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The Economics of Schizophrenia 515 CHAPTER 49 INVOLUNTARY COMMITMENT JONATHAN BINDMAN GRAHAM THORNICROFT BACKGROUND Involuntary Commitment and Coercive Treatment Involuntary commitment is a term used in North America for the use of legal measures to compel patients to accept psychiatric treatment. This may include treatment in a hospital or in the community (involuntary outpatient commitment [IOC]). The use of the law to compel treatment is only one aspect of a more general issue, coercion, by which patients who decline treatment may be persuaded, pressured, or threatened by professionals or others before, or as an alternative to, legal commitment. The use of coercion as a routine part of care fundamentally distinguishes psychiatry from other areas of medicine, in which the autonomy of the competent patient to refuse treatment is more usually assumed. The association of physical restraint with mental health care has historic roots, certainly established before the English law of 1714, which permitted Justices of the Peace to secure the arrest of any person “furiously mad and dan - gerous” and to lock them up securely for as long as “such lunacy and madness shall con - tinue.” Involuntary Commitment in the Hospital and in the Community Involuntary commitment has historically been taken to mean detention in a hospital, though this was commonly associated with restrictions that could be applied after dis - charge to the community, using the threat of readmission (conditional discharge). As community care has developed in economically developed countries in the last 40 years, the association between coercion and hospital admission has increasingly been ques - tioned. It has been successfully argued that as the locus of treatment moves to the com - munity, coercive powers that can be applied outside a hospital are needed. The spread of IOC through a number of jurisdictions in recent decades as a result has also aroused con - troversy and calls for restrictions on its use. The extent to which evidence supports and contests IOC is considered further below. 516 Commitment in Different Jurisdictions The legal structures that govern the use of involuntary commitment vary in their detailed application between jurisdictions, resulting in differences between countries and states; however, broad themes are common to all jurisdictions. First, it is commonly the case that a specific law regulates the commitment of men - tally ill persons. Therefore, from a legal point of view they are distinguishable from other people who may require medical treatment but are unable to consent to treatment due to temporary or permanent mental incapacity, such as dementia or learning disability. How - ever, as the core concept of mental illness has changed over time, so lawmakers must de - cide whether to leave the definition entirely to clinical judgment or to circumscribe it in some way. This might involve inclusion criteria, such as a diagnosis included in a formal classification system, or exclusion criteria, such as substance abuse problems or unusual sexual behaviors. Second, the law must state the criteria for commitment. The criteria that are usually included are considered further below. A distinction is usually made also between the stringency of the criteria applied in an emergency or to detain someone for a short period of assessment, and those applied for longer term treatments, and additional safeguards may be required for controversial or irreversible treatments, such as electroconvulsive therapy (ECT) and psychosurgery. Third, the law must describe the way in which compulsion will be exercised, the roles assigned to police, doctors, other professionals (e.g., social workers or nurses), and the role of the courts. In different jurisdictions, the courts may have the primary role in authorizing detention, or this may be left to mental health professionals, who have vary- ing degrees of police powers to exercise physical restraint. However, even in systems in which mental health professionals are given wide discretion to manage commitment, they are likely to rely on the police to support them in physically removing patients to hospi- tal. Fourth, the law will include mechanisms of appeal whereby a committed patient, or an authorized representative, can challenge professional decisions, and relatives or care- givers are also likely to have specified rights either to seek commitment or to oppose it. Fifth, a distinction is usually made between the application of mental health legisla - tion to people with mental disorders who have committed criminal offenses, with com - pulsory psychiatric treatment being one of the “disposal” options available to the courts, and to those who have not committed offenses and are therefore subject to civil commit - ment measures. Criteria for Commitment Criteria for commitment, although they do vary in different jurisdictions, also have com - mon themes. It is usual for them to include the presence of mental illness, a consequent risk to the patient or to others, and the likelihood of treatment having a positive effect. The least restrictive principle, that treatment should be given with the least restriction of liberty possible, may be stated. A useful version of these criteria is that prepared by the World Health Organization (WHO) in its Resource Book on Mental Health, Human Rights and Legislation, which recommends