Decisions to Initiate Involuntary Commitment: The Role of Intensive Community Services and Other Factors

Elizabeth Lloyd McGarvey, Ed.D., MaGuadalupe Leon-Verdin, M.S., Tanya Nicole Wanchek, Ph.D., J.D., and  Richard J. Bonnie, LL.B.

Objective: This study examined the predictors of actions to initiate involuntary commitment of individuals experiencing a mental health crisis. Methods: Emergency services clinicians throughout Virginia completed a questionnaire following each face-to-face evaluation of individuals experiencing a mental health crisis. Over a one-month period in 2007, a total of 2,624 adults were evaluated. Logistic hierarchical multiple regression was used to analyze the relationship between demographic, clinical, and service-related variables and outcomes of the emergency evaluations. Results: Several factors predicted 84% of the actions taken to initiate involuntary commitment. These included unavailability of alternatives to hospitalization, such as temporary housing or residential crisis stabilization; evaluation of the client in a hospital emergency room or police station or while in police custody; current enrollment in treatment; and clinical factors related to the commitment criteria, including risk of self-harm or harm to others, acuity and severity of the crisis, and current drug abuse or dependence. Conclusions: A lack of intensive communitybased treatment and support in lieu of hospitalization accounted for a significant portion of variance in actions to initiate involuntary commitment. Comprehensive community services and supports for individuals experiencing mental health crises may reduce the rate of involuntary hospitalization. There is a need to enrich intensive community mental health services and supports and to evaluate the impact of these enhancements on the frequency of involuntary mental health interventions. (Psychiatric Services 64:120–126, 2013; doi: 10.1176/

Use of Longer Periods of Temporary Detention to Reduce Mental Health Civil Commitments

Tanya Nicole Wanchek, Ph.D., J.D. and Richard J. Bonnie, LL.B.

Objective: This study examined whether lengthening the holding period for an individual experiencing a mental health crisis under a temporary detention order (TDO) can reduce the number and length of postTDO involuntary hospital commitments. Methods: Data from the Virginia Court System were matched to the Commonwealth of Virginia Medicaid claims database for July 1, 2008, through March 30, 2009. The final data set included 500 Medicaid recipients who had a mental health diagnosis and at least one TDO during the study period. Covariates included sex, race, age, primary diagnosis, and Community Service Board serving the individual. Logistic and multivariate regression models were used. Results: Longer TDO periods were correlated with an increased probability of a dismissal of the commitment petition rather than hospitalization after a TDO. Among individuals who were hospitalized, longer TDO periods were correlated with an increased likelihood of voluntary hospitalization, rather than involuntary commitment, and shorter hospitalizations, although the net care time (TDO period plus post-TDO hospitalization) increased for individuals whose TDO length was greater than 24 hours. Conclusions: Longer TDO periods were correlated with shorter hospital stays and fewer involuntary commitments. These findings support previous work showing that short TDO periods provide insufficient time to stabilize and evaluate individuals. More research is needed to establish a causal link between TDO length and health outcomes. (Psychiatric Services 63:643–648, 2012; doi: 10.1176/

The Effect of Community Mental Health Services on Hospitalization Rates in Virginia

Tanya Nicole Wanchek, Ph.D., J.D., Elizabeth L. McGarvey, Ed.D., MaGuadalupe Leon-Verdin, M.S., and Richard J. Bonnie, LL.B.

This study examined the relationship between the availability of mental health outpatient services provided by 40 publicly funded community service boards (CSBs) and the use of inpatient mental health treatment among Medicaid recipients. Methods: Three-year data were obtained for Medicaid recipients aged 18–64 from the Medicaid claims database for the Commonwealth of Virginia. Medicaid recipients who had a mental disorder diagnosis and who had received at least one community mental health service were included in the sample. A multivariate regression model was used for the analyses. Results: Of the 11,107 individuals included, 27% had schizophrenia-related disorders and 32% had affective psychoses; 60% were white and 37% were black; and the average age was 40.1±13.1 years. In this sample, greater use of outpatient mental health services, but not greater variety of services available, was correlated with fewer inpatient hospital days for mental health treatment (–1.0±.2 days of hospitalization). Conclusions: Virginia’s CSBs provide a range of outpatient mental health services that are designed to enable individuals to remain in their community. The availability of community-based mental health services was correlated with lower rates of inpatient hospitalization for mental illness. More research, however, is needed to establish causality and to determine which services are most effective at reducing the need for inpatient care. (Psychiatric Services 62:194–199, 2011)

Mental Health System Transformation After The Virginia Tech Tragedy

Richard J. Bonnie, James S. Reinhard, Phillip Hamilton and Elizabeth L. McGarvey

Health Affairs 28, no.3 (2009):793-804
doi: 10.1377/hlthaff.28.3.793

ABSTRACT: On 16 April 2007, a deeply disturbed Virginia Tech student murdered thirty-two fellow students and faculty and then shot himself. Less than one year later, the Virginia legislature improved the emergency evaluation process, modified the criteria for involuntary commitment, tightened procedures for mandatory outpatient treatment, and increased state funding for community mental health services. The unanswered question, however, is whether the necessary political momentum can be sustained for the long-term investment in community services and the fundamental legal changes needed to transform a system focused on managing access to scarce hospital beds to a community-based system of accessible voluntary services. [Health Affairs 28, no. 3 (2009): 793–804; 10.1377/ hlthaff.28.3.793]