Skip to main content

Civil commitment law, mental health services, and US homicide rates



The study considers whether involuntary civil comment (ICC) statute provisions are associated with homicide rates. Do statutes based solely upon dangerousness criteria versus broader ICC-criteria—i.e. “need for treatment,” “protection of health and safety,” and family protection–have differential associations related to their goal of reducing the frequency of homicide?


State-level data were obtained from online data bases and key-informant surveys. Ordinary-least-squares and Poisson regression were used to evaluate the association between statute characteristics, mental health system characteristics, and 2004 Homicide Rates after controlling for firearm-control-law restrictiveness and social-economic-demographic-geographic-and-political indicators historically related to homicide rate variation.


Poisson and OLS models, respectively, were significant: likelihood ratio χ2 = 108.47, df = 10; p < 0.000 and Adj. R 2 = 0.72; df = 10, 25; F = 10.21; p < 0.000. Poisson results indicate that social-economic-demographic-geographic-and-political-indicators had the strongest association with state homicide rates (p < 0.000). Lower rates were associated with: broader ICC-criteria (p ≤ 0.01), fewer inpatient-bed access problems (p ≤ 0.03), and better mental health system ratings (p ≤ 0.04).

OLS results indicate that social-economic-demographic-geographic-and-political indicators accounted for 25% of homicide rate variation. Broader ICC-criteria were associated with 1.42 less homicides per 100,000. Less access to psychiatric inpatient-beds and more poorly rated mental health systems were associated with increases in the homicide rates of 1.08 and 0.26 per 100,000, respectively.


While social-economic-demographic-geographic-and-political indicators show the strongest association with homicide rate variation, the results show the importance and potentially preventive utility of broader ICC criteria, increased psychiatric inpatient-bed access, and better performing mental health systems as factors contributing to homicide rate variation.

This is a preview of subscription content, access via your institution.


  1. 1.

    Torrey EF, Zdanowicz MT (2001) Outpatient commitment: what, why, and for whom. Psychiatr Serv 52(3):337–341

    PubMed  Article  CAS  Google Scholar 

  2. 2.

    Large MM, Nielssen OB, Lackersteen SM (2009) Did the introduction of ‘dangerousness’ and ‘risk of harm’ criteria in mental health laws increase the incidence of suicide in the United States of America? Soc Psychiatry Psychiatr Epidemiol 44(8):614–621

    PubMed  Article  Google Scholar 

  3. 3.

    Torrey EF, Kaplan RJ (1995) A national survey of the use of outpatient commitment. Psychiatr Serv 46:778–784

    PubMed  CAS  Google Scholar 

  4. 4.

    Bazelon Center for Mental Health Law (2004) Involuntary outpatient commitment: summary of state statutes. Bazelon Center for Mental Health Law, Washington DC. Accessed December 28, 2009

  5. 5.

    Treatment Advocacy Center. State Standards for Assisted Treatment. December 17, 2004. Accessed December 28, 2009

  6. 6.

    Public Policy Committee of the Board of Directors, the NAMI Department of Public Policy, Research (2004) Public Policy Platform of the National Alliance for the Mentally Ill, 7th edn. NAMI Arlington, Virginia

    Google Scholar 

  7. 7.

    Assembly Interim Committee on Ways, Means, Subcommittee on Mental Health (1966) The dilemma of mental health commitments in California: a background document. California State Legislature Sacramento, CA

    Google Scholar 

  8. 8.

    Large M, Smith G, Nielssen O (2009) The relationship between the rate of homicide by those with schizophrenia and the overall homicide rate: a systematic review and meta-analysis. Schizophr Res 112:123–129

    PubMed  Article  Google Scholar 

  9. 9.

    Taylor PJ, Gunn J (1999) Homicides by people with mental illness: myth and reality. Br J Psychiatry 174:9–14

    PubMed  Article  CAS  Google Scholar 

  10. 10.

    MIND A history of mental health and community care—key dates: downloaded, April 17 2011

  11. 11.

    Simpson AIF, McKenna B, Moskowitz A, Skipworth J, Barry-Walsh J (2004) Homicide and mental illness in New Zealand, 1970–2000. Br J Psychiatry 185:394–398

    PubMed  Article  Google Scholar 

  12. 12.

