Letter

In Reply: Certainly no one would find improvements in mortality rates for people with serious mental illness to be a trivial matter. The mechanism whereby mortality rates could improve as a result of limited periods of court monitoring after hospital discharge is not intuitively obvious; however, incidental factors may be at play. For example, the community service system may be more accountable for individuals on conditional release, giving them greater service priority or more consistent services. On the other hand, because individuals included in the study by Segal and Burgess were not randomly assigned to court-monitored and unmonitored release from psychiatric hospitals, it is possible that differential selection practices account for the gap between mortality outcomes. For instance, medically compromised individuals might be regarded as candidates for long-term care settings and not in need of postdischarge court supervision. Or to the extent that, as the authors suggest, court oversight encourages physicians to discharge patients earlier, simply getting out of the hospital quickly may lead to reduced mortality.

But this is all speculative. Notwithstanding the attraction of Segal and Burgess's findings or the impressive size and scope of their database, their associational data are just that. Without minimizing the significance of their study or the improved mortality rates, it must be noted that these data simply do not establish that court-monitored release is the formula for lower death rates—or for anything else.

Extracting a broader lesson from this research and the reaction to my comments, if reductions in mortality rates were an adequate proxy for the goals of the public mental health system, one might argue that the currently configured system (epitomized in my commentary by "15-minute outpatient 'therapy' sessions") bolstered with ramped-up court intervention might be a compelling direction to pursue. On the other hand, as articulated by the President's New Freedom Commission, many stakeholders believe that mental health care should strive for goals well beyond low death rates or recidivism rates—indeed, for recovery. Court participation in individual treatment plans is a dubious pathway to such aspirations. As a general matter, routine reliance on court intervention can be seen as diagnostic of a system that is both neglectful and neglected. When used in noncrisis situations such as hospital discharge, requests for court intervention signal reservations about the impact of inpatient care, the capacities of the community system, and the status of the individuals being served. Given the erosion of the public mental health system and the underutilized potential of innovative interventions, various schemes involving the court in treatment can be seen as buttresses to a floundering system. Through this lens, the data presented by Segal and Burgess suggest that in Victoria, Australia, the climate is quite hospitable for judicial participation in individuals' mental health treatment, so much so that court-monitored discharges are regularly sought even for those entering the hospital voluntarily.

All of this raises a much more fundamental issue facing professionals in public mental health: Is their quiet complicity in involving the courts in nonemergency treatment of competent individuals perpetuating devaluation of public mental health care, the individuals it serves, and even the providers themselves?