minimum standards to be applied in all jurisdictions (see Table 49.1). Although these are desirable criteria, and most appear in some form in jurisdictions in which mental health legislation is well developed, there is room for debate. For exam - ple, WHO criteria include both the concept of mental illness as judged by an expert prac - 49. Involuntary Commitment 517 titioner and the concept of impaired judgment (also known as impaired capacity to make decisions). It has been argued that if impaired judgment (assessed by a doctor or by an - other legal process) is present, then the criterion of diagnosed mental illness is redundant. By this argument, people with mental illness, but without impaired judgment, should be allowed to determine their own treatment, whereas people with impaired judgment may be treated involuntarily, in their own best interests, regardless of diagnosis. The criteria allow wide latitude for clinical judgment, about not only the presence of mental illness but also the seriousness or imminence of risk (notoriously hard to assess ac- curately), the likelihood of deterioration without treatment, or what treatment is appro- priate. Legal criteria provide a framework for clinical decisions but do not determine them. NATURE AND IMPORTANCE OF INVOLUNTARY COMMITMENT Involuntary commitment is widely used, with an estimated 2 million uses in the United States per year (0.8%, 800 per 100,000 population), somewhat higher than the total in - carceration rate in the criminal justice system (500 per 100,000 per year). In England, 26,000 people were committed to hospital in 2004, and a further 3,000 were detained af - ter entering a hospital voluntarily (a total of 58 per 100,000 per year), somewhat less than the total incarcerated by the criminal justice system (220 per 100,000 in 2002). These numbers, although they demonstrate the scale of involuntary commitment, do not convey the importance of the issue to consumers of mental health care, for many of whom the use of forced treatment is a key issue in determining their attitude toward treatment and the professionals who provide it. They also cannot convey the extent to which the perceived threat of involuntary treatment may affect people receiving treat - ment voluntarily, even when compulsion is not actually threatened, or even considered, by the psychiatrist. Studies of this perception that psychiatric treatment is coercive by researchers in the United States and Europe have shown that it is indeed widespread, and that although involuntary commitment is, as expected, an important factor in determining perceived coercion, patients who are treated “voluntarily” in the strict legal sense may perceive co - ercive pressures to take treatment from a number of sources, including family, housing organizations or the welfare system, as well as mental health professionals. 518 VII. POLICY, LEGAL, AND SOCIAL ISSUES TABLE 49.1. WHO Criteria for Involuntary Committment 1. A person may be admitted involuntarily to a mental health facility . . . if . . . a qualified mental health practitioner authorized by law determines . . . that the person has a mental illness and considers a. that because of that mental illness, there is a serious likelihood of immediate or imminent harm to that person or other persons; or b. that in the case of a person whose mental illness is severe and whose judgment is impaired, failure to admit . . . is likely to lead to serious deterioration . . . or will prevent the giving of appropriate treatment that can only be given by admission. 2. In the case referred to in subparagraph (b) above, a second such mental health practitioner, independent of the first, should be consulted where possible. 3. A mental health facility may receive involuntarily admitted patients only if the facility has been designated to do so by a competent authority prescribed by domestic law. Note. From World Health Organization (2005). Copyright 2005 by the World Health Organization. Adapted by per - mission. It has been suggested that coercion can helpfully be understood as forming part of a spectrum of “treatment pressures” placed on people. Szmukler and Applebaum (2001) have conceptualized a hierarchy of “treatment pressures” (Table 49.2) that may assist in understanding and making decisions to treat an individual involuntarily. Persuasion, Leverage, and Inducement These may be described as “positive pressures” to take treatment—the “carrots” rather than the “sticks.” The lowest level of treatment pressure is persuasion, in which the pro - fessional sets out for the client the benefits of a particular course of action and attempts to counter objections. The patient is free to reject advice. The next level of pressure, lever - age, assumes an interpersonal relationship between the client and professional that has an element of emotional dependence. This gives the professional power to pressure the client by demonstrating approval of one course of action or disapproval of another. Greater pressure may be exerted by inducement, in which acceptance of treatment is linked to material help, such as support in accessing charitable or welfare funds over and above any basic entitlement. Threats and Compulsion These “negative pressures” are overtly coercive. A threat could be made to withdraw ser- vices on which the client normally relies (which is more coercive than simply failing to of- fer inducements over and above normal services), or