT also refers to involuntary outpatient commitment (OPC)

Page 4: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

Assisted Outpatient Treatment (AOT)

What is it?

Procedure whereby a judge directs a patient

with a history of treatment non-adherence to

comply with a court-authorized treatment

plan

Permitted in all but a few states

Explicitly permitted by 44 states and the

District of Columbia

Despite statutory support, used inconsistently

Page 5: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

VARIANTS OF AOT

• Conditional release for involuntarily

hospitalized patients

• Alternative to hospitalization for patients

who meet inpatient commitment criteria

• Alternative status for patients who do not

meet inpatient criteria

Page 6: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

Criteria for OPC in N.C.

• Presence of a serious mental illness

• Capacity to survive in the community with

available supports

• Clinical history indicating a need for treatment

to prevent deterioration that would predictably

result in dangerousness

• Mental status that limits or negates the

individual's ability to make informed decisions

to seek or comply voluntarily with

recommended treatment

Page 7: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

Controversies about AOT

• Availability of appropriate services might

obviate the need

• Should not be used as a substitute for

inadequacies in service systems

• Counter-argument: Given the apparent

benefits of mental health courts in

mobilizing resources do patients need to

commit a crime to get such benefit?

Page 8: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson
Page 9: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

Odds ratio for hospital readmission during any

given month of 1-year trial

------------------------------------------------------------------

Odds

Ratio 95% CI p value

======================================

Control group [1.00]

OPC group 0.64 (0.46 – 0.88) p<0.01

----------------------------------------------------------

Page 10: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

Mean Psychiatric Hospital Days by Days of OPC

0

5

10

15

20

25

30

35

40

Controls <180 days OPC 180+ days OPC

27.9

37.7

7.51

Page 11: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

0

5

10

15

20

25

30

35

40

45

50

55

60

65

<180 days OPC 180+ days OPC

Percent Violent at 12 Months by Days of OPC

0

5

10

15

20

25

30

35

40

Controls <180 days OPC 180+ days OPC

Per

cen

t V

iole

nt

Randomized Group

36.8 39.7

22.7

63.3

37.5

Per

cen

t V

iole

nt

Baseline Violent Group

Page 12: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

Adjusted Probability of Arrest by OPC Days and Baseline History of

Dual-System Recidivism

0.14

0.47

0.11

0.44

0.21

0.12

No Yes

Dual system recidivism history (hospitalization + arrest/violence)

0

0.1

0.2

0.3

0.4

0.5

0.6

Pro

ba

bil

ity

of

an

y a

rres

t in

yea

r No OPC 0-179 days 180-365 days

Page 13: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

Summary of NC OPC Study

OPC can reduce hospital recidivism

However:

• OPC must be applied for an extended period

• It is only effective when delivered in

combination with frequent mental health

services.

Page 14: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

Summary (continued)

Other findings:

• OPC can reduce violence, victimization,

family strain, arrests and improve

medication adherence and quality of life.

However:

• To be effective, it must be delivered for

an extended period AND in combination

with regular mental health services.

• Limitations: the ‘dose’ of OPC and

service intensity could not be controlled.

Page 15: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson
Page 16: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

New York City

region enlarged

New York City

region

Page 17: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

0%

20%

40%

60%

80%

100%

Total Central Hudson Long Island New York West

Hospital Prison/Jail Community

Pe

rce

nt to

tal A

OT

ord

ers

Exhibit 1.3. Origin of AOT orders, 2002-2007, for various regions of New York.

n=186 n=264n=2068 n=1551n=29 n=38

Source: OMH evaluation data

Page 18: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

Description of AOT Program and Regional

Variations: Summary of Findings

• AOT statute can be used to prevent relapse or

deterioration before hospitalization is needed.

• In nearly 3/4s of all cases used as a discharge

planning tool for hospitalized patients.

• AOT is largely used as a transition plan intended

to improve the effectiveness of treatment

following a hospitalization and as a method to

reduce hospital recidivism.

Page 19: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

Recipient Outcomes During AOT: Findings

• Substantial reduction in psychiatric hospitalizations and in days in the hospital

• Modest evidence that AOT reduces arrests

• Substantial increases in receipt of intensive case management services

• More likely to adhere to psychotropic medications

• Subjective improvements in personal functioning.

