Twenty Years After Kendra’s Law: The Case Against AOT

There is no question that Andrew Rich, on the evening of May 8, 2017, was in a disturbed state. A 911 caller in Kohler, Wisconsin had said that there was a “naked man in the parking lot (of a golf course) howling like a wolf,” and, according to police reports, when officers arrived and approached Rich, his legs were covered with mud and he squared off “as if to fight.” The police subdued him with a taser and handcuffed him, and even then, as he lay face down on the ground, he shouted Bible verses and proclaimed himself to be God, Jesus, Damien and the devil.

After taking Rich to a nearby hospital, the police filed criminal charges against him for disorderly conduct and resisting an officer. In addition, the police filed a Chapter 51 emergency detention petition, which allows the police to detain and seek treatment for a person deemed mentally ill and a danger to self or others. Rich was soon taken to a county detention center.

At that moment, there were two possible legal paths ahead of Rich. He could be tried on the criminal charges or he could be committed, through a civil proceeding, to a psychiatric facility.

The county pushed for the second option, and while Rich fought against it, his mother Elizabeth, who had worked as a civil and criminal defense attorney in Sheboygan County for more than 30 years, supported it. Her son wouldn’t get a criminal conviction on his record, she reasoned, and instead would get treatment for whatever had led to his psychotic behavior.

Soon Rich, after a spate of legal proceedings, was committed to six months of treatment and sent to Winnebago Mental Health Institute. After roughly a month at Winnebago, he was discharged on an outpatient order that required him to get regular injections of Invega Sustenna, a long-acting form of the antipsychotic paliperidone.

Although Rich thought he would be free after that six months, in December 2017 a civil court judge extended the outpatient commitment order for another 12 months, and then on December 4, 2018, the order was renewed for yet another year. At each extension hearing, Rich’s psychiatrist, Daniel Knoedler, testified that Rich wouldn’t admit that he was mentally ill and needed medication, and that was why the court-mandated treatment was necessary.

After the last hearing, Rich’s despair about being under state control deepened, and he began talking about suicide. On January 11, he was found dead from an overdose of morphine and codeine.

“Looking back on it,” his mother Elizabeth said, in an interview with MIA, “I made so many mistakes in how much faith I had in the mental health system to help my son.”

AOT at 20 Years

Twenty years ago, New York State passed Kendra’s Law, which authorized compulsory outpatient treatment of the “seriously mentally ill.” While this was not the first state statute authorizing compulsory treatment outside psychiatric wards and hospitals, this was the law that kicked off the expansion of “assisted outpatient treatment” (AOT), and today, 47 states have passed such laws, with Massachusetts, Connecticut, and Maryland the only holdouts. SAMSHA and the Department of Justice provide federal funding for AOT initiatives, and AOT is now supported by Congress, the National Sheriffs’ Association, the National Alliance on Mental Illness, and the American Psychiatric Association.

Although there are still peer-led organizations—and other organizations that are sensitive to their arguments—that are opposed to AOT, any larger societal debate over its merits seems mostly over. But much as it was an anecdote of deadly violence—the story of Andrew Goldstein pushing Kendra Webdale in front of a New York subway train—that prompted New York’s passage of Kendra’s Law in 1999, the story of Rich’s death provides reason to take a fresh look at AOT, and its operation in real life.

Rich didn’t have a record of psychiatric hospitalization prior to the day he was reported naked and howling at the moon, but rather a criminal record, from 2008 to 2013, mostly for drug-possession and petty theft to fund his drug habit. If he had stayed within that criminal justice framework, facing charges of disorderly conduct and resisting an officer, he very likely wouldn’t have done any jail time, or a short stint at most. In May of 2017 there were 68 defendants charged with resisting/obstructing an officer or disorderly conduct in Sheboygan County, and those defendants were sentenced to a combined total of 132 days in jail. Most received no jail time at all. But Andrew, against his will, had been shuttled into compulsory treatment, and that sentence, in his case, had no end.

The questions raised by Rich’s story are many. Did Rich meet the stated criteria for AOT in Wisconsin? Were the civil proceedings that mandated treatment conducted in a manner that provided Rich with a fair hearing? And more broadly, now that AOT has a 20-year-record, is there evidence that it is—in the language of medicine—effective? Does it provide the “benefits” that the public has been told it does?

E. Fuller Torrey: Making the Case for AOT

In the early 1980s, the failures of deinstitutionalization—the emptying of the state mental hospitals—had become visibly evident. The “seriously mentally ill” were cycling in and out of hospitals, showing up homeless on city streets, and being carted off to jail for petty offenses. Now and then there was a report of a mentally ill person committing a violent crime. This was the societal landscape that led psychiatrist E. Fuller Torrey and others to call for compulsory outpatient treatment.

In his 1988 book Nowhere To Go: The Tragic Odyssey of The Homeless Mentally Ill, Torrey set forth his case. “Serious mental illnesses like schizophrenia are brain diseases in which parts of the brain are not functioning properly,” he wrote. “Since the organ is impaired, it makes little sense to insist that only those persons should be treated who want help and ask for it.”

Those who resist taking antipsychotics lack insight into their illness, Torrey argued. Compulsory drug treatment, rather than infringe on the civil liberties of the mentally ill, would serve to protect “their minds and their lives.”

Torrey was making this case at a time that the American Psychiatric Association was promoting its “chemical imbalance theory of mental disorders,” which, if true, provided his argument with a compelling logic. The public was being told that antipsychotics fixed a dopamine imbalance in the brain, like insulin for diabetes, and if that were so, then compulsory outpatient treatment could be seen as bringing help and comfort to the severely mentally ill who didn’t understand they needed this treatment.

This argument was repeatedly echoed by proponents of AOT in newspaper op-eds and other forums, and often such pleas came from parents, who told of their desperation to help their adult children. One such op-ed, which is still promoted on the Mental Illness Policy website today, was penned by Herschel Hardin, the father of an adult child with schizophrenia, who, according to the website, was known for his “defense of liberty” work with Amnesty International. Hardin wrote that people diagnosed with schizophrenia were “prisoners of their illness,” and that mandated outpatient treatment could set them free.

Compulsory outpatient treatment was being presented to the public as an instrument of freedom and liberation for the seriously mentally ill, and, at the same time, as legislation that would protect the public from seriously mentally ill people who went off their meds and turned homicidally violent. Torrey claimed that mentally ill people were murdering more than 1000 people a year, and the implication was that nearly all of these murders were by those who had stopped taking their meds.

