Arrest: The “Front Door” to Long-Term Care?

To the Editor: Thank you for publishing the recent study by Robst and colleagues (1) on the correlation between involuntary psychiatric evaluations and increased arrest rates in the subsequent quarter. The authors conclude, in part, that the public safety objective of involuntary evaluations appears to have been disconnected from its “parens patriae” role as a gateway to longer-term inpatient care. For that reason, they suggest that “[i]t may be inadequate to think of diversion from only the criminal justice system; it may become necessary to think about diverting people from interventions historically thought to be therapeutic as well.” Certainly, it is evident to anyone working in an emergency or an acute inpatient setting that involuntary civil commitment rarely leads to long-term inpatient care. In other words, if these involuntary interventions do no good, why do we keep doing them?

The authors stop short of suggesting what is obvious to us working in the public mental health system: arrest is now the gateway to long-term inpatient care. In the state hospital where I work, we have seen our forensic population shift from about 30% in 2004 to about 65% today. This is partly related to policy decisions to downsize the state hospital system and to divert uninsured civil patients into private settings and partly to the recognition by our criminal justice partners that, in fact, they are our front door. The growth of specialized criminal justice approaches, such as law enforcement crisis intervention training, mental health courts, and novel probation approaches in recent years, as summarized by the Council of State Governments (www.consensusproject.org), supports this assertion.

Therefore, my conclusion is that the reason for the correlation found in the study by Robst and colleagues is that arrest is now essentially the only way that people with serious mental illnesses in need of long-term inpatient care can access the care that they need.