to detain the client in the hospital. Finally, involuntary commitment, at the highest level of the hierarchy of pressure, carries with it the power to use physical force to overcome resistance to treatment. PERTINENT RESEARCH FINDINGS The act of detaining a patient is a legal intervention, though one with clinical conse - quences. Depending on the research question being addressed, legal analysis, the princi - pally qualitative methods of the social sciences, or the epidemiological and statistical methods of the medical sciences may be required. An example of a question requiring legal analysis arose when the United Kingdom passed the Human Rights Act (2000), which introduced into domestic law the rights af - forded by the European Convention on Human Rights (ECHR). It was suggested that this might lead to widespread challenges to psychiatric practice in the United Kingdom as articles of ECHR protecting the liberty and privacy of the subject were invoked, and some commentators predicted a “flood” of cases. An analysis of decisions of the Euro - 49. Involuntary Commitment 519 TABLE 49.2. Hierarchy of Treatment Pressures • Persuasion • Leverage • Inducements • Threats • Compulsion (including the use of physical force) Note. From Szmukler and Applebaum (2001). Copyright 2001 by Oxford University Press. Adapted by permission. pean Court over many years, combined with a review of cases arising in the first year of the new Act, suggested that in fact courts, both European and UK, have historically been deferential to medical expertise and very unlikely to regard the current routine practice of commitment as breaching the human rights protected by the ECHR. This appears to be correct, and no flood of cases has resulted, though the low level of evidence presented for doctors’ assertions about the level of risk posed by many committed patients would ap - pear to leave their decisions vulnerable to legal challenge. In an example of the application of qualitative methods, Peay (2003) sought to un - derstand the reasoning underlying professionals’ decisions to detain and to discharge pa - tients using the English Mental Health Act. She did this by developing “case vignettes,” videotaped interviews of “typical” patients, that were shown to professional pairs, a psy - chiatrist and a social worker, who were then asked to discuss the cases together, replicat - ing the process by which actual commitment decisions are arrived at. It became apparent that a majority of psychiatrists made an initial assessment favoring compulsion. The so - cial workers were much less likely to start from this position, and once dialogue between the professionals began, the eventual joint decision was more likely to reflect the social workers’ initial assessment, with a joint recommendation of fewer commitments than the psychiatrists initially had suggested would be necessary. It was possible to distinguish three distinct approaches to the decision: Clinical decision makers formed their own view of the best interests of the patient and the wider society, and looked to interpret the legal criteria in such a way as to serve those interests. Legal decision makers had a detailed awareness of the legal criteria and attempted to use these to guide their decision. Ethical decision makers attempted to assess patients’ capacity for judgment and take account of the patients’ own views of their best interests. A general finding of the research was that the same vignette resulted in widely differing decisions, with different professional pairs assessing the various admission criteria relative to risk or the appropriateness of noncom- pulsory treatment as either justifying or not requiring involuntary commitment. Though legislation in different jurisdictions may have elements in common, the ac- tual rate of involuntary commitment that results is highly variable between cultures and nations. Evidence for this comes from survey data and analysis of routine statistics; for example, a recent review of psychiatric detention across Europe found that comparable estimates of rates of detention could be obtained from 12 states (Salize & Dressing, 2004). They varied enormously, from 6 per 100,000 population per year in Portugal and 11 per 100,000 in France, to 175 per 100,000 in Austria and Germany and 218 in 100,000 in Finland. England had a fairly high rate, 93 per 100,000 (in 1998). Generally countries with high detention rates also had high rates of informal admission, but Sweden and the United Kingdom had only moderate levels of overall admissions, a high propor - tion of which were involuntary (25–30%, including those detained after informal admis - sion). The rate of detention appeared to have risen during the 1990s in many countries, but this seemed to be due to more frequent, but shorter, admissions rather than an abso - lute increase in compulsion. Though there are considerable differences between countries’ criteria for detention, legal processes, and the use of detention for dementia or substance abuse, none of these account for the difference in rates. However, there tend to be lower levels of detention in countries that require involvement of a legal representative for all detained patients. The results of epidemiological studies also suggest that individual clinicians’ inter - pretation of criteria for commitment vary. An ecological study of rates of detention in hospitals in 34 catchment areas in England showed that rates varied widely, and that al - though the level of socioeconomic deprivation was a strong predictor of the rate, there was a high level of unexplained variation, likely due to differing approaches by clinical teams or individual clinicians. 