In 1998, Torrey created the Treatment Advocacy Center to lobby for outpatient laws that would “establish clear consequences for noncompliance,” and the following January, Andrew Goldstein made Torrey’s case for him when he pushed 34-year-old Kendra Webdale in front of an oncoming subway.

Twenty-nine years old, Goldstein had a long record of psychiatric hospitalizations and assaults, and now the press had a story of the violent “madman” that Torrey had been warning about. Goldstein, wrote the New York Times, “should have come with a message plastered on his forehead: ‘Ticking time bomb. Suffers schizophrenia. If off medication, run for cover!’ “

In November of that year, New York State enacted Kendra’s law, which set forth a civil procedure for committing the severely mentally ill to compulsory outpatient treatment. According to the statute, only those who had a history of non-adherence to treatment and had either been hospitalized twice in the past three years, or had committed an act of serious violence toward self or others in the last four years, would be subjected to such forced treatment.

While several groups mounted legal challenges to Kendra’s Law, arguing that it violated the constitutional rights of those deemed “mentally ill,” in 2004 the New York Court of Appeals put its stamp of approval on the legislation. The state already had legal authority to commit people to a mental hospital, and Kendra’s Law simply extended that existing commitment power to a community setting. Newsday called the court’s decision a “triumph of common sense.”

At this point, the one element missing from the “case for AOT” was evidence that it was “effective,” and that it achieved the promised ends. It had been pitched as a medical intervention, but the first two randomized clinical trials of AOT had not shown that it met this efficacy standard. However, in March 2005, New York issued a “Final Report on Kendra’s Law,” and while it didn’t provide any findings from a scientific study, it still provided Torrey and other proponents of AOT with results that they could use to push for expansion of AOT laws nationwide.

From November 1999 through the end of 2004, there had been 4,041 petitions filed for AOT orders under Kendra’s Law, with 3,766 of those petitions granted. In its report, the state detailed how often this group had experienced various problematic behaviors in their three years prior to AOT, and then calculated the “percentage” that these problematic behaviors decreased during their time on AOT (which could be six months or longer.)

The results, at least at first glance, did tell of impressive results. Incarcerations were down 87%; arrests 83%; psychiatric hospitalizations 77%; homelessness 74%; harmful behaviors 44%; difficulties in self-care and community living 23%; and difficulties in social, interpersonal and family function 22%.

Torrey and others still cite this report today. Here is a picture of Treatment Advocacy Center’s “one page” summary of the evidence for AOT:

Once New York issued its report, Torrey and others continued to lobby other states to adopt AOT legislation. Torrey regularly played up the violence element, informing the public that it was due to the seriously mentally ill being off their antipsychotic medication. In a 2013 appearance on 60 Minutes, Torrey said that even mass shootings could be blamed on the absence of forced treatment laws.

Again and again, it was this “dangerousness” argument that prompted states to adopt AOT laws, with state legislatures moved to act after someone with a “mental illness” committed a homicide. Many of the state laws were named after the murdered person. California passed Laura’s Law; Louisiana passed Nicola’s Law; New Jersey passed Gregory’s Law; Kentucky passed Tim’s Law; Michigan passed Kevin’s law, and so forth.

In 2011, DJ Jaffe, a founding board member of the Treatment Advocacy Center, launched Mentalillnesspolicy.org, to promote the benefits of AOT to the media. Torrey was already the go-to psychiatrist for media covering this topic, and soon Jaffe became a second favorite source for newspapers and broadcast media, his website today listing his many interviews.

Their efforts have stirred newspapers and other media to report on the “success” of AOT. “The treatment required by Kendra’s Law,” the New York Times wrote, “is proven to reduce a patient’s risk of hospitalization, suicide, and violence.”

In 2016, the 21^st Century Cures Act signed into law by President Obama expanded federal funding for involuntary outpatient treatment programs, which gave Torrey reason to declare victory. “After lounging on the doorstep of respectability for the past decade,” he wrote in the Psychiatric Times, “assisted outpatient treatment has finally entered the mainstream.” 

The Case Against AOT

The case for AOT, when carefully parsed, is based on six assertions:

• The societal failure evident in the early 1980s—revolving door patients, homeless mentally ill, and so forth—was due, at least in part, to the failure of the seriously mentally ill to take their medications.
• Antipsychotic medications are drugs that treat a brain illness, and effectively so.
• People who don’t want to take their antipsychotic medication lack insight into their illness.
• Antipsychotics are protective against violence.
• Studies have shown that AOT reduces hospitalization, arrests, violence, and difficulties in social functioning.
• AOT laws have strict criteria that limit their application to the severely mentally ill who haven’t adhered to treatment, and either have had repeated hospitalizations, or are a danger to self or others.

The case against AOT—and this is quite apart from any civil liberty claims—is that all six of these assertions are belied by history, science, and a critical review of AOT research.

The Revolving Door Syndrome

In 1963, when President John Kennedy unveiled his plan for reforming the nation’s care of the mentally ill, he announced that the discovery of new antipsychotics had made it “possible for most of the mentally ill to be successfully and quickly treated in their own communities and returned to a useful place in society.” The state mental hospitals could be closed and replaced with a matrix of community care.

That vision never turned into a reality, and not long after Kennedy set the nation on this new path, the first study of the longer-term effects of antipsychotics provided scientific reason to doubt that it ever would. 

In 1961, the NIMH launched a nine-hospital study of newly admitted schizophrenia patients. At the end of six weeks, those treated with one of three antipsychotics (known as phenothiazines) were doing better than the placebo group. This finding was understood to establish the short-term efficacy of these drugs, and helped create societal belief that it would now be possible to move care of the seriously mentally ill into the community. However, the one-year results, which NIMH investigators announced in 1967, were of an opposite sort. The patients that had been treated with “placebo” in the hospital, the researchers reported, “were less likely to be rehospitalized than those who received any of the three active phenothiazines.”

This was a result that hinted of in-hospital drug treatment that increased the likelihood that a person diagnosed with schizophrenia or some other psychotic disorder would become chronically ill, and clinical observations soon added reason to suspect that might be the case. Patients were now cycling in and out of mental hospitals, and in the 1960s, psychiatrists dubbed this new clinical course the “revolving door syndrome.”

Jonathan Cole and other prominent psychiatrists at the National Institute of Mental Health soon described what they thought was happening. Patients regularly hated how the drugs made them feel, and after discharge from the hospital often abruptly quit taking them, which led to relapses that tended to “persist and intensify.” Yet, even when patients reliably took their medications, relapse was common, and it seemed that “relapse during drug administration is greater in severity than when no drugs are given.”

