Is our legal commitment process an evidence-based model?

By Bryan Kozusko

The research methods used by the Policy Surveillance Program to develop datasets mapping health laws and policies include secondary research that provides context to the law, identifies the legal strategy it embodies, and uncovers any evidence to suggest whether it is improving health and well-being. While policy surveillance is meant to facilitate an evidence-building process by producing robust data for analysis, researchers attempt to uncover some indication that existing policies are evidence-based.

The Policy Surveillance Program has been mapping involuntary civil commitment laws at various levels: short-term inpatient commitment, long-term inpatient commitment, and outpatient civil commitment. So far, a literature review is inconclusive on the effectiveness of involuntary outpatient civil commitment.

Domestically, a handful of studies appear to exist. To date, only two systematic studies have been performed, both of which yield inconclusive or inconsistent results (see Kisely & Campbell, 2014, and Ridgely, Borum & Petrila, 2001). The Kisely and Campbell review shows an overall improvement in areas such as social functioning and quality of life; however, researchers acknowledge the sample size is very small and the quality of the trials range from low to medium. The Ridgely et al. review gathered similar unreliable data, inconsistent or conflicting results on quality of life after commitment.

A quick Google Scholar search reveals most of the relevant literature was published around 15-16 years ago, at the beginning of the new millennium, and is arguably outdated. A brief scan of literature published after 2015 reveals that the information is not necessarily missing, but that it has not been cohesively analyzed. Additionally, most of the existing literature in the United States varies in focus and variables, meaning the studies cannot be effectively compared or generalized.

A small number of studies have been highly recognized in secondary literature: A 2005 study of Kendra’s Law in New York concluded outpatient commitment improves treatment outcomes and decreases hospital readmissions rates and lengths of stay. The Duke Mental Health Study published in 1999 concluded patients received no benefit. Likewise, a three-year pilot program conducted at Bellevue Hospital, New York, ending in 1996, concluded no significant differences in hospitalizations, arrests, quality of life, symptoms, homelessness, and other outcomes after commitment.

Additional perspective could be gained by taking an international perspective on commitment. The US-based data on commitment that exists is neither conclusive nor current. In Norway, a 2015 study focused on in-depth interviews with participants. In 1997, Appelbaum advocated for garnering greater attention to practices in other countries, such as Wales and England, to promote reform.

From January 2000 to March 2016, five additional jurisdictions have adopted their first outpatient commitment laws: Colorado, the District of Columbia, Delaware, Florida, and Louisiana. As these laws continue to proliferate, continued research must attempt to build on our current understanding of civil commitment laws and their impact on health and well-being.

Bryan Kozusko, is a student finishing his final year at Widener University School of Law: Delaware Campus. He is also a graduate student at Thomas Jefferson University School of Population Health (expected graduation, May 2017). He is an intern at the Policy Surveillance Program at Temple University’s Center for Health Law, Policy and Practice.

Temple University Center for Public Health Law Research

Temple University Center for Public Health Law Research

Based at the Temple University Beasley School of Law, the Center for Public Health Law Research supports the widespread adoption of scientific tools and methods for mapping and evaluating the impact of law on health. It works by developing and teaching public health law research and legal epidemiology methods (including legal mapping and policy surveillance); researching laws and policies that improve health, increase access to care, and create or remove barriers to health (e.g., laws or policies that create or remove inequity); and communicating and disseminating evidence to facilitate innovation.

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