520 VII. POLICY, LEGAL, AND SOCIAL ISSUES POLICY AND SOCIAL IMPLICATIONS Evidence for and Justification of IOC An important and controversial policy issue in many jurisdictions has been the extent to which involuntary treatment should be extended into the community. Two randomized controlled studies have compared the effectiveness of IOC in reduc - ing hospital admission. The first, carried out in New York, randomly assigned 78 people discharged from Bellevue Hospital to compulsory community treatment and compared them with 64 people treated voluntarily by the same intensive treatment team (Steadman et al., 2001). Over the following 11 months, no difference was observed in the rate of ad - mission, symptoms, or quality of life, and no patient in either group was charged with a violent offense. The second study, in North Carolina, randomly assigned 129 people to compulsory treatment and 135 to voluntary treatment of varying intensity and by four different teams (Swartz et al., 2001). In this study, the compulsorily treated group had 57% fewer admis - sions and spent 20 days more in the community over the 1-year follow-up. However, the reduction in admissions occurred only when compulsory orders were associated with more intensive treatment. It may be that it is the availability of intensive treatment that matters, and if this is available to everyone, as in New York, compulsion adds nothing. A 2000 review published by the RAND Corporation also concluded that the evidence gath- ered across the United States did not support the use of IOC, and a database study in Australia had similar negative conclusions (Kisely, Xiao, & Preston, 2004). Although re- search evidence is only one of a number of factors that should be taken into account in formulating policy, it has had very little impact on the spread of IOC legislation intro- duced in many jurisdictions in recent decades. However, the question of whether IOC “works” remains an important one for future research. Ethical Basis of Detention As described earlier, legislation usually requires that commitment be justified on the grounds that failure to accept psychiatric treatment involve risks to the health or safety of the patient or of others, though these risks are often rather poorly defined and rarely quantifiable. Deciding what level of treatment pressure is commensurate with the risk is not straightforward, but it may be helpful to try to apply an ethical framework com - monly used to assist decision making in general medicine. This requires consideration of the person’s capacity to take treatment decisions that are in his or her best interests. Ca - pacity is usually defined as the ability to understand and retain information about the proposed treatment, and to weigh in the balance the consequences of alternative decisions about it. People with capacity can determine what treatment is in their own best interests, even where their views are not in accord with those of clinicians, and minimal pressure, perhaps limited to persuasion, is all that can be justified. If capacity is lacking, the treat - ment that is in the person’s best interest may need to be determined by clinicians, though taking account, if possible, of the past and present wishes of the patient, and the views of significant others. Advance statements about treatment preferences, made with capacity in anticipation of a future loss of capacity, such as might occur in psychotic relapse, car - ries weight in the assessment of what is in someone’s best interests. Once the treatment that is in the best interests of the patient is established, the minimal level of pressure nec - essary to achieve the objectives of this treatment can then be exerted. Although the application of this framework is helpful in clarifying the decision to be made, mental health professionals are often faced with situations in which a simple judg - ment of capacity is not easy to make. A client may, apparently through choice, live in 49. Involuntary Commitment 521 squalor or on the streets. Does such an apparently irrational choice necessarily imply a lack of capacity, or must delusional reasoning be established? Even if capacity seems to be absent, what minimum standard of living is in the best interests of a patient who ex - presses no desire for material comforts? Faced with such complex issues, it is tempting to resort to the traditional medical ap - proach of assuming that best interests are best determined by a beneficent doctor. How - ever, attempting to apply a capacity-based approach clarifies that the client’s reasoning about his or her situation is the starting point for the decision, and makes it less likely that the values, anxieties, or prejudices of others will prevail over the client’s expressed views. Sharing difficult decisions with multidisciplinary teams, caregivers and advocates similarly reduces the risk of poor or hasty judgments. Though the law may allow compulsion on the grounds of risk to others, and mental health services are exposed to strong societal expectations that they should prevent vio - lence by their patients, attempting to take an ethical approach to treatment pressure on these grounds presents considerable