Letter

In Reply: We agree that outpatient commitment can work in some circumstances for some individuals. However, as we noted in our column, outpatient commitment statutes are rarely used in California and in Florida, and there are significant barriers to their use in many other states ( 1 ). Given that outpatient commitment often has been portrayed as a panacea, it is important for policy makers to begin to understand why it is used so sparingly in many jurisdictions.

One obvious reason is a lack of adequate resources. As Swartz and colleagues ( 2 ) observed in reporting on outcomes from North Carolina's experience, "Outpatient commitment can improve treatment outcomes when the court order is sustained and combined with relatively intensive community treatment. A court order alone cannot substitute for effective treatment in improving outcomes." New York State invested vast new resources in its publicly funded mental health system when it enacted Kendra's Law. However, in most states, funding for community services on a per capita basis has been flat, at best, over the past few years, and fragmentation and erosion of existing service capacity are the rule more than the exception. In such a service environment, statutory change is unlikely to have more than a marginal impact from a systemic perspective.

The results reported from Seminole County are important, though it would be helpful if they were presented more fully in a venue in which the underlying data could be examined more closely. It would also be interesting to know more about individuals enrolled in the program who did not do well and the reasons for a lack of success. There is no question, as Esposito and her colleagues observe, that outpatient commitment can be very helpful for some individuals. However, there is also no question that if it is going to be adopted as a tool for system change, we need to know much more about the practical reasons it appears to be so often ignored.