These clinical perceptions led the NIMH to fund three studies in the 1970s that assessed the longer-term outcomes of schizophrenia patients treated with and without antipsychotic drugs. In each study, the longer-term outcomes were worse for those randomly assigned to the medication group. This led William Carpenter, who conducted one of the three studies, to pose a haunting question: was it possible that antipsychotic medications made patients “more biologically vulnerable to future relapse than would be the case in the natural course of their illness?”

This was a breathtaking moment for psychiatry. If this were so, these drugs were worsening the very symptom—psychosis—that they were supposed to treat.

Two physicians at McGill University, Guy Chouinard and Barry Jones, then put forth a biological explanation for why this might be so. Antipsychotics block dopamine receptors in the brain, and in compensatory response, the brain increases the density of its dopamine receptors. In other words, they induce the very abnormality—a dopamine supersensitivity—hypothesized to cause psychosis in the first place.

 

 

 

 

 

“Neuroleptics can produce a dopamine supersensitivity that leads to both dyskinetic and psychotic symptoms,” they wrote. “An implication is that the tendency toward psychotic relapse in a patient who has developed such a supersensitivity is determined by more than just the normal course of the illness.”

As a result of this drug-induced dopamine supersensitivity, patients were at particularly high risk of relapse when they withdrew from the drugs, Chouinard and Jones said. Yet, if patients stayed on the drugs indefinitely, they were at risk of developing a chronic “tardive psychosis.” When this happened, they concluded, “the illness appears worse” than ever before. “New schizophrenic or original symptoms of greater severity will appear.”

That was the state of the research literature on antipsychotics in the early 1980s, when the failures of deinstitutionalization were becoming so apparent. And while there were obvious social factors that had contributed to this failure—the United States never fully funded the matrix of community care that President Kennedy had envisioned, and homelessness spiked in the early 1980s after President Ronald Reagan cut federal funding for mental health services—the research literature revealed that deinstitutionalization had rested on a clinical hope that had never panned out.

The scientific literature was telling of drugs that increased the likelihood that patients would become chronically psychotic and functionally impaired over the long term. The fact that so many patients hated how the drugs made them feel only added to this system-wide failure, because it led many discharged patients to abruptly stop taking the drugs and fall out of any system of care, and into homelessness or jail.

Today, it is clear that this research presented our society with a defining moment. If these scientific findings were to guide societal thinking, then we would have needed to rethink the use of these drugs. However, the public heard little of this research. Instead, Torrey and others put forth an argument that the failures of deinstitutionalization arose, in large part, because of a failure of the seriously mentally ill to take their drugs. By making this argument, Torrey and others were in essence doubling down on the very drug-centered paradigm of care that had failed.

Scientific research should be predictive of the future, and given the research literature that had emerged by the early 1980s, it could be expected that this doubling-down would lead to a continuing societal failure, and that has indeed proven to be the case. While there are many metrics that attest to that failure, two in particular stand out.

The first is the nationwide disability count. In 1987, there were 1.25 million adults on government disability due to mental illness, or one in every 148 Americans. Today, there are more than 5 million adults on disability due to mental illness, or one in every 61 Americans. The disability rates have soared in the past 40 years.

Second, recovery rates for schizophrenia patients have steadily declined in the antipsychotic era, from a high of 18% in the 15 years prior to the introduction of antipsychotics in 1955 down to 6% in studies conducted since 1997. This current recovery rate is the lowest for any period since the schizophrenia diagnosis was first constructed more than a century ago.

 

Antipsychotics are medications that treat a brain disease, and thus are an essential treatment for this illness.

In their arguments, Torrey and other promoters of AOT speak of schizophrenia as a brain disease, and for the longest time, the public was informed that this illness was due to too much dopamine activity in the brain. Antipsychotic medications, by blocking dopamine, helped normalize that dopamine activity, like insulin for diabetes. That was the soundbite that helped sell AOT.

However, the dopamine hypothesis of schizophrenia started falling apart in the 1980s, and in 1994, John Kane, a well-known schizophrenia researcher, concluded that “a simple dopaminergic excess model of schizophrenia is no longer credible.” While there have been researchers since then who have continued to investigate dopamine function in people so diagnosed, in 2012 Swedish researchers echoed Kane’s conclusion. “It is unlikely that a single neurotransmitter system can explain such diverse symptoms [of schizophrenia] . . . Thus, any simple, exclusive pathology of the dopamine system was and is doubtful.”

Instead, research has shown that antipsychotics, over time, alter the brain in harmful ways. As Chouinard and Jones noted, they induce a “dopamine supersensitivity” that appears to make patients more biologically prone to psychotic episodes than they would otherwise be. They also cause tardive dyskinesia in a significant percentage of patients, which is a form of permanent injury to the basal ganglia region of the brain. MRI studies have found that these drugs shrink the brain, with Nancy Andreasen, the long-time editor of the American Journal of Psychiatry, linking this shrinkage to cognitive decline and increased functional impairment in one of her reports.

This is not a record of scientific findings that tell of a class of medications that—as Torrey and other AOT proponents inform the public—are an “essential” treatment for a known brain disease.

People who don’t want to take their antipsychotic medication lack insight into their illness.

Torrey argues that 50% of people diagnosed with schizophrenia, and 40% of those diagnosed with bipolar, suffer from anosognosia, or a lack of insight into their illness, and this is why they refuse to take antipsychotics and other prescribed medications. Yet, the research described above reveals how such drugs can make patients feel worse and hinder their functional capacities, which is precisely what many people so diagnosed complain about. In addition, long-term studies reveal that tapering off antipsychotic medication, rather than being a route to clinical deterioration, can be a path to long-term recovery.

The most compelling evidence for this comes from Martin Harrow and Thomas Jobe. In the late 1970s and early 1980s, they enrolled 200 psychotic patients, who were mostly suffering from either a first or second episode of psychosis, into a longitudinal study. All were treated with drugs in the hospital and discharged, and then Harrow and Jobe periodically assessed how they were faring and whether they were taking antipsychotic medication. A difference in outcomes between the medicated patients and those who, on their own, had stopped taking the drugs, showed up at the 4.5 year followup, and by the end of 15 years, the schizophrenia patients who had quit taking antipsychotics were eight times more likely to be in recovery than those who had continued taking the drugs.

