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Assisted Outpatient Treatment Doesn’t Work. Mamdani Could Stop It.

Claims that coercive mental health care is a necessary evil are not supported by evidence.

AOT allows a judge to order a person to adhere to a treatment plan while living outside of a hospital setting.

New York state enacted Kendra’s Law in 1999, in the shadow of a tragedy. The law is named for Kendra Webdale, who was pushed in front of a subway train by a man with untreated psychosis. It created the nation’s most expansive systems for Assisted Outpatient Treatment, or AOT: civil court orders requiring people with mental illness to comply with community-based treatment.

A quarter-century later, AOT is embedded in the state’s mental health system, and New York City is its main engine, accounting for over 60 percent of AOT petitions granted statewide. As Mayor Zohran Mamdani looks to establish a new Department of Community Safety and to reform the city’s mental health and homelessness policies, he will have to choose whether to continue AOT and associated forced treatment programs at their current scale. As he deliberates, he will face a lot of impassioned defenses of these programs. AOT in particular is often singled out as a humane alternative to forced commitment. Many parents of individuals living with mental illness as well as police lobbies and advocates within the psychiatric and pharmaceutical industries consider court-ordered treatment an indispensable tool for public safety, improving health outcomes, and saving lives.

These claims, although they may be emotionally compelling, are not supported by the evidence. The most rigorous experimental data makes clear that perpetuating—let alone expanding—AOT is scientifically, fiscally, and ethically indefensible, ultimately deflecting attention and funding away from what New York City must actually do to support its most vulnerable residents.

AOT allows a judge to order a person to adhere to a treatment plan while living outside of a hospital setting. Orders typically last 90 to 180 days but can be renewed repeatedly. Programs vary, but AOT usually involves mandated medication—typically long-acting injectable antipsychotics that are infamous for their serious side effects and which, while life-saving and enabling for some, are ineffective for a large proportion of people living with bipolar disorder or psychotic experiences. AOT also includes required outpatient appointments and ongoing monitoring. Noncompliance can lead to seizure by police, involuntary transport for psychiatric evaluation and, potentially, hospitalization and resumption of forced medication, often regardless of whether such treatment has been effective for a given patient.

Today, 48 states and the District of Columbia authorize some form of AOT. In every instance, the authorization and defense of AOT rests on the idea that the court order itself produces better outcomes—fewer hospitalizations and homeless nights, less incarceration, reduced violence—than the same services offered voluntarily.

Yet among the three randomized controlled trials that have examined the practice, none found statistically significant improvements in primary clinical outcomes for people under court order compared with controls receiving services without a mandate. A major meta-analysis pooling these trials found no significant effect on hospitalization, symptoms, arrests, or quality of life, and calculated that 142 people would need to be subjected to court orders to avert a single hospitalization.

When AOT “works” in observational studies, it is usually because something else changed: services, housing access, or provider follow-through.

The studies cited by AOT advocates typically compare people’s outcomes before AOT enrollment and after. These studies often show improvement, but their findings do not answer the real question: Does the court order produce better outcomes than the same services delivered voluntarily?

People are usually enrolled in AOT at their worst point after repeated crises. Statistical improvement from that low point is expected even without coercive interventions. The studies also fail to account for the fact that AOT enrollment brings priority access to intensive services: assertive community treatment, intensive case management, disability benefits advocacy, and supportive housing. If hospitalizations or........

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