Managed mental health care’s effects on arrest and forensic commitment William H. Fisher a, * , Sharon-Lise T. Normand b , Barbara Dickey c , Ira K. Packer a , Albert J. Grudzinskas b , Hocine Azeni c a Center for Mental Health Services Research, Department of Psychiatry, University of Massachusetts Medical School (UMMS), 55 Lake Avenue North, Worcester, MA 01655, USA b Department of Health Care Policy, Harvard Medical School, Boston, MA, USA c Department of Psychiatry, Harvard Medical School, Boston, MA, USA 1. Introduction Reducing the use of inpatient treatment has been a consistent theme of American mental health policy for the last half century and, over that time, has been the focus of numerous service system interventions. Among these was passage of reformed civil commitment statutes by state legislatures across the country. These reforms, enacted mainly in the late 1960s and early 1970s, limited the availability of involuntary psychiatric hospitalization as a means for managing deviant behavior in the community, and made a significant contribution to expanding the rights of persons with mental illness (Appelbaum, 1994). But the passage of these reforms was also seen as having a number of unintended and less desirable sequelae. In particular, their enactment was followed by reports of increased involvement in the criminal justice system among persons with mental illness, many of whom were former state hospital patients—an outcome that came to be referred to as the ‘‘criminalization’’ of mental illness (Abramson, 1972). By the 1990s, the use of state hospitals had declined substantially, and the principal locus of inpatient treatment for severe mental illness had shifted to general hospitals. Many advantages were cited in support of this shift, but chief among them, perhaps, was that a portion of the cost of treatment provided in these settings would be borne by the federal government through the Medicaid program (Dorwart & Epstein, 1993; Fisher, Dorwart, Schlesinger, Epstein, & Davidson, 1992). But this cost shifting soon contributed to a growing fiscal crisis in these programs, and many states introduced managed care to control the spiraling cost of their Medicaid behavioral health programs. The implementation of managed mental health care was driven largely by economic, rather than civil, liberties concerns. Nevertheless, like the nationwide civil commitment reforms enacted two decades 0160-2527/$ - see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.ijlp.2003.12.002 * Corresponding author. Tel.: +1-508-856-8711; fax: +1-508-856-8700. E-mail address: Bill.Fisher@Umassmed.edu (W.H. Fisher). International Journal of Law and Psychiatry 27 (2004) 65–77