Furthermore, Harrow and Jobe found that those who got off antipsychotics early and stayed off them throughout the study were much less likely to suffer relapses than those who were consistently medication compliant. They reported that 72% of the patients who were “always on antipsychotics” were persistently psychotic; 46% who were “sometimes” on antipsychotics fell into this category, and only 7% of those who never used antipsychotics after year two did.

In a presentation at the 2008 annual meeting of the American Psychiatric Association, Harrow summed up his findings in this way: “I conclude that patients with schizophrenia not on antipsychotic medication for a long period of time have significantly better global functioning than those on antipsychotics.”

There are several other long-term studies that have found higher recovery rates for psychotic patients that have quit taking their medications. Furthermore, surveys of psychotic patients reveal that their beliefs about the drugs are in line with that research. While many patients told researchers that they found the drugs helpful over the short-term, the majority said that the drugs impaired functioning over the long-term, and thus were a “barrier” to recovery.

When this research is considered, it is easy to see that stopping antipsychotic medication, rather than be taken as a sign that a person lacks insight into an illness, might instead be seen as a sign that a person is finding that the drug treatment is worsening symptoms and his or her capacity to function, and that by stopping antipsychotic medication they are giving themselves a better chance of recovering over the long term.

Antipsychotics are protective against violence.

It is clear that when people diagnosed with a psychotic disorder go abruptly off their drugs, they are at high risk of becoming psychotic again, and that in this state, there is an increased risk that they may commit an act of violence. But that is a risk that arises within a drug-based paradigm of care, as opposed to a risk that might arise in relation to the disorder itself.

Prior to the introduction of antipsychotics in 1955, four studies of patients discharged from mental hospitals found that that they committed crimes at either the same or lower rate than the general population. However, this risk of criminal behavior changed once hospitalized patients were regularly treated with antipsychotics. Eight studies conducted from 1965 to 1979 determined that discharged patients were being arrested at rates that exceeded those of the general population.

The research literature provides reason why that might be so. The drugs may induce violent urges, and, at the same time, abrupt withdrawal from the drugs may also lead to a period of elevated risk of violence.

In the 1960s and 1970s, patients treated with haloperidol and other powerful antipsychotics regularly complained that these drugs, rather than serve as tranquilizers, could induce an excruciating inner restlessness and anxiety, the pain so severe that they “just wanted to jump out of their skins.” Starting in the 1970s, a handful of researchers began publishing case reports about this phenomenon, which they dubbed akathisia, and concluded that it led to an increased risk of suicide and violence.

In their case reports, researchers described how patients treated with these drugs, seeking to escape from this misery, had jumped from buildings, hung themselves, and stabbed themselves. In one study, 79% of mentally ill people who had tried to kill themselves were found to have been suffering from akathisia.

Such violent urges, the researchers reported, could also be directed at others. Patients suffering from akathisia described “violent urges to assault anyone near,” and wanting to kill “the motherfuckers” tormenting them in this way. A 1990 study determined that 50% of all fights on a psychiatric ward could be tied to akathisia. Yet another study concluded that moderate to high doses of haloperidol made half of the patients markedly more aggressive.

A few case reports linked akathisia to bizarre murders. One thirty-five-year-old man, asked why he had stabbed a grocer he had known for some time, said he did it to get the drug-induced pain out of his head. “The only reason I knifed the guy was Haldol messed me up. Prolixin makes me want to kill, too.” Such case reports led researchers to conclude that haloperidol could produce a “marked increase in violent behavior,” even among those without any prior history of assault. (See Mad in America, pages 186-189.)

This drug-induced anxiety also showed up in Harrow’s long-term study of psychotic patients. More than 60% of those on medication reported suffering from “high anxiety” throughout the study, compared to 15% of those off antipsychotics.

While such case reports tell of violent behavior by people on antipsychotics (and in particular on high-potency drugs like haloperidol), researchers have also reported that akathisia may become more severe after quitting the drugs. Add in the fact that psychotic symptoms following drug withdrawal may often “persist and intensify,” then it is easy to see why a drug-centered paradigm of care, which exposes patients to the hazards of akathisia while they are taking the drugs, and to increased akathisia and psychosis when withdrawing from them, could lead to an increase in violence by the “severely mentally ill.”

In fact, the poster boy for AOT, Andrew Goldstein, is better seen through that lens, rather than as someone who committed a senseless murder while “off his meds.” His first “psychotic” episode occurred at age 19, when, while on vacation with his family, he bizarrely turned over a table where two women were sitting. Over the next few years, he became a revolving-door patient. He was hospitalized 13 times alone in 1997 and 1998, and during a two-year period, he assaulted people 13 times, which included assaults on clinical and hospital staff. As his hospital record on 7/30/98 noted, for the “last 6-12 months patient has been acting aggressively and impulsively by striking out unprovoked.”

Goldstein’s last hospitalization in 1998 was from November 24 to December 15. He was treated with antipsychotics and yet, at discharge, was described as still quite psychotic. The drugs had not quelled his symptoms, and it was only 18 days later, during which time he apparently stopped taking his medication, that he pushed Kendra Webdale in front of a subway train.

Goldstein’s behavior was presented to the public as a binary story. Off medication he was a murderous psychotic; on medication, or at least this was the implication, he was fine. But, in fact, his story is of a revolving-door patient who became quite assaultive and ever more psychotic while going on and off drugs. He serves as an example of a failed paradigm of care, rather than as an example of how people diagnosed with schizophrenia may become violent if they go off their medication.

There is still much controversy over the risk of violence by the seriously mentally ill. The increased risk has been found to be of a minimal sort in some studies, particularly if the “seriously mentally ill” are matched to a “normal” cohort  living in the same community (and thus of a similar class). The risk is certainly exaggerated in the public mind, and this is particularly true of the societal understanding that the violence that does occur can be attributed to people being “off their meds.”

A meta-analysis of 110 studies that looked for “risk factors for violence” in psychotic patients found that medication non-adherence was of only “moderate importance.” Factors that were of greater importance included having been a victim of violence, homelessness, substance abuse, and most notably of all, non-adherence with psychological therapies.

In sum, the risk of violence by the “severely” mentally ill emerged within a drug-centered paradigm of care that helps create revolving-door patients, who may then go off their drugs upon discharge. Meanwhile, studies that predate the antipsychotic era remind us of a time when this elevated risk of violence was not found to be present in the “mentally ill.”

Studies have shown that AOT reduces hospitalization, arrests, violence, and difficulties in social functioning.

