In Reply: I agree wholeheartedly with Dr. Kane's suggestion that addressing the issue of competency to accept treatment in civil commitment statutes has the potential to reduce the criminalization problem that exists in the United States. For those with severe mental illness, civil commitment statutes provide an important buffer between the voluntary mental health and criminal justice systems. Over time, these statutes have become more rigorous in the protection of due process and liberty interests of persons with mental illness (1). Before deinstitutionalization, a patient could be committed to a state hospital for an extended period if two physicians determined that the patient was mentally ill and "in need of treatment." In the late 1960s civil commitment laws were altered, and patients could be involuntarily confined only if they were mentally ill and presented a danger to themselves or others or were gravely disabled.

In my opinion, these laws would be more effective if they addressed the deficit in insight that many individuals with severe mental illness suffer.

Approximately 50 percent of patients with schizophrenia and bipolar disorder suffer from a lack of insight into their illness (2). Insight is a multidimensional ability that includes three components: a realization that one is mentally ill, an attribution of one's symptoms to the illness, and acknowledgment of a need for treatment. Studies of individuals with bipolar disorder have shown impaired insight to be strongly correlated with nonadherence to community treatment, a need for involuntary treatment, revolving-door psychiatric admissions, and a poor clinical outcome. As we found in the study that we reported in the July issue, this pattern of community treatment utilization is also characteristic of patients with bipolar disorder who are arrested.

Unfortunately, in most states, mental health laws governing the involuntary treatment of patients do not take insight into consideration. Persons who do not recognize they are suffering from a mental disorder fail the critical first step in assessing capacity. They do not possess an understanding of the nature of their medical condition and are thus unable to accurately weigh the benefits and risks of treatment. Current civil commitment laws assume that patients have full capacity to act in their own best interests when deciding whether or not to choose treatment voluntarily. Although the American Psychiatric Association's 1983 model commitment statute included a determination of capacity in its ideal civil commitment procedures, only Utah considers capacity to accept voluntary treatment in its statute. In British Columbia's Mental Health Act, which is the civil commitment statute in Dr. Kane's jurisdiction, criteria for involuntary hospitalization also include a capacity assessment (4). A patient can be committed if he or she has a mental disorder that requires treatment in order to prevent substantial mental or physical deterioration or for the protection of self or others. Voluntary admission would be unsuitable if the person is too ill to be legally capable of making a request for admission or consenting to treatment—for example, if the person does not believe that he or she is ill and in need of treatment. Including these criteria in civil commitment statutes has the potential to successfully engage persons with severe mental illness in community treatment and could help prevent criminal arrest and its adverse consequences.