Improving Outcomes for Transitional Population Management and Persons with Serious Mental Illness: Assisted Outpatient Treatment and Interactive SMS Communications


Written by Cathie Hughes, Dr. William Harms, Howard Rosen


Over ten million people over the age of 18 suffer with a serious mental illness (SMI).  The SMI population is disproportionately counted amongst those who are at risk for homelessness, are engaged in violent crime, commit suicide, and have a high recidivism rate in the criminal justice system.  Approximately 4 % of this population represents the most serious conditions.  This subpopulation is more likely to exhibit adverse levels of daily living skills and engage in acts of violence, than others.  Causal factors include conditions that go untreated, under- or non-use of prescribed medications, and substance abuse either combined with medications or used to self-medicate (Mental Illness Policy Org. Home, 2015).

Recent findings (American Jail Association: Stepping up initiative, 2015, May) report that there are more people with SMI in jails than in psychiatric facilities.  Other researchers report “Most persons in correctional facilities have mental disorders as defined by the Diagnostic and Statistical Manual of Medical Disorders” (Kouyoumdjian, Schuler, Matheson, & Hwang, S. W. 2016, p. 217).  According to the World Health Organization (WHO), “people with substance abuse disorders or people who, at least in part due to a mental disorder, have committed minor offences are often sent to prison rather than treated for their disorder.  These disorders therefore continue to go unnoticed, undiagnosed and untreated” (p. 1).  Housing the mentally ill in jails is a national crisis, and jail personnel are struggling with a lack of proper resources to manage this population.  Expert consultants with The Human Rights Watch (2015) reported that the “misuse of force against prisoners with mental health problems is widespread and may be increasing.  Among the reasons they cite are deficient mental health treatment in correctional facilities, inadequate policies to protect prisoners from unnecessary force, insufficient staff training and supervision, a lack of accountability for the misuse of force, and poor leadership” (para. 5).  People with mental illness may go undetected, and the condition of incarceration intensifies their trauma.

Many factors contribute to a worsening of mental health conditions in jails and prisons.  These include, “overcrowding, various forms of violence, enforced solitude or conversely, lack of privacy, lack of meaningful activity, isolation from social networks, insecurity about future prospects (work, relationships, etc.), and inadequate mental health services” (World Health Organization, p. 1).  Correctional personnel struggle to find solutions to a dilemma that leaves them culpable for mismanaging this population.  “It is well known that US prisons and jails have taken on the role of mental health facilities.  This new role for them reflects, to a great extent, the limited availability of community-based outpatient and residential mental health programs and resources, and the lack of alternatives to incarceration for men and women with mental disabilities who have engaged in minor offenses” (Human Rights Watch, 2015, para. 6).  A lack of mental health programs for those incarcerated further exacerbates collaboration with needed programs and services upon release.

Unlike prison reentry, transition into the community is less likely to involve a reentry plan.  “Individuals committed to jails have diverse risks and needs, and their length of stay in jails is brief when compared to prison stays.  For many inmates being released, no organization or individual is responsible for their supervision or treatment in the community” (NIC, 2015).  Persons with SMI, substance addiction, and developmental disabilities are less likely to be able to care for themselves, access services, obtain prescriptions and needed medical care, and choose not to engage in community-based mental health care (Kendra’s Law, 2015).  Another study found “people recently released from correctional facilities in Ontario had a risk of dying from a drug overdose 56 times greater than the general population” (Medical Press, 2016, para.  1). Insufficient coordination with community-based services to develop collaborative reentry plans leaves this subset of persons hopeless, helpless and at risk of repeat offenses, including harm to self or others.

Many persons with SMI and substance dependencies are, upon exit, released without consideration for public safety (NIC, 2015).  Legal and public health interventions, and public safety advocates are leading recommendations to address this crisis, particularly in light of the increase in mass shootings and violent crimes on persons (King, et. al., 2015, NICA, 2015).  Studies suggest, “Reducing substance abuse has a greater influence in reducing violent acts by patients with severe mental illness” (Wilde, 2014, para. 2).  Assisted Outpatient Treatment (AOT) is a tool that represents a legal and systematic response to meeting this need.  AOT allows courts to order persons into community-based treatment as an alternative to inpatient care.  The law obliges community based mental health facilitates to provide treatment, and obligates patients to accept care as a condition of living in the community (Kendra’s Law, 2015).  Systematically, persons “comply with an approved treatment plan as a condition of remaining in the community and receive intensive case management and monitoring” (Stettin, 2014, p. 1).