    Hiroeh U, Appleby L, Mortensen PB, Dunn G (2001) Death by homicide, suicide, and other unnatural causes in people with mental illness: a population-based study. Lancet 358:2110–2112

    PubMed  Article  CAS  Google Scholar 

  13. 13.

    Fazel S, Grann M (2006) The population impact of severe mental illness on violent crime. Am J Psychiatry 163:1397–1403

    PubMed  Article  Google Scholar 

  14. 14.

    Bureau of Justice Statistics, Department of Justice. Accessed December 30, 2009

  15. 15.

    NAMI (2006) Grading the states—a report on America’s health care system for serious mental illness. NAMI Arlington, Virginia

    Google Scholar 

  16. 16.

    FBI Uniform Crime Statistics for 2004. October, 2005

  17. 17.

    Large MM, Smith G, Swinson N, Shaw J, Nielssen O (2008) Homicide due to mental disorder in England and Wales over 50 years. Br J Psychiatry 193:130–133

    PubMed  Article  Google Scholar 

  18. 18.

    Fitzgerald PB, de Castella AR, Filia KM, Filia SL, Benitez J, Kulkarni J (2005) Victimization of patients with schizophrenia and related disorders. Aust N Z J Psychiatry 39:169–174

    PubMed  Article  Google Scholar 

  19. 19.

    Teplin LA, McClelland GM, Abram KM, Weiner DA (2005) Crime victimization in adults with severe mental illness: comparison with the national crime victimization survey. Arch Gen Psychiatry 62:911–921

    PubMed  Article  Google Scholar 

  20. 20.

    Choe JY, Teplin LA, Abram KM (2008) Perpetration of violence, violent victimization, and severe mental illness: balancing public health concerns. Psychiatr Serv 59:153–164

    PubMed  Article  Google Scholar 

  21. 21.

    Bureau of Justice Statistics Bulletin. State Court Processing Statistics, 2004. Felony Defendants in Large Urban. April 2008, NCJ 221152 U.S. Department of Justice Office of Justice Programs

  22. 22.

    Manderscheid RW, Henderson MJ (2002) Mental health, United States, 2002. Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, Rockville

  23. 23.

    2004 CMHS Uniform Reporting System Output Tables. Accessed December 30, 2009

  24. 24.

    Segal SP (2006) Survey of outpatient-commitment utilization. (Unpublished memo)

  25. 25.

    Conner KR, Zhong Y (2003) State firearm laws and rates of suicide in men and women. Am J Prev Med 25(4):320–324

    PubMed  Article  Google Scholar 

  26. 26.

    Miller M, Hemenway D, Azrael D (2007) State-level homicide victimization rates in the US in relation to survey measures of household firearm ownership, 2001–2003. Soc Sci Med 64:656–664

    PubMed  Article  Google Scholar 

  27. 27.

    Behavioral Risk Factor Surveillance System. Behavioral Risk Factor Surveillance System. 2001. Survey data. Accessed December 28, 2009

  28. 28.

    Land KC, McCall PL, Cohen LE (1990) Structural covariates of homicide rates: any invariances across time and social space? Am J Sociol 95(4):922–963

    Article  Google Scholar 

  29. 29.

    Baller RD, Anselin L, Messner SF, Deane G, Hawkins DF (2001) Structural covariates of U.S. county homicide rates: incorporating spatial effects. Criminology 39(3):561–590

    Article  Google Scholar 

  30. 30.

    Kubrin CE (2003) Structural covariates of homicide rates: does type of homicide matter? J Res Crime Delinq 40(2):139–170

    Article  Google Scholar 

  31. 31.

    American Community Survey (2004) Accessed December 28, 2009

  32. 32.

    SAMHSA Office of Applied Studies (2004) State Estimates of Substance Use from the 2003–2004. National Surveys on Drug Use and Health. Accessed December 30, 2009

  33. 33.

    American Conservative Union (2004). Accessed December 28, 2009

  34. 34.

    Mosher CJ, Terance D, Miethe TD, Phillips DM (2002) Mismeasure of crime. Sage Publications, California

    Google Scholar 

  35. 35.

    FBI Uniform Crime Report for 2008 (Published Sept. 2009). Accessed June 14, 2010

  36. 36.

    ICC statutes by state. Go to site and from there to specific state IOC statute. Accessed December 28, 2009

  37. 37.