Page 20: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

14%

11%

9%

0%

2%

4%

6%

8%

10%

12%

14%

16%

Pre-AOT AOT 1-6

months

AOT 7-12

months

Exhibit 3.8 Adjusted percent* with psychiatric inpatient admission in month, by AOT status

*Adjusted probability estimates were generated from repeated measures regression models controlled

for time, region, race, age, sex, diagnosis, and co-insurance status. Models were also weighted for

propensity to initially receive AOT and to receive more than 6 months of AOT.

Source: Medicaid claims and OMH admissions data.

Adju

sted p

erc

ent

Page 21: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

Exhibit 3.9. Adjusted* average inpatient days during any 6 month period, by

AOT status

*Adjusted mean estimates were generated from repeated measures regression models controlled for

time, region, race, age, sex, diagnosis, and co-insurance status. Models were also weighted for

propensity to initially receive AOT and to receive more than 6 months of AOT.

Source: Medicaid claims and AOT Evaluation database.

Ave

rag

e n

um

be

r of

da

ys

18

1110

0

2

4

6

8

10

12

14

16

18

20

Pre-AOT AOT 1-6 months AOT 7-12 months

Page 22: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

35%

44%

50%

20%

25%

30%

35%

40%

45%

50%

55%

Pre-AOT AOT 1-6

months

AOT 7-12

months

Exhibit 3.10 Adjusted percent* with at least 80% medication possession in month by AOT status

*Adjusted probability estimates were generated from repeated measures regression models controlled

for time, region, race, age, sex, diagnosis, and co-insurance status. Models were also weighted for

propensity to initially receive AOT and to receive more than 6 months of AOT.

Source: Medicaid and OMH records.

Adju

ste

d p

erc

ent

Page 23: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

3.7

1.9

2.8

0

0.5

1

1.5

2

2.5

3

3.5

4

Pre-AOT and Pre-EVS Current AOT Current EVS

Exhibit 3.2. Adjusted* percent arrested in month by current receipt of

AOT and EVSA

dju

ste

d p

erc

en

t a

rrest

ed

in m

on

th

*Adjusted arrest rate estimates were produced using multivariable time-series regression analysis, controlling for time,

region, age, sex, race, education, and diagnosis. Months spent in hospital are excluded from analysis.

Source: 6-county interviews and Division of Criminal Justice Services.

Page 24: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

Cost of AOT, mental health and criminal justice services before and after AOT in NYC

$104,753

$52,386

$59,924

Page 25: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

Summary: AOT reduces costs for those it serves

• New York City sample: total costs declined

• 50% in the first year after AOT began

• additional 13% in the second year

• 5-county sample: total costs declined

• 62% in the first year

• additional 27% in the second year

• Overall, significantly reduced costs under AOT

attributable mainly to a marked shift in service patterns

from inpatient to outpatient care settings

Page 26: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

Bottom Line on AOT Net Costs

• AOT can reduce overall net service costs for individuals with

serious mental illness,

• mainly by shifting patterns of service provision from

inpatient to outpatient settings

• In New York AOT utilizes a substantial investment of state

resources to provide community-based services,

• but could yield significant long-term savings

Page 27: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

Overall Summary of NYS Findings • NYS’s AOT Program improves a range of

important outcomes for its recipients including reduction in arrests.

• Increased services available under AOT clearly improve recipient outcomes

– however, the AOT court order and its monitoring do appear to offer additional benefits in improving outcomes.

• The AOT order exerts a critical effect on service providers stimulating their efforts

Page 28: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

Thanks!

Page 29: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

Stakeholders Views of Mandated Treatment

How do representative stakeholders evaluate

the evidence regarding OPC?

What importance do they give to the

outcomes?

Are the inherent trade-offs in mandates

acceptable?

Page 30: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

Four Outcomes Evaluated

AOT

Involuntary Hospitalization

Interpersonal relationships

Violent behavior

Page 31: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

Vignette Example:

Upon discharge from the hospital, a judge ordered Mr.

Smith to go to the mental health center for treatment

for the next six months. If he doesn’t keep his

appointments and take prescribed medications, the police

will take him to treatment. After getting out of the

hospital, he argues a lot with his family, friends, and

other people. He becomes upset and suddenly hits a

stranger on the street who he thinks might hurt him. His

symptoms worsen and he is again admitted

involuntarily to the psychiatric hospital for a week or

more.

Page 32: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

Rating the Vignettes:

Think about how it would feel to be Mr. Smith in that

situation (and how good or bad that would be).

You will be asked to give each story a score from 0 to

10.

Zero is a score for the worst possible situation for Mr.

