December 9, 2009
SUMMARY: New York’s Assisted Outpatient Treatment Law (commonly known as “Kendra’s Law”) has been the subject of two empirical investigations: a 2005 study conducted by the New York State Office of Mental Health (“the OMH study”),1 and a 2009 evaluation performed under contract with New York State, by an independent research team (“the independent evaluation”).2 Taken together, the two reports establish that assisted outpatient treatment (“AOT”) drastically reduces hospitalization, homelessness, arrest, and incarceration among people with severe psychiatric disorders, while increasing adherence to treatment and overall quality of life. The independent evaluation further indicates that the effectiveness of Kendra’s Law is not simply a product of systemic service enhancements, but is in part attributable to the value of AOT court orders in motivating treatment compliance.
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Kendra’s Law helps those who need it most
The independent evaluation documents that from the inception of Kendra’s Law in 1999 through June 30, 2007, 8,752 individuals were subjects of initial court orders for AOT, representing a very small segment of OMH’s adult service population. For example, in 2005, only 1.7 percent of OMH’s 138,602 adult service recipients received AOT.
However few in number, these patients represent those in most desperate need for psychiatric treatment. In the OMH study, it was found that in the three years prior to the court order, almost every participant – 97 percent – had at least one psychiatric hospitalization (with an average of three hospitalizations per recipient). When compared with a similar population of mental health service recipients, those placed in AOT had been twice as likely to have been homeless, 50 percent more likely to have had contact with the criminal justice system, and 58 percent more likely to have a co-occurring mental illness and substance abuse condition. The independent evaluation establishes the success of Kendra’s Law in ensuring this highly vulnerable population’s receipt of treatment. AOT recipients were found “far more likely to receive psychotropic medications appropriate to their psychiatric conditions compared to their experiences pre-AOT,”3 and “far more likely to receive intensive forms of case management.”4
Kendra’s Law reduces the severest consequences from lack of treatment
During the course of court-ordered treatment, when compared to the three years prior to participation in the program, AOT recipients experienced far fewer negative outcomes. Specifically, the OMH study found that for those in the AOT program:
- 74 percent fewer experienced homelessness;
- 77 percent fewer experienced psychiatric hospitalization;
- 83 percent fewer experienced arrest; and
- 87 percent fewer experienced incarceration.
The related findings of the independent evaluation were also impressive. AOT was found to cut both the likelihood of being arrested over a one-month period and the likelihood of hospital admission over a six-month period by about half (from 3.7 percent to 1.9 percent for arrest, and from 74 percent to 36 percent for hospitalization).
Kendra’s Law reduces costs for the most expensive services
Inpatient hospitalization is by far the most expensive form of psychiatric treatment. In both New York studies, participation in the Kendra’s Law program was found to markedly reduce the total number of days a person spent hospitalized.
The independent evaluation found that AOT recipients on average spent eighteen days in the hospital for psychiatric care during the six months prior to AOT, but only eleven during the first six months of AOT and ten for the seventh through twelfth months of AOT. As noted in the evaluators’ report, “[w]hile this decrease in hospital days per six month period might appear modest, it would represent substantial reductions in hospital days statewide.”
Kendra’s Law reduces harmful behavior
Kendra’s Law also resulted in dramatic reductions in the incidence of harmful behaviors. Comparing the experience of AOT recipients over the first six months of AOT to the same period immediately prior to AOT, the OMH study found:
- 55 percent fewer recipients engaged in suicide attempts or physical harm to self;
- 49 percent fewer abused alcohol;
- 48 percent fewer abused drugs;
- 47 percent fewer physically harmed others;
- 46 percent fewer damaged or destroyed property; and
- 43 percent fewer threatened physical harm to others.
Overall, the average decrease in harmful behavior was 44 percent.
Kendra's Law's results are sustainable
The independent evaluators considered the important question of what happens to AOT recipients after they leave the program. In so doing, they made a critical finding as to the sustainability of the gains achieved during AOT.
For individuals who had received AOT for periods of six months or less, the evaluation found that the sustainability of improvements in medication receipt depended on whether intensive outpatient services continued after AOT. Those who continued with intensive services maintained their substantial increase in medication receipt relative to the pre-AOT period (from 37 to 45 percent), while those who discontinued such assistance dropped back to near the pre-AOT levels (33 percent). The same finding was made with respect to hospitalization rates: post-AOT intensive service recipients maintained their gains relative to the pre-AOT period (7 percent per month hospitalized vs. 11 percent pre-AOT), while those who discontinued such assistance saw hospitalization rates creep back up (10 percent).