    NAMI (2009) Grading the states—a report on America = s Health Care System for Serious Mental Illness. NAMI, Arlington, Virginia. Accessed June 14 2009

  38. 38.

    Salvo JJ, Lobo AP, Willett AL, Alvarez JA (2007) An evaluation of the quality and utility of ACS five year estimates for Bronx census tracts and neighborhoods. 2007 Joint Statistical Meetings, Salt Lake City, Utah. Accessed June 14, 2010

  39. 39.

    Tanay E (2007) Virginia Tech mass murder: a forensic psychiatrist’s perspective. J Am Acad Psychiatry Law 35(2):152

    PubMed  Google Scholar 

  40. 40.

    Matejkowski JC, Cullen SW, Solomon PL (2008) Characteristics of persons with severe mental illness who have been incarcerated for murder. J Am Acad Psychiatry Law 36:74–86

    PubMed  Google Scholar 

  41. 41.

    Baker A (2009) Homicide near record low rate in New York City. New York Times CLIX (54,904):A1, A3

  42. 42.

    Munroe E, Rumgay J (2000) Role of risk assessment in reducing homicide by people with mental illness. Br J Psychiatry 176:116–120

    Article  Google Scholar 

  43. 43.

    Simpson AI, Allnutt S, Chaplow D (2001) Inquiries into homicides and serious violence perpetrated by psychiatric patients in New Zealand: need for consistency of method and result analysis. Aust N Z J Psychiatry 35(3):364–369

    PubMed  Article  CAS  Google Scholar 

  44. 44.

    Hiday VA, Swartz MS, Swanson JW, Borum R, Wagner HR (2002) Impact of outpatient commitment on victimization of people with severe mental illness. Am J Psychiatry 159:1403–1411

    Google Scholar 

  45. 45.

    Segal SP, Burgess P (2006) Effect of conditional release from hospitalization on mortality risk. Psychiatr Serv 57:1607–1613

    PubMed  Article  Google Scholar 

  46. 46.

    Bagby RM, Atkinson L (1988) The effects of legislative reform on civil commitment admission rates. Behav Sci Law 6(1):45–61

    Article  Google Scholar 

  47. 47.

    Leiby J (1967) Charity and correction in New Jersey: a history of state welfare institutions. Rutgers University Press, New Brunswick

    Google Scholar 

  48. 48.

    Segal SP (2008) Deinstitutionalization. Encyclopedia of social work, 20th edn, vol 2. Co-published by the NASW Press and Oxford University Press, pp 10–20

  49. 49.

    Segal SP, Lauri T, Segal MJ (2001) Factors in the use of coercive retention in civil commitment evaluations in psychiatric emergency services. Psychiatr Serv 52(4):514–521

    PubMed  Article  CAS  Google Scholar 

  50. 50.

    Large M, Neilssen O, Ryan CJ et al (2008) Mental health laws that require dangerousness for involuntary admission may delay the initial treatment of schizophrenia. Soc Psychiatry Psychiatr Epidemiol 43:251–256

    PubMed  Article  Google Scholar 

  51. 51.

    Segal SP (1989) Civil commitment standards and patient mix in England/Wales, Italy, and the United States. Am J Psychiatry 146(2):187–193

    PubMed  CAS  Google Scholar 

  52. 52.

    Luckey JW, Berman JJ (1979) Effects of a new commitment law involuntary admissions and service utilization patterns. Law Hum Behav 3(3):149–161

    Article  Google Scholar 

  53. 53.

    Large M, Nielssen O (2008) Evidence for a relationship between the duration of untreated psychosis and the proportion of psychotic homicides prior to treatment. Soc Psychiatry Psychiatr Epidemiol 43:7–44

    Google Scholar 

  54. 54.

    Nielssen OB, Westmore BD, Large MM et al (2007) Homicide during psychotic illness in New South Wales between 1993 and 2002. Med J Aust 186:301–304

    PubMed  Google Scholar 

  55. 55.

    Swanson JW, Swartz MS, Essock SM, Osher FC, Wagner R, Goodman LA, Rosenberg SD, Meador KG (2002) The social–environmental context of violent behavior in persons treated for severe mental illness. Am J Public Health 92:1523–1531

    PubMed  Article  Google Scholar 

  56. 56.