Smith. Ten is a score for the best possible situation for

him.

Page 33: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

Mean Preference Weights by Domain

Page 34: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

Mean Preference Weights by Sample

Page 35: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

Summary

Method elicits preferences from representative stakeholders and allows them to evaluate selected outcomes.

Outcomes can be preference-weighted

Stakeholders give greatest importance to avoiding hospitalization followed by avoiding violence, maintaining good relations and avoiding OPC.

Generally agree in rank-ordering preferences, giving least importance to OPC.

Families differ in preference for OPC.

Page 36: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

Is OPC Fairly Applied?

Page 37: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

April 7, 2005

Racial Disproportion Seen in Applying 'Kendra's Law'

By Michael Cooper

ALBANY, April 6 - State officials say the statute, known as Kendra's Law, has been a great success, and Gov. George E. Pataki wants to make it permanent when it comes up for renewal in June. But an analysis of state data by a group that opposes its compulsory-treatment provision found that the law has been disproportionately applied to black New Yorkers.

The group, New York Lawyers for the Public Interest, concluded that blacks were nearly five times as likely as whites to be the subject of court orders stemming from Kendra's Law. Examining court orders for treatment that have been issued since the law took effect, the group found that 42 percent of the 3,958 orders for treatment were invoked against blacks, who make up 16 percent of the state's population, while 34 percent of the orders applied to whites, who make up 62 percent.

Page 38: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

Black

(16%)

Black

(44%)

White

(62%)

Other

(22%)

White

(34%)

Other

(24%)

New York State Population

(N=19,262,545)

Kendra’s Law (AOT) Orders

(N=3,958)

Page 39: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

Why does it matter?

• "It’s important to know if our mental health

policy is disproportionately taking away the

freedom of groups of people who have

historically been oppressed."

-- John A. Gresham, Senior Litigation Counsel, New York

Lawyers for the Public Interest, New York Times, April 2005

Page 40: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

Disparity in AOT is ambiguous and raises several key

questions:

• Is it about the services or sanctions?

– Care vs. coercion

• What is the starting point or “baseline state” for AOT?

– Hospital vs. community

• What is the source of the racial imbalance in AOT orders?

– Discrimination at decision points for AOT referral, investigation, and court order?

[or]

– Upstream socioeconomic factors that sort people differentially into the pool of service recipients from which AOT orders are drawn?

Page 41: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

Parity line

(ratio = 1.0)

Alternative AOT case rate denominators

* Period-prevalence of AOT cases active at any time during 2003, by selected denominators.

0

2

4

6

8

AOT racial disparity indices in New York County: Ratios of AOT rates* for blacks

compared to whites, using alternative denominators

County

population

County SMI

population

County SMI

population in

OMH

services

County SMI

population in OMH

services and

hospitalized in year

County SMI

population with >1

involuntary

hospitalizations in

year

Y a

xis

: R

ati

o o

f A

OT

ra

te f

or

bla

ck

s t

o A

OT

ra

te f

or

wh

ite

s

Ra

tio

of

AO

T r

ate

fo

r b

lac

ks

to

AO

T r

ate

fo

r w

hit

es

Over 7:1

4:1

2:1 2:1

Almost 1:1

Page 42: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

Implications

• Question of racial disparity in AOT is ambiguous: – Disparity in access to treatment (a public “good”) vs. disparity in limitations

on personal liberty (a public “bad”)

• Interpretation may depend on assumed baseline situation: – Hospitalization AOT as less restrictive alternative

– Community AOT as initiating coercion

• Findings suggest that the source of overrepresentation of blacks in AOT – Is not intrinsically related to race and discrimination

– Lies “upstream” from the AOT referral/petition decision point

– Is nested within broader, systemic disparities, which may be rooted in the social-epidemiological patterns of mental illness and the organization/financing of care in the public mental health system.

Page 43: Marvin S. Swartz, M.D. Duke University Medical Center Saks ... · Saks Institute for Mental Health Law, Policy and Ethics Spring Symposium, 2013 . Collaborators •Jeffrey Swanson

Racial Bias in AOT Program?

Summary of Findings

• We find that the over-representation of African Americans in the AOT Program: – is a function of African Americans’ higher likelihood of being

uninsured,

– higher likelihood of being served by the public mental health system (rather than by private mental health professionals),

– and higher likelihood of having a history of psychiatric hospitalization.

• We find no evidence that the AOT Program is disproportionately selecting African Americans or other minorities for court orders.