To the Editor: I read with great interest the article by Jeffrey W. Swanson, Ph.D., et al. entitled “Violence and Leveraged Community Treatment for Persons with Mental Disorders” in the August 2006 edition of the Journal (1). In this article, the authors attempted to scientifically establish associations between those mentally ill individuals who have violent histories and the decision to implement mandated interventions.
This topic becomes particularly important in the current days of random violence, along with the increased public awareness and participation in issues relating to mental illness (2). I commend Dr. Swanson and colleagues for investigating not simply the connection between mental illness and mandated interventions, but also for considering various other demographic and clinical factors. These factors were noted to also be associated with the determination to recommend these interventions.
My initial concern is that social and legal mandates are being thought of as leverages. This projects the impression that these mandates are being used to coerce an individual in a punitive manner. Instead, I believe it is important to remember that the goal of these mandate laws is ultimately to improve patient and community well being. Mandate laws aim to reduce patient violence by improving patient compliance and ensuring that the individuals most at risk for violent decompensation remain well compensated. It is also important to note that the application of these mandates to an individual patient is reliant upon the proof that the patient’s violent behavior is a direct result of the patient’s mental illness.
It has already been generally accepted among those in the psychiatric community that the combination of risk of violence and medication nonadherence strongly influences the decision to mandate treatment. However, there is a noted lack of information related to the outcome of implementing such mandated interventions (3). The question, therefore, still remains regarding the effectiveness of these measures in ultimately reducing violent behavior in the mentally ill.
This information is essential as a further topic of exploration. Without solid outcome measures, it becomes difficult to translate theory into practice. Statistical information could lay the foundation for the writing of protocols to be implemented in our daily clinical practice and may even be used to inform public policy.
1.Swanson JW, Van Dorn RA, Monahan J, Swartz M: Violence and leveraged community treatment for persons with mental disorders. Am J Psychiatry 2006; 163:1404–1411
2.Appelbaum PS: Violence and mental disorders: data and public policy. Am J Psychiatry 2006; 163:1319–1321
3.Hiday VA: Outpatient commitment: the state of empirical research on its outcomes. Psychol Public Policy Law 2003; 9:8–32