In the November Taking Issue, Robert Bernstein (1) commented on three of our research reports published in the same issue. He wrote that reliance on conditional hospital release sends the wrong message because it implies that professionals must turn to the courts to ensure effective postdischarge treatment. Whether a research message is judged to be right or wrong depends not only on content but also on the preconceived notions and political agenda of the stakeholder-reader.
We endeavored to present a message based on a decade's experience of 24,973 individuals who required psychiatric hospitalization. Within acknowledged limits, the protective oversight provided by conditional release was associated with saving 709 years of life and reducing the probability of death by 14 percent among 8,879 patients given conditional release compared with the other 16,094 patients released without such oversight. Conditional release was also associated with shorter inpatient episodes and, when used early in a patient's illness, prevention of a revolving-door dependence on hospitalization.
The evidence documents the positive effects of being on conditional release over and above the treatment provided, although our methods do not permit us to make causal attributions with the same confidence as for a randomized controlled trial. Our analyses indicated that conditional release is not for all patients—nor is it an intervention without problems. Our focus on the utility of early use of conditional release early—and on use of extended court orders for community treatment (2)—is an effort to improve understanding of the timing and objectives of different modes of conditional release in order to specify its benefits and liabilities.
Unlike Dr. Bernstein, we see the mental health system's engagement of the courts as perhaps well considered in view of the vulnerabilities of this population. The Mental Health Review Board played a positive role, providing oversight that protected individual rights, health, and safety. The consequences of failing to ignore the vulnerabilities of these severely ill patients (3) in view of increasing evidence that protective oversight reduces vulnerability (4) are of grave concern.
We agree with Dr. Bernstein's characterizations of the mental health system's failures and dependency-producing aspects, yet we see these as challenges to overcome through provision of empowering recovery-focused and well-monitored programs. The system's failures do not seem to require the elimination of conditional release procedures; in most jurisdictions the consequences of noncompliance with the conditions of release is return to the hospital for evaluation. Such action may be viewed as a demonstration by the state that it cares enough about its citizens to provide oversight during their time of need.
In reviewing the literature on outpatient commitment Geller (5) notes that it "has been characterized by considerably more opinion than fact…. Its assets and liabilities are all too often lost sight of in a cacophonous bluster that obscures reasoned positions." We hope that our investigative effort will result in selective use of conditional release and that our findings will promote the design of better research to understand its assets and liabilities and how to employ it in a way that preserves the dignity and hope of patients to the greatest extent possible while protecting their health and safety.
1.Bernstein R: Conditional hospital release: conveying the wrong message? Psychiatric Services 57:1553, 20062.Segal SP, Burgess PM: The utility of extended outpatient civil commitment. International Journal of Law and Psychiatry, in press3.Teplin LA, McClelland GM, Abram KM, et al: Crime victimization in adults with severe mental illness: comparison with the National Crime Victimization Survey. Archives of General Psychiatry 62:911-921, 20054.Hiday VA, Swartz MS, Swanson JW, et al: Impact of outpatient commitment on victimization of people with severe mental illness. American Journal of Psychiatry 159:1403-1411, 20025.Geller JL: The evolution of outpatient commitment in the USA: from conundrum to quagmire. International Journal of Law and Psychiatry 29:234-248, 2006