Although Kendra’s law was passed 20 years ago, and AOT laws have been enacted in 47 states, with such programs supported by federal agencies, there have been only three randomized clinical trials (RCTs) of AOT—two in the United States and one in the UK. RCTs, of course, are seen as the gold standard in medical research, and thus these three studies can be seen as providing the best evidence regarding the “efficacy” of AOT.

The first RCT was conducted as part of a pilot project on AOT at Bellevue Hospital in New York City during the 1990s. In the study, 142 patients were randomized either to court-mandated outpatient treatment and enhanced services, or to enhanced services alone, and after 11 months following discharge, “on all major outcome measures, no statistically significant differences were found,” the researchers reported. Rates of rehospitalization, arrest, and treatment adherence were all the same, as were the patients’ “quality of life” and “symptomatology.”

The second RCT, known as the Duke Mental Health Study, assessed outcomes for 331 people who had been involuntarily hospitalized and were then randomly assigned, upon discharge, to regular community care or to outpatient commitment under North Carolina law. There were no significant differences between the two groups at the end of one year, including arrest rates, which were 19% for both groups.

The Cochrane Collaboration is known for its systematic reviews of medical interventions, and in a review of AOT, Cochrane researchers calculated that, based on the two RCTs in the United States, it would require placing 238 patients on AOT orders to prevent one arrest, 85 on AOT orders to prevent one hospital readmission, and 27 on AOT orders to prevent one episode of homelessness.

The RCT in the UK, which was conducted more recently than the two in the United States, involved 333 hospital patients discharged to either a compulsory treatment order or to similar outpatient care but without the compulsory aspect. The researchers “found no support in terms of any reduction in overall hospital admission to justify the significant curtailment of patients’ personal liberty” by commitment orders.

In all three RCTs, there was no significant difference in outcomes. The Cochrane review concluded that compulsory outpatient treatment orders do not “result in better service use, social functioning, mental state, or quality of life compared with either standard voluntary or supervised care.” The only superior outcome for those on compulsory orders in these three RCTs was that the patients were “less likely to be victims of violent or non-violent crime.”

However, Torrey and other promoters of AOT do not cite those RCT results when making their case, or else they dismiss the findings as insignificant or irrelevant. Instead, they mostly depend on three sources for making their case: a “subgroup” finding from the North Carolina RCT; the 2005 report by New York State; and a study of rates of violence by people on AOT orders in New York.

After the North Carolina RCT failed to show superior outcomes for the AOT group, the investigators combed through their data looking for evidence of efficacy among subgroups in the AOT cohort. They determined that those who were on compulsory treatment orders for longer than six months, and who also had three or more clinical contacts per month, had better outcomes—lower hospital readmissions, arrest rates, violent acts, etc.—than the patients in the non-compulsory cohort.

This is the type of data mining that pharmaceutical companies, when faced with a failed trial, will do. They will seek to isolate a subgroup of patients treated with their drug who fared better than the median outcomes in the placebo group, and thus declare that the drug works for that particular type of patients. It’s a biased comparison, because you are comparing outcomes for a select set of “good responders” in one group to the average response in the comparison group, and it is known to be an example of bad science.

In this case, those who were under an AOT order for a sustained period were a group of initial “good responders” to that “treatment.” Those who had to be rehospitalized wouldn’t be included in the outcomes of the “sustained AOT” group, because they would have been deemed treatment failures in the first six months. The researchers then compared this subgroup of good AOT responders to the outcomes for all of those in the comparison cohort, including its failures during the first six months. In that way, the North Carolina investigators claimed that it was “sustained AOT” that produced a benefit, which is a finding that has been echoed by Torrey and other AOT promoters.

As for the 2005 report by New York State, which Torrey’s Treatment Advocacy Center features today on its website, it did not tell of outcomes from a scientific study. The state simply compared the frequency of problematic behaviors among the 3,766 recipients of AOT in the three years prior to their being committed to AOT to the frequency of such behaviors during their time—six months or more—they were on AOT. It is a before-and-after comparison, and it was bound to show a reduction in problematic behaviors during the AOT period.

In order to be eligible for AOT, the “mentally ill” patients needed to have had a difficult time in the three prior years. It should be expected, then, that they would have fewer difficulties during the much shorter time they were on AOT, when they were also receiving a “package of enhanced services,” which included better access to housing and vocational services.

For instance, the 2005 study tells of a “77% reduction in hospitalization.” Ninety-seven percent of the AOT patients had been hospitalized prior to being put on AOT, and that is because hospitalization was basically a requirement for an AOT order. These patients were then treated with enhanced services in the community for six months or more, and the only possibility was that their collective hospitalization rate would go down. In this case, 22% of the AOT patients were rehospitalized. Is that good or bad? What would the rehospitalization rate have been for this same group of patients if they had been given enhanced services, but without the compulsory treatment? Without a comparison group, which an RCT provides, there is no way to know.

In addition, the state’s use of “percentage reduction” in unwanted outcomes during AOT leads to a misleading impression. For instance, 9% of the 3,766 AOT recipients sought to “physically harm self” prior to AOT and only 4% did during AOT. Even though there was an improvement in only 5% of the patients, this was calculated, in the 2005 report, as a 55% reduction in self-harming behaviors. Seven percent had engaged in “theft” before AOT; 5% did during AOT. This was recorded as a 29% reduction in theft. And so on, as the graph below shows.

This misleading presentation of outcomes is present in all of the New York State statistics cited by Torrey. The majority of the 3,766 AOT patients were not deemed to have behavioral problems during the three years prior to their AOT commitment, or to have difficulties in “self-care” and “functioning” at the time of their commitment. As a result, if there was even a small percentage of patients who moved from the “had problems” category before AOT to the “didn’t have problems” category during AOT, it showed up as a substantial “reduction” in the unwanted behaviors.

The data cited by Torrey regarding the reduction of violence by AOT orders in New York State is similarly misleading. The statistic that Torrey loves to promote is that patients who are not on AOT are four times more likely to be violent than those who are. This claim comes from a 2010 study commissioned by New York that compared outcomes for 76 individuals mandated to AOT, who received enhanced services and “priority to housing and vocational services,” to a group of 108 patients discharged from a mental hospital who only got standard community care. There was one act of serious violence in the AOT group of 76, and five such acts in the second group of 108, and while that second number is indeed more than four times higher, it obscures the fact that 96% of the non-AOT patients did not commit any violence.

Indeed, the investigators who conducted the study viewed their findings very differently than Torrey, as they noted that mandated treatment included “priority to housing” and other enhanced services, which the comparison group did not receive. As such, they wrote, “the results do not support the expansion of coercion in psychiatric treatment.” 

