Psychiatric hospitalization by court observation order in Israel: A ten-year follow-up study

Objectives: To explore the proportion of defendants hospitalized by court observation order (COO) who were diagnosed as having a psychiatric disorder during: 1) the COO period, or 2) a 10-year follow-up period. Methods: Data on all adult defendants, who underwent psychiatric hospitalization by COO between 1991 and 1995, were extracted from the National Psychiatric Case Registry of the Israel Ministry of Health, and rehospitalizations over the next ten years were identified. ANOVA and Wilcoxon signed-rank test were used for comparing the diagnosed and undiagnosed defendant cohorts. Results: Only 17% of defendants hospitalized by COO received a psychiatric diagnosis (N=316), while the remaining referred defendants (N=1,532) were not diagnosed as suffering from any psychiatric disorder. Although 56% of the initially undiagnosed group (N=863) were rehospitalized and received a psychiatric diagnosis during the next ten years, 36% of the original cohort never received a diagnosis subsequent to hospitalization (N=556). Significant median differences in inpatient days associated with a follow-up diagnosis of psychotic disorder were found between the diagnosed and undiagnosed defendant cohorts (z=4.89, p<.001). Conclusions: The high rate of diagnosis of defendants who were undiagnosed at the index hospitalization suggests that the COO is ineffective and tends to discharge without diagnosis defendants who are later found to be psychotic. Therefore, an independent examination of the accuracy of the forensic psychiatric evaluation (FPE) process is called for, to determine whether actual disorders are being missed. There should be a professional and public debate on the unnecessary use of court-ordered hospitalizations and ways of their prevention.