Maryland is one of three states in the country that doesn’t have assisted outpatient (AOT) treatment programs which involve court-ordered mental health treatment for individuals who have severe mental illness and a history of noncompliance with therapy. Cynthia Major Lewis, director of adult psychiatric emergency services at Johns Hopkins, testified before the Maryland house and senate in support of a pending state bill (MD House Bill 823/MD Senate Bill 480) that would authorize AOT.

Lewis spoke with Brain Wise recently about the benefits of AOT.

 

How did you get interested in AOT?

Lewis:  I’ve been doing community psychiatry work for most of my post-residency life, but it wasn’t until I got embedded in the Johns Hopkins Emergency Department in 2019 that I started to see patients who were cycling in and out of the ED multiple times a month, sometimes multiple times a week. These patients often have severe chronic mental illness that impacts their ability to utilize resources in the community that can keep them well. I found that a lot of these chronic visits were being paid for by insurance, to the tune of hundreds of thousands of dollars a year. While doing research for a Grand Rounds lecture, I learned Maryland is one of three states that does not have AOT. I realized that Maryland’s lack of an AOT program was contributing to this population of patients who are not getting the proper care and support that they deserve, but there was only so much I could do from the frontlines. I joined the Maryland Psychiatric Society’s legislative committee and agreed to testify in support of the bill.

How does AOT work?

Lewis: AOT is a mechanism to get patients who are chronically ill, not participating in treatment and doing poorly in the community into psychiatric care. Patients who meet certain criteria are court- ordered to a comprehensive care plan where they’re given the proper support and treatment to get them stable and well. They are evaluated every year to see if they can be successfully discharged from the program, with the goal of them gaining the needed insight and ability to participate in outpatient treatment without a court order.   

Why is AOT needed?

Lewis: People who oppose AOT think we shouldn’t need a court order to get people into treatment, that we should utilize peers or other ways to get people to realize they need care. Sadly, there is a population of patients with severe psychotic and mental illness who have anosognosia, a debilitating symptom that leaves patients with a lack of insight or inability to appreciate how ill they are and that they need treatment.  For this population, trying to talk them into treatment does not work. These patients are often emergency petitioned to the ED against their will and involuntarily committed to a psychiatric hospital if they meet the criteria for dangerousness that is required for psychiatric impatient commitment. Once these patients no longer meet criteria that make them a danger to themselves or others, they are discharged with a treatment plan.  

However, a frequent pattern is that soon after discharge, they stop their medication and fail to follow up with outpatient care. Their symptoms return, they become unable to care for themselves, and they find themselves with burned-out family members who are no longer able to care for them. They re-present to the ED, often on emergency petition, only to repeat the cycle.  AOT would help stop this cycle. 

What is the status of the bill?

Lewis: The bill failed to pass but, for the first time in the nearly 17 years that this bill has been brought to the floor, it managed to get out of the House. There appears to be growing momentum and a better appreciation that Maryland will need to eventually pass this bill. 

What is your goal regarding AOT?

Lewis: My hope is that Maryland will pass this legislation and adopt a statewide AOT program. That would allow providers and all of us involved in this work to have a means to get patients who are failing outpatient treatment into care. Passage of this bill would pay off in dividends. Studies of AOT demonstrate that it decreases incarceration by 87% and inpatient hospitalizations by 70%, and it leads to 83% fewer arrests, and an 87% decrease in homelessness. It would demonstrate that we are investing in our chronic mentally ill patients and that we value their right to lifesaving mental health care and the right to live a healthy, sustainable and dignified life. I will not rest until Maryland passes AOT.