difficulties. There are very few circumstances in which citizens without mental disorder can be detained preventively on the grounds of risk, and it is hard to justify taking a different approach to clients with capacity. The chal - lenge for professionals is to avoid being pressured into applying an ethical double stan - dard, in which behavior that would not justify significant sanction in the absence of mental disorder is used to justify loss of liberty, or in which levels of treatment pressure are not commensurate with the actual level of risk. KEY POINTS • Involuntary commitment has historically been seen as a central aspect of the treatment of schizophrenia. • Criteria for commitment vary between jurisdictions but typically include the presence of a mental disorder, risk to the patient, risk to others, and an expectation of therapeutic benefit (or the prevention of deterioration). • These criteria are seldom capable of rigid definition, and their interpretation varies among clinicians and jurisdictions, resulting in highly variable proportions of those diagnosed with schizophrenia being assumed to require commitment in different mental health systems. • The ethical basis of this is not always made explicit in law; therefore, clinicians must com - bine an understanding of the legal criteria for commitment with an ethical understanding of the basis for clinical involvement in state-sanctioned detention. • Good clinical practice requires the use of the least restrictive form of treatment. REFERENCES AND RECOMMENDED READINGS Allen, M., & Smith, V. F. (2001). Opening Pandora’s box: The practical and legal dangers of involun - tary outpatient commitment. Psychiatric Services, 52, 343–346. Applebaum, P. (2001). Thinking carefully about outpatient commitment. Psychiatric Services, 52, 347–350. Bindman, J., Tighe, J., Thornicroft, G., & Leese, M. (2002). Poverty, poor services, and compulsory psychiatric admissionin England.Social Psychiatry and Psychiatric Epidemiology, 37, 341–345. Holloway, F., Szmukler, G., & Sullivan, D. (2000). Involuntary outpatient treatment. Current Opin - ion in Psychiatry, 13, 689—692. Kisely, S., Campbell, L., & Preston, N. (2005). Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Cochrane Database Systematic Reviews, 3, CD004408. Kisely, S. R., Xiao, J., & Preston, N. J. (2004). Impact of compulsory community treatment on admis - 522 VII. POLICY, LEGAL, AND SOCIAL ISSUES sion rates:Survival analysis usinglinked mentalhealth and offenderdatabases. British Journal of Psychiatry, 184, 432–438. Monahan, J., Bonnie, R. J., Applebaum, P. S., Hyde, P. S., Steadman, H. J., & Swartz, M. S. (2001). Mandated community treatment: Beyond outpatient commitment. Psychiatric Services, 52, 1198—1205. Peay, J. (2003). Decisions and dilemmas working with mental health law. Oxford, UK: Hart. Rand Corporation. (2000). Does involuntary outpatient treatment work? (Law & Health Research Brief No. RB-4537), Santa Monica, CA: Author. Retrieved from http://www.rand.org/pubs/re - search_briefs/RB4537/index1.html Salize, H. J., & Dressing, H. (2004). Epidemiology of involuntary placement of mentally ill people across the European Union. British Journal of Psychiatry, 184, 163–168. Steadman, H. J., Gounis, K. L., Dennis, D., Hopper, K., Roche, B., Swartz, M., et al. (2001). Assessing the New York City involuntary outpatient commitment pilot program. Psychiatric Services, 52 330–336. Swartz, M. S., Swanson, J. W., Hiday, V. A., Wagner, H. R., Burns, B. J., & Borum, R. (2001). A ran - domized controlled trial of outpatient commitment in North Carolina. Psychiatric Services, 52, 325–329. Szmukler, G., & Appelbaum, P. (2001). Treatment pressures, coercion and compulsion. In G. Thornicroft & G. Szmukler (Eds.), Textbook of community psychiatry (pp. 529–544). Oxford, UK: Oxford University Press. Torrey, E. F., & Zdanowicz, M. (2001). Outpatient commitment: What, why, and for whom. Psychi - atric Services, 52, 337—341. World Health Organization. (2005). Resource book on mental health, human rights and legislation. Geneva: Author. 49. Involuntary Commitment 523 CHAPTER 50 JAIL DIVERSION JOSEPH P. MORRISSEY GARY S. CUDDEBACK Currently, more people with severe mental illness are admitted to jails in the United States each year than are admitted to psychiatric hospitals. The numbers are truly stag- gering. In 2000, there were more than 1 million jail admissions of persons with severe mental illness and only about 645,000 hospitalizations. That means the relative risk of jail detention for a person with severe mental illness is about 150% greater than the risk of hospitalization. The phrase often bandied about is that “jails have become the new mental hospitals,” but jails provide mental health services only as a last resort to meet obligations concerning the conditions of safe confinement mandated by the U.S. Consti- tution. Most have very inadequate mental health staffing even for assessment and imme - diate crisis intervention, which together, at a minimum, should be the limited goals for any in-jail mental health service program. Many mental health experts would agree that any in-jail mental health services should focus on assessment, crisis stabilization, and diversion—not on long-term treat - ment. Given this goal, any needs for ongoing treatment and rehabilitation are more effi - ciently and effectively met in community-based settings. This principle underlies the many attempts to use jail diversion to deal with this problem in communities across the country. This chapter reviews the basic types of jail diversion programs, their common features, the available research evidence about their successes and failures, and some di - rections for more effective approaches in the future. NATURE AND IMPORTANCE OF JAIL DIVERSION Jails and Prisons There are about 3,365 jails in the United States. Jails are local detention facilities, usually operated by county sheriffs. In some large cities a municipal jail is operated by the police department separate from the county jail that serves multiple cities and towns. Some mu - nicipal or county jails are operated by civilian correctional administrations, independent 524 [...]