In the last decade, the federal government has provided $146 million to organizations that provide outpatient care to people with serious mental health conditions like psychosis. The people were ordered to undergo treatment so they wouldn’t be a threat to themselves or society.
Did it work?
Depends on who you ask. The Department of Health and Human Services and its subagencies — which issue and manage these grants — have looked at the effectiveness over the years and have generally found favorable outcomes. One federal evaluation, for instance, found that people who participated in the programs had a reduced likelihood of violent behavior, homelessness, and drug use, among other outcomes.
But a new Government Accountability Office report suggests those earlier conclusions are not reliable because of methodological flaws in how those assessments were made.
“Based on its review, GAO determined that HHS’s assessments were inconclusive,” GAO said. “Both efforts were hampered by methodological challenges, many of which were inherent in the program and beyond the two agencies’ control.”
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The GAO findings come at a time when more states are actively considering involuntary commitment — assisted outpatient treatment (AOT), as the government calls it — as a way to address crime and homelessness. Proponents say AOT helps adults live safely in the community without supervision, but the World Health Organization and people with lived experience have increasingly called into question the ethics and necessity of involuntary treatments, in addition to the unreliability of favorable reports. And in New York City, activists have pointed out racial discrepancies in which populations have been nominated for treatment.
The efficacy of AOT is a pressing question for mental health providers and the nearly 15 million adults in the United States with a serious mental illness. The GAO review lobs a giant question mark into an ongoing societal discussion of whether more federal dollars should fund a controversial treatment option — especially for a population facing worsening health outcomes, increased medical costs, and higher rates of involvement with the criminal justice system.
“The GAO report underscores that assessments of assisted outpatient treatment programs/involuntary outpatient commitment remain inconclusive,” said Sakeena Trice, a senior staff attorney on New York Lawyers for Public Interest’s Disability Justice team. “To protect civil rights and address racial disparities in implementation, mental health care and policy should shift toward culturally competent, community-based voluntary care that centers the lived experiences of those impacted.”
AOT typically consists of a judge mandating that a person with a serious mental illness adhere to treatment for a given time period. Health providers often petition the court for this, but it can also be parole officers, parents — in New York, even a roommate can lobby a judge for treatment. But many of the particulars in eligibility, methods, and timelines vary widely among states. The GAO report cites this heterogeneity as one of the main reasons for calling earlier federal reports “inconclusive.”
Also, much of the patient outcome data were gathered by staff interviewing patients, who may be hesitant to candidly answer questions on sensitive topics such as substance use.
Program variability and self-reported bias were not the only hindrances toward acquiring good data. In a 2024 report by the Office of the Assistant Secretary for Planning and Evaluation, many of the AOT programs that were awarded federal grants in the last decade actually accepted voluntary participants as part of their treatment programs. The GAO review suggests that this inclusion undermined the ASPE’s rosy results and reduced the agency’s ability to “assess the core concept of AOT.”
Furthermore, the ASPE report’s conclusion that people with repeated inpatient psychiatric hospitalizations are better suited to AOT than to voluntary treatment is based on data from a single program. The GAO review cautions against using this report and two similar reports from another federal agency as a policymaking tool. The authors suggest that these research challenges are inherent to the widespread implementation of AOT programs and are unlikely to fade as states like New York and California expand eligibility in their programs.