AOT laws have strict criteria that limit their application to the severely mentally ill who have had repeated hospitalizations of arrests and a history of non-adherence to treatment.

Kendra’s Law requires that all of the following criteria must be met before a New Yorker can be placed on AOT.

• Be unlikely to survive safely in the community without supervision
• Have a history of non-adherence to treatment that has resulted in hospitalization or act of violence toward others or self
• Be unlikely to voluntarily participate in treatment
• Need AOT to prevent a relapse that would likely involve risk of harm to self or others

Yet, according to New York’s 2005 report on Kendra’s law, of the 3,766 individuals who had been placed on AOT by that time:

• Only 18% had difficulties in self-care and community living at the onset of the court order (an average across a range of tasks)
• Only 32% had “difficulties” in social and family functioning (an average across a range of tasks)
• Only 36% had difficulties with “medication management” (and 34% were taking the medications just as prescribed)
• Only 15% had threatened suicide or physically harmed others in the 90 days prior to the order

According to this 2005 report, the majority of the 3,766 people who had been placed on AOT, at the onset of their order, were living in the community and taking their medications, and only a small minority had threatened to harm self or others in the previous 90 days. Nearly all of them had been hospitalized in the past three years, and so it would seem that inpatient hospitalization was the one criteria that all met. But clearly the majority didn’t fulfill all of the criteria that was legally required before one could be put on AOT. 

The Case for AOT Deconstructed

As can be seen, Torrey, Jaffe and others have sold the public on AOT with a public argument that appears to be based in science, but, in fact, ignores science at every turn. There is no presentation to the public of the research that tells of a failed paradigm of care, e.g. of drugs that may worsen psychotic symptoms, shrink the brain, impair the chance of long-term recovery, and produce an inner agitation associated with suicide and violence. There is no telling of how outcomes for schizophrenia patients are now worse than ever before, and that RCTs have found that adding compulsory treatment to decent community care produces no added benefit.

And as Andrew Rich’s story reveals, this ignorance of science—and the slapping of AOT orders on people who don’t meet the criteria—can produce a fatal despair.

Death in Wisconsin

Andrew Rich is remembered by his mother Elizabeth, and other family members, as being quite precocious as a toddler—reading by age three and naming a child’s version of Homer’s Odyssey as his favorite book by kindergarten. “He was very, very intelligent, bright and charming from the beginning,” she said.

He was the oldest of three children, his mother an attorney and his father a plumber, and as a Sheboygan Press article wrote, his childhood didn’t foretell of later problems. “He was a writer, an animal lover, a Boy Scout who hiked with this father and attended plays with his grandparents. He was an altar boy throughout his youth and enjoyed traveling. He saw most of the 50 states and countries like Australia and Fiji with his family.”

The one place he did struggle was in school. His teachers described him as a “square peg in a round hole,” his mother said. “Andrew was the kid not lining up. I was forever getting calls about that. Andrew doesn’t sit still, doesn’t stay in the line, follow instructions.”

His real troubles began in high school, when, at age fifteen, he was in a car crash and injured his knee. A doctor prescribed Oxycontin for his pain, and when his prescription ran out, he turned to petty theft to fund his newly developed drug habit. Friends remember him getting into some fights in high school, and soon he was a regular in the courtroom, appearing in Wisconsin and Illinois courts 11 times from 2008 to 2013. “He was in trouble most of his [adult] life,” his brother Jacob said. “Nothing serious or violent. Mostly drugs.”

A felony conviction for heroin possession in 2013 turned Andrew in a new direction. He stopped using drugs, and found a girl who, he told his mother, was the “love of his life.” However, the felony conviction made it difficult for him to qualify for educational loans and get a good job. He worked building roof trusses, but “felt that he was stuck in a dead end, like his life wasn’t going anywhere,” his mother said.

Then, in early 2017, he broke up with his girlfriend. He became quite despondent, took a 30-day sabbatical from work, and moved back into his mother’s home that April to write a book. It was then he started showing signs of emotional instability. “He was manic, just really up there in terms of racing thoughts and energy. He was talking on a really deep level,” his mother recalled.

That was the lead-up to his arrest, on May 8, for disorderly conduct and resisting an officer. This date had special meaning in this life.

Andrew had always been close to his father, Jeff, and when he was a child, they had often gone on hikes together, where they would swim in rivers during the day, and howl at the moon like wolves at night. But that was before Andrew became addicted to Oxycontin and his life spiraled out of control. Then, in 2010, his father died unexpectedly. The night before his funeral, Andrew was so distraught he took out a gun and threatened to kill himself. And now, seven years later, with his mind racing, he was thinking of how May 8 was his father’s birthday, and, as one friend remembered, Andrew was hearing his Dad’s voice, telling him “to come find him.”

And so, after hitching a ride to visit his Dad’s grave in Plymouth, he began walking to the Kohler golf course with his Dad’s words urging him on.

The first legal battle

Soon after Andrew’s arrest, the Sheboygan County DA dropped the criminal charges, and instead decided to petition a civil court judge to commit Andrew to a mental hospital. Andrew’s county-appointed public defender urged him to take the deal, but Andrew refused. “I’m not crazy,” he told his mom. “I don’t belong in there.” 

The county now had to prove, at a probable cause hearing, that Andrew met the criteria for an extended period of involuntary commitment to a psychiatric institution. Andrew acted as his own attorney at the hearing. He argued that none of the prosecution’s witnesses had provided adequate evidence that he had a mental illness, and noted that none of the police units that had responded could provide body-cam or dash-cam footage of his parking lot behavior. Remarkably, the judge ruled in his favor.

“He was brilliant and extremely articulate,” said his mom. “No one wins mental health probable cause hearings. I’ve never seen it happen.”

At that point, it seemed that Andrew would go free. However, county authorities put him back in jail, and, on May 25, filed a new Chapter 51 emergency petition. This plea was signed by three Sheboygan county employees who had interacted with him, and although Rich had successfully defended himself at the first hearing, the three now described Rich as having been persistently delusional since his initial arrest. They described him as becoming “increasingly more delusional and paranoid”  and acting in violent ways, both toward himself and others. He also was “refusing medication.”

At the second probable cause hearing, a medical expert testified that Andrew was mentally ill, and a trial was scheduled for June 14. Andrew represented himself at that trial, and while he waged a valiant battle—the trial last for ten hours—he lost and was mandated to six months of inpatient treatment at Winnebago Mental Health Institute in Oshkosh, Wisconsin.

