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AFTER Cho Seung-Hui shot and killed 32 people on the Virginia Tech campus on 16 April last year, it quickly became apparent that he was seriously ill at the time. We will never have a precise diagnosis, as Cho also took his own life, but it seems likely he was suffering from paranoid delusions, probably due to untreated schizophrenia.

After years of denial, mental health professionals are increasingly coming to recognise that a handful of people like Cho with untreated schizophrenia are at risk of committing serious acts of violence. Most recently, the spotlight has fallen on people with schizophrenia suffering their first bout of severe psychosis.

Fortunately, incidents like the Virginia Tech shootings are rare, and almost totally preventable with gun control. Nevertheless, public anxiety has led politicians to look for ways to get patients into treatment quickly, and keep them there 鈥� even if it means doing so against their will. Increasingly hopes are being pinned on so-called preventive involuntary outpatient commitment (IOC), both to reduce the risk of violence and to safeguard the health of those who are ill.

Typically, IOC court orders force patients who are not sick enough to be committed as inpatients to undergo treatment in the community 鈥� backed up by the threat of forced hospitalisation if they don鈥檛 comply. The hope is that if people with serious psychiatric conditions are required to get treatment, they will not deteriorate to the point where they have to be detained against their will, or end up harming themselves or others.

IOC is already used in seven states in the US, and in New Zealand, Australia and Scotland. It is due to be introduced in England and Wales in October this year (see 鈥淗ow the laws work鈥�). Such policies are, however, being called into question, not least because there is little evidence that IOC either reduces violence or improves the health of the people it is applied to.

At present, only around half of those with schizophrenia in these countries who need treatment actually get it. Among the reasons for this are the difficulty of gaining access to psychiatric services, and unacceptable side effects some people experience from the drugs. To make matters worse, schizophrenia often robs patients of any awareness that they need treatment, making them even more likely to reject it. This point is often cited by those in favour of coercion.

However it is the argument that forcing people into treatment might reduce violence against others, especially homicide, that primarily sways legislators. This risk of violence has been a hot topic since the widespread shift from keeping mentally ill people in hospital to treating them within the community.

It was debated recently in a report in last month鈥檚 issue of Psychiatric Services (). 鈥淭here is clearly some relationship between mental disorder and violence 鈥� it would be completely disingenuous to deny it 鈥� but it is not large,鈥� says John Monahan, a psychologist and authority on mental health law at the University of Virginia who co-authored the report.

It is generally agreed that serious violence is most likely to be perpetrated by people with certain types of disorder. The most important of these conditions are antisocial personality disorder, which is extremely difficult to treat, and a minority of cases of schizophrenia, which is highly treatable. Recent studies are narrowing down the risk particularly to people in the early stages of schizophrenia (see 鈥淯rgent treatment鈥�).

So would forcing people to be treated help? A systematic review of IOC published last year by Rachel Churchill, head of evidence-based mental health at the Institute of Psychiatry in London, concluded that 鈥渞esearch in this area has been beset by conceptual, practical and methodological problems鈥�, and that 鈥渋t is not possible to say whether [IOC is] beneficial or harmful to patients鈥�.

Only two large randomised studies have ever investigated IOC鈥檚 effectiveness. One study of 264 psychiatric patients, led by Marvin Swartz at Duke University in North Carolina, found small reductions in violence and re-hospitalisation among patients who received at least three treatment sessions a month for at least six months under an IOC order, compared to patients who were not under a court order.

However, a second study of 142 psychiatric patients in New York found no benefit from IOC, and the results have been widely interpreted to suggest that better voluntary psychiatric care and support such as housing are the key, rather than coercion.

This raises the spectre that mentally ill people are having their civil rights curtailed for no good reason. 鈥淚t鈥檚 the mental health version of the 鈥榳ar on terror鈥�, says Ira Burnim of the Bazelon Center for Mental Health Law in Washington DC. 鈥淐haracterise others as individuals with whom we can鈥檛 reason, who are bent on doing us violence, and use it to justify extraordinary legal approaches.鈥�

Paul Mullen, clinical director of Forensicare, which provides psychiatric services to mentally ill offenders in the Australian state of Victoria, also thinks IOC is the wrong way to go. 鈥淧eople who are likely to be violent are by and large disorganised and impulsive, and likely to ignore an IOC order,鈥� he says. 鈥淔orce is not the way to offer any type of healthcare, least of all mental healthcare. Force simply alienates them more.鈥�

鈥淔orce is not the way to offer any type of healthcare, least of all mental healthcare. Force simply alienates them more鈥�

Mullen points out that only a small proportion of people with schizophrenia are violent, and even fewer will commit acts of serious violence. As factors such as substance abuse and homelessness are thought to aggravate the risk, a better approach, he says, would be to increase the time patients at high risk of violence spend in involuntary hospital treatment 鈥� from the current seven to 10 days, to up to eight weeks 鈥� to ensure that their illness and any addiction problems are under control. Once people are released from hospital, more effort needs to go into ensuring that they get adequate voluntary treatment and rehabilitation 鈥� whether or not they pose a risk of violence.

Burnim agrees that improved voluntary services should be the first line of attack. 鈥淚f we still find that a small group of people are avoiding treatment, let鈥檚 see what we can do then,鈥� he says.

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