However, results were starkly different for those who had received AOT for periods of longer than six months. For these former recipients, increases in medication receipt and reductions in hospitalization were sustained in the post-AOT period, whether or not intensive services were continued. Both those who continued intensive services and those who did not maintained a hospitalization rate of 7 percent per month, down from 11 percent in the pre-AOT period. The medication receipt rate was higher for those who continued intensive services than for those who did not (50 percent vs. 43 percent), but both groups maintained substantial improvements from the pre-AOT rate (37 percent). On the basis of these findings, the evaluators concluded that “improvements are more likely to be sustained if AOT continues for longer than six months.”
Kendra’s Law recipients value the program
As a component of the OMH study, researchers with the New York State Psychiatric Institute and Columbia University conducted face-to-face interviews with 76 AOT recipients to assess their opinions about the program and its impact on their quality of life. The interviews showed that after receiving treatment, AOT recipients overwhelmingly endorsed the program:
- 75 percent reported that AOT helped them gain control over their lives;
- 81 percent said that AOT helped them to get and stay well; and
- 90 percent said AOT made them more likely to keep appointments and take medication.
Additionally, 87 percent said they were confident in their case manager’s ability to help them – and 88 percent said that they and their case manager agreed on what is important for them to work on. AOT had a positive effect on the therapeutic alliance.
Patient interviews were also a component of the independent evaluation, including a large number of interviews with voluntary, non-AOT patients and a smaller group of recent AOT graduates, for purposes of comparison. These interviews debunk the familiar claim of opponents that AOT will be regarded by recipients as coercive and stigmatizing, and lead to disengagement from treatment. Current and former AOT recipients and those receiving comparable services on a voluntary basis were found to be “remarkably similar” in their attitudes toward treatment and reported experiences with the mental health system, suggesting to the evaluators that “positive and negative attitudes toward treatment are more strongly influenced by other experiences with mental illness and treatment than by recent experiences with AOT itself.”
Kendra’s Law shows the value of court orders in improving outcomes
The independent evaluation supplies ample evidence to refute the conjecture of some that the success of Kendra’s Law is entirely due to the high quality of services made available to AOT recipients, and that comparable results could be obtained by making the same services available on a voluntary basis. The evaluators conducted numerous comparisons between AOT recipients and individuals who, despite meeting the statutory criteria for AOT, were offered and agreed to receive equivalent services voluntarily, without involving the court.5 Despite an identical level of service access and service quality, the evaluators found a number of critical differences between the groups. For example:
- The likelihood of a hospital admission over six months was lower among AOT recipients than among voluntary recipients (36 percent vs. 58 percent). This difference was characterized by the evaluators as “highly statistically significant.”
- AOT patients were less likely to be arrested than their voluntary counterparts (1.9 percent arrested per month vs. 2.8 percent.)
- Persons receiving AOT for a period of 12 months or more had a substantially higher level of personal engagement in their treatment than those receiving services voluntarily for the same periods (55 percent “good” or “excellent” vs. 43 percent).
Based on these and other findings, the evaluators concluded: “The increased services available under AOT clearly improve recipient outcomes. However, the AOT court order, itself, and its monitoring do appear to offer additional benefits in improving outcomes.”
1 N.Y. State Office of Mental Health (March 2005). Kendra’s Law: Final Report on the Status of Assisted Outpatient Treatment.
2 Duke University School of Medicine et. al. (June 2009). New York State Assisted Outpatient Treatment Program Evaluation.
3 For persons under AOT orders, medication receipt (defined as having filled a prescription for an appropriate medication and having a sufficient supply during at least 80 percent of the days in a given month) increased from 35 percent per month prior to AOT, to 44 percent during the first six months of AOT and 50 percent during months seven to twelve.
4 Receipt of Assertive Community Treatment (ACT) or Intensive Case Management (ICM) services increased from 11 percent in the pre-AOT period to 28 percent in the first six months of AOT and 33 percent during months seven to twelve.
5 Voluntary recipients are common in several New York counties where the policy is to first offer voluntary participation to those deemed AOT-eligible, and to only petition the court for AOT if a patient refuses such overture. Of course, even these individuals should not be viewed as purely “voluntary” participants, if one presumes that desire to avoid a court order was a significant factor in securing their assent to treatment.