Six months of mandated treatment

Winnebago was a facility with a troubled past. In 2007, it had been reported that nearly three dozen acts of violence or sexual aggression had occurred during a two-year period, including three patient deaths and a rape. Andrew landed there on May 25, and, based on a report by federal investigators seven months later, the institute was still beset by problems. The investigators issued Winnebago 48 citations for improper patient care, inadequate nursing staff, poor oversight of medical staff, and an unsafe physical environment. One patient who fell and hit his head didn’t get any medical treatment for 12 hours and died 17 days later. Google reviews of the facility, written by former patients, are filled with complaints about unprofessional staff, medication mismanagement, and prison-like conditions.

Andrew ran into his own spate of trouble during his thirty days there. He made a complaint about the treatment and soon a staff report told of how Andrew had been restrained because of “aggressive” and “dangerous” behavior. Andrew’s version of the event, however, was quite different. He told his mom that, as he was making a “soft-spoken complaint,” four guys “came up behind him, grabbed him, slammed him on a steel table, tied up his wrists and ankles, and left him in seclusion for hours and hours.”

Despite the case report, Andrew was transferred to a less-restrictive residential facility on June 23, and then he was soon discharged from that facility, on an outpatient treatment order that required him to get regular injections of Invega, a long-acting antipsychotic.

Andrew, his mother recalled, hated how the injections made him feel. “Everyone could see the Invega completely changed his personality. He was impotent. He had no physical sensation. He couldn’t taste food. He couldn’t experience [anything].”

Twice, Andrew missed an appointed to get his injection, and soon the police were knocking on his door. “You know, those appointments that they said I missed, I don’t feel I got any type of proper notice to come and show up,” Andrew later told the court. “I got arrested almost the day after the appointment on both cases. The cops showed up at my house, in front of my house and made me look bad in front of my neighbors and came and cuffed me and brought me [to the hospital] . . . somebody could have called me and asked me to come [to the hospital]. I would have showed up, you know.”

This was his life on the outpatient order. Andrew “was afraid to express himself,” said his friend Tanya Payne. “He thought if he said something wrong he would be sent to get more medication or to go back to Winnebago.”

But other than those two missed injections, Andrew complied with the order. He had moved into his own apartment and secured a job as a laborer. He looked forward to December 2017, when he could expect to go free.

A Second Legal Battle

In its 2018 “Grading the States” AOT report card, Torrey’s Treatment Advocacy Center gave its highest grade to Wisconsin, a 96 out of a possible 100. The Wisconsin law, much like Kendra’s law, stated that an AOT petition could be granted only if specific criteria for eligibility were met, such as being a danger to self or others, or being “unable to satisfy basic needs for nourishment, medical care, shelter or safety.”

These criteria didn’t seem to apply to Andrew at all, at least at this time. He wasn’t suicidal, he was working, and he was living on his own. However, Sheboygan County’s Department of Health and Human Services petitioned the county court to extend the outpatient order another six months, and a social worker employed by the county, Leigh Ullman, laid out the argument for why it was needed in a deposition. “Andrew Rich views himself as an unconventional individual who is being treated unfairly by society,” he wrote. “Basically, he has no insight into the fact that he has a mental illness. Finally, he has no understanding of the benefits of psychotropic medication.”

This clearly was not an argument specific to the legal criteria for an AOT order. Instead, it was a petition that echoed E. Fuller Torrey’s talking points for AOT, and how people with schizophrenia suffered from anosognosia.

At his trial, the county called upon psychiatrist Daniel Knoedler, who was under contract with Sheboygan County Health and Human Services, and who had been Andrew’s supervising psychiatrist since June 23. Although the first psychiatrists and professionals who had seen Andrew following the May 8 incident had given him various diagnoses, including bipolar and psychosis NOS (not otherwise specified), Knoedler—who was appearing remotely through videoconferencing—told the court that, after having seen or spoken to Andrew on the phone at least six times, his diagnosis was that Andrew had schizophrenia.

Knoedler acknowledged that he had never seen Andrew in a psychotic state, but he said that his diagnosis was consistent with the description of Andrew’s behavior on May 8 and the following few days. In addition, he testified that Andrew had told him in August that he was “thinking of telling someone he knew that he was a werewolf just to see what their reaction was.” This, Knoedler concluded, “is a very unusual statement to make and so I am concerned that again reflects his underlying illness.”

Having diagnosed Rich with schizophrenia, Knoedler told the court that the order needed to be extended because Andrew “said he doesn’t have a mental illness, and he doesn’t think that he needs the medication, and repeatedly indicated he would like to be off the medication.”

That was the county’s case against Andrew. It didn’t produce any evidence of erratic or dangerous behavior by Andrew, beyond his behavior on May 8 at the golf course. It didn’t provide any evidence of ongoing psychotic symptoms. As Andrew’s attorney Charles Wingrove noted, the county’s case rested on how Andrew “might” act, and what he might “think.” Those “mights” didn’t meet criteria for an AOT order.

Judge Kent Hoffman thought otherwise. He explained his reasoning:

In other words, Andrew’s past actions didn’t meet the standards for commitment. He was being placed under state control for another year because of what might happen in the future, a verdict that left Andrew’s mother aghast.

“Andrew’s done nothing wrong since May, not so much as a traffic ticket. He’s just working and minding his own business. How can they keep him under this commitment when all of the evidence [of mental illness] goes back to the original incident?”

Under Wisconsin law, Andrew was entitled to a second hearing in court if he could find a medical expert to challenge the testimony. He met with three psychiatrists to plead his case, but all three refused to testify on his behalf, with one of the three, forensic psychiatrist Robert Rawski, refusing in large part because of Andrew’s “skepticism about mental illness . . . and the anti-med bias he shares with his mother.”

The three doctors, his mother said, “all sang from the same hymnal.”

Toby Watson, who formerly worked as the chief supervising psychologist for the Wisconsin Department of Corrections, said this was no surprise. “Defense attorneys only have access to a small pool of psychiatrists and psychologists who are indoctrinated into the faith that meds work. It’s sacrilegious for these doctors to speak out against the mainstream medical model.”

And now, with this extension order in place, Andrew’s psychiatric care—and chance that he would ever get out from under state control—remained in the hands of Daniel Knoedler.