... interviewed participants at baseline, at 3 months, and at 530 VII POLICY, LEGAL, AND SOCIAL ISSUES 12 months using a common interview protocol A total of 1 ,96 6 participants (97 1 diverted and 99 5 nondiverted) were enrolled, with 76% retention at 3 months and 69% at 12 months The main findings (based on 1,185 participants who completed 12-month interviews) indicated the following: 1 Diverted participants... National Institute of Mental Health Gladwell, M (2002) The tipping point: How little things can make a big difference New York: Little, Brown Jerrel, J M., & Ridgely, M S ( 199 9) Impact of robustness of program implementation on outcomes of clients in dual diagnosis programs Psychiatric Services, 50, 1 09 112 Lehman, A F., Steinwachs, D M., & the Survey Coinvestigators of the PORT Project ( 199 8) Translating... dominance of allopathy in health education and policies The traditional healers are the customary practitioners of curative and preventive care They continue to influence several treatment-related variables, such as acceptance of care and outcome of the illness The importance of emotional and mental well-being is a part of the illness constructs and the healing process in these systems of medicine 5 49 550... Review of Sociology, 27, 363– 385 Link, B G., Yang, L H., Phelan, J C., & Collins, P Y (2004) Measuring mental illness stigma Schizophrenia Bulletin, 30, 511–541 Pescosolido, B A., Monahan, J., Link, B G., Stueve, A., & Kikuzawa, S ( 199 9) The public’s view of competence, dangerousness, and need for legal coercion of persons with mental health problems American Journal of Public Health, 89, 13 39 1345... understanding and management of schizophrenia THE NATURE OF SCHIZOPHRENIA ACROSS CULTURES The Cross-Cultural Conflict in Systems of Care Globalization of health care policies mandates that all member countries of the World Health Organization (WHO) conform to a standardized pattern of curative, preventive, and epidemiological strategies Health care guidelines are formulated along the theories of the allopathic... several large-scale studies of implementation Although these evidence-based practices could improve many lives, they are not routinely available to people in mental health settings In the most extensive demonstration of this issue, the Schizophrenia Patient Outcome Research Team (PORT; Lehman, Steinwachs, & Survey Coinvestigators of the PORT Project, 199 8) showed that people with a diagnosis of schizophrenia. .. support of the National Alliance on Mental Illness (NAMI), CITs have diffused rapidly since the prototype program was developed in Memphis, Tennessee, in the early 199 0s Now CITs can be found in police departments in many large and mid-size cities across the country Postbooking diversions occur at one of several points after the filing of formal charges by a police officer Here, the police officer... Psychology Press Wahl, O ( 199 7) Media madness: Public images of mental illness New Brunswick, NJ: Rutgers University Press Wahl, O ( 199 9) Telling is risky business: Mental health consumers confront stigma New Brunswick, NJ: Rutgers University Press C H A P TE R 52 EVIDENCE-BASED PRACTICES MATTHEW R MERRENS ROBERT E DRAKE The desire to improve outcomes by promoting evidence-based health care has recently... Federal departments of corrections, which are staffed separately from law enforcement As long-stay facilities, they are equipped and staffed to provide recreational, vocational, and health care services for their inmates All persons serving time in prison have spent some time in jail as part of their criminal justice processing On June 30, 2004, there were 713 ,99 0 persons in jails and another 1, 494 ,216... for Mental Health Services ( 199 9) Mental health: A report of the surgeon general Rockville, MD: Author Drake, R E., Goldman, H H., Leff, S H., Lehman, A F., Dixon, L., Mueser, K T., et al (2002) Implementing evidence-based practices in routine mental health settings Compendium on Psychosis and Schizophrenia, 2, 18– 19 Drake, R E., Merrens, M R., & Lynde, D (2005) Evidence-based mental health practice: . Another year of escalatingcosts. Washington,DC: Author. Rice, D. ( 199 9). The economic impact of schizophrenia. Journal of Clinical Psychiatry, 60(Suppl. 1), 4–6. Rice, D., & Miller, L. ( 199 6). The. and privacy of the subject were invoked, and some commentators predicted a “flood” of cases. An analysis of decisions of the Euro - 49. Involuntary Commitment 5 19 TABLE 49. 2. Hierarchy of Treatment. Diversion 5 29 12 months using a common interview protocol. A total of 1 ,96 6 participants (97 1 di - verted and 99 5 nondiverted) were enrolled, with 76% retention at 3 months and 69% at 12 months. The