Serious Mental Illness: HHS Assessments of Assisted Outpatient Treatment Have Yielded Inconclusive Results
Fast Facts
Serious mental illnesses affected 14.6 million adults in 2023. Left untreated, such illnesses can lead to issues like poor health and higher medical costs.
Assisted outpatient treatment can help adults with serious mental illnesses who can't live safely on their own. It can include medication and referrals for social services. But it is controversial because it's court-ordered and involuntary.
HHS awards grants to organizations to provide this treatment. However, we found HHS had challenges assessing the effects of these grants. For example, most results were self-reported by people receiving treatment, and such data could have errors.
Highlights
What GAO Found
Under assisted outpatient treatment, adults with serious mental illnesses can be ordered by a judge in a civil court proceeding to adhere to community-based treatment in accordance with applicable state laws. It is generally intended for individuals who have been assessed as unlikely to be able to live safely in the community without supervision. In 2014, federal law authorized the Department of Health and Human Services (HHS) to award grants to organizations to implement assisted outpatient treatment programs. The Substance Abuse and Mental Health Services Administration (SAMHSA), a component agency of HHS, has awarded about $146 million in assisted outpatient treatment grants to 63 grantees since the program's inception in 2016. These 4-year grants were primarily awarded in three cycles: 2016, 2020, and 2024.
Two HHS agencies—the Office of the Assistant Secretary for Planning and Evaluation (ASPE) and SAMHSA—have made efforts to assess the grant program. Topics studied included participant outcomes such as treatment adherence, psychiatric emergency room visits, hospitalizations, and arrests.
HHS Assessments of the Assisted Outpatient Treatment Grant Program
|
Assessment characteristic |
Office of the Assistant Secretary for Planning and Evaluation |
Substance Abuse and Mental Health Services Administration |
|---|---|---|
|
Assessment type |
Cross-site impact evaluation focused on six of the 17 grantees from 2016. Published in 2024. |
Two reports focused on program outcomes submitted to Congress in 2019 and 2024. |
|
Primary data source(s) used |
Surveys of participants, supplemented with other data, where available. |
Surveys of participants. |
Source: GAO analysis of Department of Health and Human Services (HHS) information. | GAO-25-107526
Based on its review, GAO determined that HHS's assessments were inconclusive. Both efforts were hampered by methodological challenges, many of which were inherent in the program and beyond the two agencies' control.
Examples of HHS Challenges Assessing the Assisted Outpatient Treatment Grant Program
|
Challenge |
Description |
|---|---|
|
Program variation |
Assisted outpatient treatment programs are governed by state laws and are highly variable. Some of the programs studied included characteristics that differed from what was expected, such as enrolling participants voluntarily in what is inherently an involuntary program, which complicated evaluation efforts. |
|
Self-reported data |
HHS primarily relied on self-reported data from participants. Self-reported data have drawbacks, including the potential for hesitancy to candidly answer questions on sensitive topics such as substance use. |
Source: GAO analysis of Department of Health and Human Services (HHS) information. | GAO-25-107526
ASPE's outcome report also included an analysis comparing assisted outpatient treatment participants to individuals enrolled in voluntary treatment of similar intensity. However, data on both groups came from one of the six grantees, and factors such as small sample size limited ASPE's ability to detect differences between the two groups.
Challenges assessing the grant program are likely to persist because, for example, state laws will continue to vary.
Why GAO Did This Study
Serious mental illnesses affected an estimated 14.6 million adults in 2023. Some of these individuals had not received any treatment in the previous year. Untreated mental illnesses can have negative effects, including worsening health, increased medical costs, and possible involvement with the criminal justice system.
Assisted outpatient treatment can help individuals with serious mental illnesses who do not recognize they are ill to receive needed treatment, according to its proponents. However, its involuntary nature makes its use controversial, and research on its effectiveness has produced mixed results.
The Consolidated Appropriations Act, 2023, includes a provision for GAO to report on assisted outpatient treatment programs that received grants from SAMHSA. This report describes HHS's efforts to assess the effects of the grant program on participants' health and social outcomes, and what the assessments have revealed.
GAO reviewed documentation and interviewed officials from HHS regarding its assessment efforts. GAO interviewed a nongeneralizable sample of six grantees, which GAO selected to obtain variation in, among other things, geographic location and levels of urbanization. GAO also interviewed representatives of six stakeholder organizations, including mental health professional associations and advocacy groups. The groups were selected to provide a range of views on assisted outpatient treatment.
For more information, contact Michelle B. Rosenberg at osenbergm@gao.gov.