TO THE EDITOR: Dr. Hassenfeld raises several important points in his letter. His observation that our study did not address the long-term consequences of antipsychotic medication refusal and involuntary treatment is, of course, correct. It has been suggested that involuntary treatment may have considerable psychological effects and that some patients may become alienated from treatment as a result. This claim has not been empirically substantiated. In the only study to date, Cournos and colleagues (1) compared state hospital patients who were involuntarily medicated under New York State's judicial review system with patients who were compliant with treatment; they failed to find any differences in rates of discharge, subsequent outpatient compliance, or rehospitalization. While that study is an important contribution to the literature on refusal of treatment, I agree with Dr. Hassenfeld that many questions about the long-term course of refusers remain unanswered. We need to know more about the course of patients who refuse treatment and are not taken to review. A prospective study conducted in Massachusetts, a jurisdiction with a judicial review system, found that only 18% of refusing patients reached review (2). Of particular concern are patients who are discharged from the hospital untreated; approximately one-fourth of the group in the Massachusetts study fell into this category.