Should We Try to Avoid Civil Commitments?

To the Editor: In their article in the July issue, Wanchek and Bonnie (1) described how they combined data from Medicaid and the Court Management Systems database in Virginia to demonstrate that individuals who were held for a longer period under a temporary detention order (TDO) were less likely than those with a shorter TDO to have a subsequent compulsory hospital admission. However, because the overall time that an individual spent in the hospital increased for those with longer TDOs, introducing longer TDOs could have financial implications.

Although in general it can be informative to examine aggregated data from a large group of patients to evaluate trends in compulsory admissions (2), more detailed information is needed before one can make policy recommendations. The authors themselves mentioned that patients admitted on a TDO during weekends (when TDOs were longer) may not be the same types of individuals as those admitted on a TDO during regular office hours. Not emphasized by the authors but probably also relevant is that the treatment provided during weekends may not be the same because fewer staff are available. In their discussion, the authors note that longer TDOs can reduce coercion. However, voluntary patients can also feel coerced (3)—for example, when they feel that they are not involved in the admission process (4). Patients might well feel coerced during a TDO and might even feel coerced during a voluntary admission after a TDO. Although the effects of feelings of coercion on future engagement in treatment are not clear (5), there is a lot to be said for trying to reduce experiences of coercion among patients with mental health problems. However, the authors do not provide any information about experiences of coercion, and such information is needed to inform decisions about whether longer TDOs are advisable.

In Reply: We agree with Dr. Hubbeling's observations, particularly the importance of recognizing that patients' agreement to remain in the hospital voluntarily before or during a commitment hearing does not necessarily indicate that they feel less coerced. However, it is also important to emphasize that, in our view, the main finding of the study is that longer TDO periods were associated with an increased rate of dismissals at the subsequent commitment hearings. We presume that in most of these cases the evaluating clinicians and the judges determined that the patients had become sufficiently stabilized to be discharged safely to outpatient settings for voluntary treatment.