Guilty before Trial

Knoedler worked under contract to Sheboygan Health and Human Services, earning $163 per hour for his services. He was known by patients in the area for being quick with the prescription pad, a reputation backed up by prescription data published by the Centers for Medicare and Medicaid. In 2016, he wrote 38 prescriptions per patient, double the 19 prescriptions-per-patient average among the other Wisconsin psychiatrists who accepted Medicare. That year, the government paid more than $1 million for the drugs Knoedler prescribed, which put him into the top 3% of all U.S. psychiatrists who accepted Medicare, in terms of their government prescribing costs.

In March of 2018, Knoedler changed Andrew’s mandated treatment from a drug injection of Invega to Abilify, a less powerful antipsychotic. This led to an improvement in Andrew’s mood and energy, his mother said, but he still struggled with physical and mental side effects with this drug.

Beyond that, Andrew and Knoedler remained at odds in therapy sessions, as Knoedler would focus on getting him to acknowledge that he was mentally ill and needed antipsychotic medication. “His ‘diagnoses’ always seemed to involve a swipe at Andrew,” his mother said.

“He clearly did not like him. Andrew would get so frustrated at the sessions, because he said nothing that comes out of my mouth can be right. If he would relate an accomplishment at work, he was narcissistic. If he would talk about something he was writing that he thought was particularly insightful, he was exhibiting grandiose thinking. Nothing was right. If he said, ‘I can’t do anything right,’ then he is clinically depressed. He said every word that comes out turns against me.”

Andrew’s AOT order was set to expire in December 2018, and it was expected that Knoedler would wait until November to submit a recommendation to the court on whether it should be renewed. Instead, several months earlier, he informed Andrew that he had already made up his mind and that he would advise the court that the outpatient commitment order should continue.

“I was outraged that [Knoedler] would rob him of hope like that,” his mother said. “It’s not supposed to work like that. There is supposed to be a proceeding with a fact finder.”

Soon Andrew stopped talking to Knoedler during their mandated sessions. While his family tried to buoy his spirits, Andrew “was just getting more and more depressed,” his mother said. “He was living a life he didn’t want.”

His brother and friends saw the same thing. “He said he could never escape the state, the forced drugs,” Jacob said. “He felt like this was going to be a permanent thing. And he felt like he wasn’t able to keep relationships while being on the drug because it just really dulled his personality.”

Added his friend Tanya Payne: “He would call crying and upset, just to have someone to talk to. He was miserable with everything he had to go through. I think the drug dissolved his will to be here.”

The Final Trial

The “recommitment hearing” that was held on December 4, 2018 proceeded in much the same way that the trial a year before had, although this time it was even more perfunctory. The county’s attorney, Samantha Bastil, only called one witness, Daniel Knoedler, who once again testified via videoconference. Knoedler told the court that he had diagnosed Andrew as having schizophrenia, a diagnosis that established he was mentally ill. Most of the questioning then focused on Andrew’s state of mind, and his possible future actions. What “might” he do if was not recommitted, for another year, to outpatient treatment?

Knoedler told the court that Andrew mistakenly viewed his psychotic behavior at the golf course as a “one time episode,” rather than an “ongoing illness.” The AOT order should not be lifted until Andrew understood that he had a chronic illness that required antipsychotic medication, Knoedler said. “If he stops the medication, his [likelihood] of psychosis will be extremely high.”

Nobody was called by the prosecution to testify that they had ever witnessed Andrew in a psychotic state. Upon cross-examination by Andrew’s attorney, Knoedler acknowledged that he had not personally witnessed any psychotic symptoms in Andrew during the 18 months he had been treating him. Andrew, he said, “was actually doing very well . . . living in the community.”

In his turn on the witness stand, Andrew told the court he had been working at Plymouth Industries for more than a year, and now had his own health insurance. If the commitment order were lifted, he promised that he would voluntarily see a psychiatrist, meet with a therapist, and take medication. He testified:

The prosecutor did not cross-examine Andrew. His mother then took the stand, telling the court that initially she had been “relieved that the county was taking over and putting him on a commitment” order, but her feelings had changed.

The drug treatment, she added, “impairs [Andrew’s] ability to think quickly and clearly . . . He is a human being with his own mind and he is being denied the opportunity to participate meaningfully in his treatment . . . this has been going on for way too long.”

At the end of the testimony, there was little dispute over Andrew’s past actions. Andrew had behaved in a psychotic manner on May 8, 2017, and after that initial psychotic episode, which may have lasted several weeks, nobody had seen any psychotic symptoms return. During the last year, he had been working and living successfully in the community. At issue was that he didn’t agree with his psychiatrist that he was chronically ill.

“The bottom line is this is your life,” Judge Stengel said, as he prepared to announce his decision. “And we want you to have it to the fullest extent possible under your control. And it sounds like you’re doing so many positive things with your life. You’re out there working. You’re helping your mom. You seem to have a vested interest in your situation and tried to learn as much as you can.”

All of this sounded promising. But then Judge Stengel decreed that Andrew would be placed under outpatient treatment for another 12 months. “There are certain areas that the Court has to rely upon expert opinions because that’s not within my area of expertise,” he said.

This was a decision that reflected, in every way, the story told by Torrey and other promoters of AOT. The “patient’s” own self perceptions could be discounted because the “severely mentally ill” lacked insight into their illness. The testimony of his psychiatrist, who understood that psychosis was a brain disease that required antipsychotic medication, should govern his life.

Andrew, crushed upon hearing the decision, now had a haunting question for the court, and really for all who would countenance AOT:

A Life Gone

After the hearing, his mother said, “everybody was worried. We spent Christmas Day with my mother-in-law. . . [On our way home] We had a four-hour conversation about [suicide]. He was curious about death, and what it would feel like.”

His brother Jacob made him promise to call if he thought about “hurting himself.”

Much as Andrew had told the court, the decision “messed” with his stability. In early January, Andrew told his mother that his thoughts were now racing, but that he liked it. “It makes me feel alive.”

His mother worried that a crash was coming and that he should go see a therapist. “No,” Andrew replied, “they will lock me up.”

His mother now similarly felt there was nothing to do. “I didn’t tell anyone or call anyone to get him help [when his thoughts started racing], because I knew he was right. They would have locked him up, and not given him any meaningful treatment.”

When Andrew didn’t show up for work on January 11, the police were called to his apartment to perform a wellness check. They found Andrew on the floor, in a sitting position, with a syringe and drug paraphernalia next to him. He was dead from an overdose.

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Part Two: More on Andrew Rich, his legal battles, and MIA’s survey on forced outpatient treatment.

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MIA Reports are supported, in part, by a grant from the Open Society Foundations