A 10-year comparison of short versus long-term court-ordered psychiatric hospitalization: a follow-up study

The Israel Mental Health Act of 1991 stipulates a process for court-ordered involuntary psychiatric hospitalization. As in many Western countries, this process is initiated when an individual is deemed "not criminally responsible by reason of mental disorder (NCR-MD)" or "incompetent to stand trial (IST)." A patient thus hospitalized may be discharged by the district psychiatric committee (DPC). The decision rendered by the DPC is guided by an amendment to the Mental Health Act that states that the length of the hospitalization should be in accordance with the maximum time of incarceration associated with the alleged crime. Little empirical research has been devoted to the psychiatric, medical, and social outcome of short versus long-term hospitalization under court order.

In our study we examined the outcomes of court-ordered criminal commitments over a 10-year period (2005-2015) at the Jerusalem Mental Health Center with a catchment area of 1.5 million. We found 136 cases (between the ages of 18 and 60) of criminal commitments during that period and used the average length of hospitalization, 205 days, as a cutoff point between short and long stays. We compared the outcomes of short and long hospitalizations of discharged patients using a follow-up phone survey (at least 7 years post-discharge) and data extracted from the Israel National Register to include recidivism, patient satisfaction and trust in the system, readmission, and demise.

We found no statistically significant difference between short-term and long-term hospitalizations for reducing instances of re-hospitalization (p = 0.889) and recidivism (p = 0.54), although there was a slight trend toward short-term hospitalization vis-à-vis reduced recidivism. We did not find a statistical difference in mortality or incidents of suicide between the two groups, but the absolute numbers are higher than expected in both of them. Moreover, our survey showed that short-term hospitalization inspired more trust in the legal process (conduct of the DPC), in pharmacological treatment satisfaction, and in understanding the NCR-MD as a step toward avoiding future hospitalization and that it resulted in a higher level of patient satisfaction.

The results we present show that as far as recidivism and readmission are concerned, there is no evidence to suggest that there is an advantage to long-term hospitalization. Although there may be unmeasured variables not investigated in the present study that might have contributed to the discrepancy between long- and short-term hospitalization, we believe that longer hospitalizations may not serve the intended treatment purpose. Additionally, the high cost of long-term hospitalization and overcrowded wards are obviously major practical drawbacks. The impact of the clinical outcomes should be reflected in medico-legal legislation and in court-ordered hospitalization in particular.