    Friedman RA (2006) Violence and mental illness: how strong is the link? N Engl J Med 355(20):2064–2066

    PubMed  Article  CAS  Google Scholar 

  57. 57.

    Eronen M, Angermeyer MC, Schulze B (1998) The psychiatric epidemiology of violent behavior. Soc Psychiatry Psychiatr Epidemiol 33:S13–S23

    PubMed  Article  Google Scholar 

  58. 58.

    Swartz MS, Swanson JW, Hiday VA et al (1998) Violence and severe mental illness: the effects of substance abuse and nonadherence to medication. Am J Psychiatry 155:226–231

    PubMed  CAS  Google Scholar 

  59. 59.

    Arseneault L, Moffitt TE, Caspi A et al (2000) Mental disorders and violence in a total birth cohort. Arch Gen Psychiatry 57:979–986

    PubMed  Article  CAS  Google Scholar 

  60. 60.

    Elbogen EB, Van Dorn RA, Swanson JW et al (2006) Treatment engagement and violence risk in mental disorders. Br J Psychiatry 189:354–360

    PubMed  Article  Google Scholar 

  61. 61.

    Rachbeisel J, Scott J, Dixon L (1999) Co-occurring severe mental illness and substance use disorders and other risk factors. Psychiatr Serv 50:1427–1434

    PubMed  CAS  Google Scholar 

  62. 62.

    Wallace C, Mullen P, Burgess P (2004) Criminal offending in schizophrenia over a 25-year period marked by deinstitutionalization and increasing prevalence of comorbid substance use disorders. Am J Psychiatry 161:716–727

    PubMed  Article  Google Scholar 

  63. 63.

    Segal SP, Watson M, Goldfinger S, Averbuck D (1988) Civil commitment in the psychiatric emergency room: III. Disposition as a function of mental disorder and dangerousness indicators. Arch Gen Psychiatry 45:759–763

    PubMed  Article  CAS  Google Scholar 

  64. 64.

    Theriot M, Segal SP (2005) Involvement with the criminal justice system among new clients at outpatient mental health agencies. Psychiatr Serv 56(2):179–185

    PubMed  Article  Google Scholar 

  65. 65.

    Torrey EF, Entsminger K, Geller J et al (2008) The shortage of public hospital beds for mentally ill persons. Treatment Advocacy Center, Arlington

    Google Scholar 

  66. 66.

    Torrey F (2006) Violence and schizophrenia. Schizophr Res 88:3–4

    Google Scholar 

  67. 67.

    Segal SP, Watson M, Akutsu P (1996) Quality of care and use of less restrictive alternatives in the psychiatric emergency service. Psychiatr Serv 47(6):623–627

    PubMed  CAS  Google Scholar 

  68. 68.

    Solomon P, Draine J, Marcus SC (2002) Predicting incarceration of clients of a psychiatric probation and parole service. Psychiatr Serv 53(1):50–56

    PubMed  Article  Google Scholar 

  69. 69.

    Segal SP (2005) Ponencia: La atención de urgencias en Salud Mental en los Estados Unidos; dificultades y soluciones. VII JORNADAS INTERNACIONALES DE ACTUALIZACIÓN EN SALUD MENTAL;INTERVENCIONES DE URGENCIA EN SALUD MENTAL Las Palmas de Gran Canaria. 17 y 18 de noviembre de 2005

  70. 70.

    Segal SP, Watson M, Akutsu P (1998) Factors associated with involuntary return to a psychiatric emergency service within twelve months. Psychiatr Serv 49(9):1212–1217

    PubMed  CAS  Google Scholar 

  71. 71.

    Phelan JC, Link BG (1998) The growing belief that people with mental illnesses are violent: the role of the dangerousness criterion for civil commitment. Soc Psychiatry Psychiatr Epidemiol 33:S7–S12

    PubMed  Article  Google Scholar 

Download references

Conflict of interest

I have no conflict of interest.

Author information



Corresponding author

Correspondence to Steven P. Segal.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Segal, S.P. Civil commitment law, mental health services, and US homicide rates. Soc Psychiatry Psychiatr Epidemiol 47, 1449–1458 (2012).

Download citation


  • Civil commitment
  • Dangerousness
  • Inpatient-bed access
  • Better mental health systems