AOT “is a practice designed to improve treatment outcomes for people with severe mental illness whose difficulties adhering to voluntary outpatient care have left them trapped in the revolving door of the mental health and criminal justice systems” (Stettin, 2014, p. 1).  According to Stettin, (2014), “While 45 states and the District of Columbia have laws authorizing local mental health systems to practice AOT, implementation of these laws remains spotty in all but a few” (p. 1).  California’s Laura’s Law and New York State’s Kendra’s Law are the most widely known AOT implementations.  In 2009, New York State’s Office of Mental Health (OMH) submitted a program evaluation final report to the legislature (OMH, 2009).  “The OMH report provided the first glimpse into the law’s effectiveness in improving access to and engagement with treatment for the most challenging patients in the public  mental health system, reducing harmful behaviors, and enhancing public safety” (Stettin, 2014, p. 1).

Mobile phone information technologies and interactive messaging are emerging as innovative approaches to improve healthcare and provide psychosocial interventions to assist persons with episodic disorder behaviors.  (Ben-Zeev, Breener, Begale, Duffecy, Mohr, & Muser, 2014; Wenze, Armey, & Miller, 2014).  According to the Substance Abuse and Mental Health Services Agency (SAMHSA), “Technology-based therapeutic tools not only offer clinical information and support to diverse audiences, but also provide social and supportive functions that may be absent or inaccessible to certain populations via traditional healthcare systems” (TIP-60, 2015, p. 28).  One such application could include interactive messaging communication for patient medication adherence.  Recent statistics show that medication non-adherence among patients with schizophrenia, for example, is common (Psych U. 2016).  The use of SMS interactive communication represents “new and innovative modalities to improve adherence and overall health outcomes” (Foreman, et. al., 2012, p. 1084).  Results of a recent study propose that those patients choosing to participate in using “text have a significantly higher chronic oral medication adherence” compared to those that did not, “and that the use of a text message reminder programs assists in preserving higher rates of adherence over time” (p. 1084).  Another study found “texting may be a more suitable treatment aid for those with mental illness than mobile applications” (Targeted News Service, 2015).  Transitional planning for SMI populations could benefit from interactive electronic communications interventions, such as SMS messaging.  This intervention engages individuals, who are less likely to call or keep face-to-face appointments, from intake to treatment and follow-up.  Interactive communications monitor behaviors and provide intensive case management services.




Persons with any type of mental illness represent eighteen percent of the population in the United States.  Twenty percent of this population is untreated, and four percent have serious mental illness (Mental Illness policy Org., 2015, Home page).  Jails are in crisis as personnel struggle to address the needs of this population, yet lack access to and coordination with community mental health services.  Jails often release persons with mental illness to the community without a transition plan.  Persons known to have SMI can refuse to participate on a volunteer basis in community mental health services, yet the threat of violence is more likely among this population; “the connection between severe mental illness, substance abuse and aggression is a significant concern for community safety, treatment programs, and public policy” (Wilde, 2014, para. 4).  Untreated, those with severe mental illness can be a danger to themselves or others, repeat offenders, homeless, jobless, impoverished, and a threat to public safety. Assisted Outpatient Treatment is a research-based program that can improve patients’ quality of life, reduce incidences leading to incarceration, and increase public safety.  The integration of SMS interactive messaging with evidence-based psychosocial interventions is a promising role for addressing barriers to transitional population management.  “Cell phone technology is in the hands of millions of American’s and early research indicates that this technology can be useful to help Americans who are suffering from some form of mental illness” (Mullen, 2015, para. 5). Technology Assisted Care (TAC) is “information tailored and responsive to each individual’s level of understanding and needs” (TIP-60, 2015, p. 28); employing this methodology “can accommodate diverse users with differing cultural needs and varying levels of health, technological, and reading literacies” (p. 28).  SMS offers an opportunity for an interactive TAC intervention initiated in jails, psychiatric and other inpatient facilities as part of community-based transitional planning.  For persons suffering with SMI, recent research suggests that SMS interactive communications may improve treatment and adherence outcomes.  Thought for AOT could include reminders, motivations, and interactive clinical survey interventions as an adjunct to a treatment modality.  Consideration for a TAC interactive SMS communication methodology may be warranted for addressing barriers to transitional population management and public safety.



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