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In "Mental Health Commitment Laws:  A Survey of the States” (Survey), the Treatment Advocacy Center comprehensively examined the laws each state uses to determine who within its population might qualify to receive involuntary or assisted outpatient treatment (AOT), for what duration, and graded each state on two measures of their response to the treatment needs of this small but high-impact population.  

For the uninitiated, an AOT program is court-ordered treatment (including medication) for individuals with severe mental illness who meet strict legal criteria, e.g., they have a history of medication noncompliance. Typically, violation of the court-ordered conditions can result in the individual being hospitalized for further treatment.

The Survey looked at the adequacy of AOT in the 45 states who have such laws.  Connecticut, Maryland, Massachusetts, New Mexico, and Tennessee do not have AOT laws.  Second, the Survey evaluated the extent these AOT laws are used to intervene and provide treatment.  

It should be noted that California passed an AOT law (Laura's Law) in 2002.  The law was extended until December 31, 2017.  Yet, of the 58 California counties, only Nevada and Orange Counties have adopted Laura's Law fully while Los Angeles and Yolo Counties operate pilot AOT programs.

The Survey found that no state earned a grade of "A" on the use of civil commitment laws.  Only 14 states earned a cumulative "B" or better for the quality of the civil commitment laws.  Seventeen states earned a cumulative grade of "D" or "F" for the quality of their laws.  Only 18 states recognized the need for treatment as a basis for civil commitment to a hospital.  While 45 states have laws authorizing the use of court-ordered treatment in the community, only 20 had optimal eligibility criteria.  Twenty-seven states provide court-ordered hospital treatment only to those persons at risk for violence or suicide even though these states allow for treatment under additional circumstances.  Twelve states rarely or never make use of AOT including 8 states with laws authorizing such treatment.

California received a grade of "F" on inpatient commitment, outpatient commitment, emergency evaluation, and cumulative quality of life;  a grade of "C" on emergency evaluation; and an "F" on use of laws.  

To alleviate these deplorable conditions, the Survey recommends enactment of AOT laws in the 5 states that do not have them; the universal adoption of need-for-treatment standards; universal adoption of emergency hospitalization standards that create no additional barriers to treatment; and sufficient inpatient treatment beds of at least 50 beds per 100,000 population.

Leaving people with a serious mental disorder on the streets is indefensible.  It is time for opponents of AOT to look at the facts.  

It should be noted that California passed an AOT law (Laura's Law) in 2002.  The law was extended until December 31, 2017.  Yet, of the 58 California counties, only Nevada and Orange Counties have adopted Laura's Law fully while Los Angeles and Yolo Counties operate pilot AOT programs.

The Survey found that no state earned a grade of "A" on the use of civil commitment laws.  Only 14 states earned a cumulative "B" or better for the quality of the civil commitment laws.  Seventeen states earned a cumulative grade of "D" or "F" for the quality of their laws.  Only 18 states recognized the need for treatment as a basis for civil commitment to a hospital.  While 45 states have laws authorizing the use of court-ordered treatment in the community, only 20 had optimal eligibility criteria.  Twenty-seven states provide court-ordered hospital treatment only to those persons at risk for violence or suicide even though these states allow for treatment under additional circumstances.  Twelve states rarely or never make use of AOT including 8 states with laws authorizing such treatment.

California received a grade of "F" on inpatient commitment, outpatient commitment, emergency evaluation, and cumulative quality of life;  a grade of "C" on emergency evaluation; and an "F" on use of laws.  

To alleviate these deplorable conditions, the Survey recommends enactment of AOT laws in the 5 states that do not have them; the universal adoption of need-for-treatment standards; universal adoption of emergency hospitalization standards that create no additional barriers to treatment; and sufficient inpatient treatment beds of at least 50 beds per 100,000 population.

There is promising action at the federal level.  In December, 2013, Senator Tim Murphy  (R-Pennsylvania) and Senator Debbie Stebenow (D-Michigan) introduced the Helping Families in Mental Health Crisis Act (HR 3717), which among other provisions, provides for a federal AOT grant program to help local mental health systems launch their own AOT programs.  If passed, the U.S. Department of Health and Human Services will have authority to award $60 million for up to 200 AOT start-up grants over the next four years. (Individual grants could be awarded up to $1 million.)

In conclusion, it is difficult to understand how anyone can oppose an AOT program.  Any intellectually honest person examining the mountain of positive evidence on AOT would have to embrace AOT.  It is just not true that the research on AOT is mixed or inconclusive, or that the research only suggests AOT might be worthwhile in an exceedingly well-funded system of community-based care.  See, for example, “An advocate’s observations on research concerning assisted outpatient treatment” by Brian Stettin in Current Psychiatry Reports (2014).  

Leaving people with a serious mental disorder on the streets is indefensible.  It is time for opponents of AOT to look at the facts.  

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