Questions and Answers about the Effectiveness of CONREP
California Department of Mental Health
- CONREP protects the public and provides a less costly vehicle for treatment of major mental disorders than expensive state hospital beds.
- CONREP reoffense rates are significantly less than the reoffense rate of a comparison group of patients who left hospitals in the past but without CONREP aftercare (1).
- CONREP reoffense rates are the lowest of three states that have published follow-up findings in the research literature regarding similar clients served by their conditional release programs (2);
- CONREP increases the numbers of patients who get jobs and who build positive social supports in the community, and CONREP reduces the numbers of those who abuse substances (3);
- CONREP patients receive intensive treatment in the community at a cost that is approximately one-fifth the cost of placement in a state hospital.
What is it about CONREP that works?
- Of key importance in protecting the public is the legal ability and clinical skill exercised by CONREP staff in revoking the conditional release of patients who show signs of dangerousness and immediately placing such patients back into secure hospitals.
- CONREP programming prevents crime: An earlier case-by-case analysis of the reasons for revocation revealed that most persons put back in hospitals had not committed arrestable acts, but rather had psychiatric and behavioral problems that if left unaddressed could have escalated in seriousness and become criminal acts (4).
- The treatment provided in CONREP programs helps patients overcome the economic and social isolation that often accompanies mental illness:
- The average CONREP patient after a year in treatment is more likely to be employed, works more hours per week, and has higher pay and job responsibilities than when he or she entered CONREP (3);
- The average CONREP patient after a year in treatment is more likely to have at least one close friend, is more likely to have friends who support the treatment program, and is a more frequent participant in recreational activities with others than when he or she entered CONREP (3).
- The average CONREP patient after a year in treatment is less likely to have alcohol or drug abuse problems than when he or she entered CONREP (3).
What proportion of CONREP patients is revoked back to state hospitals?
- In the most recent (2002) data analysis, 17.0% of CONREP NGI patients, during one year of community exposure, had to be returned from community programs to state hospitalization.
- The most common reasons for rehospitalization were psychiatric decompensation (6.4%), noncompliance with treatment requirements (9.3%), and showing symptoms considered dangerous (1.9%).
- An earlier study compared the rate of CONREP rehospitalization to those of two other states. California’s 1997 CONREP one-year rehospitalization rate of 20.4% was below that of Oregon’s conditional release program (25.8%) but higher than New York’s return-rate (14.5%) (5).
For what kinds of patients does CONREP work best?
- CONREP has the best outcomes with the bulk of its clientele, the PC 1026 or not guilty by reason of insanity (NGI) cases.
- Only 5% of NGI persons are rearrested during their first year of CONREP community exposure (6);
- The nature of offending shifts, following treatment in CONREP, toward less serious offenses. Although 77% of NGI clients in CONREP originally were committed by courts due to violent offenses, most of the reoffense charges (61%) among the relatively few clients who reoffend are nonviolent (7).
- After positive exits from CONREP jurisdiction (i.e. courts rule the patient has been “restored to sanity”), former NGI CONREP patients maintain an 80% chance of being arrest-free over a period of four years after their release from CONREP conditions (8).
How well does CONREP work for patients other than NGI?
- CONREP has a more limited mission, and consequently more limited success, with PC 1370 (Incompetent to Stand Trial) and PC 2960 (Mentally Disordered Offender) patients.
- Incompetent to Stand Trial patients had a rearrest rate of 20.2% during one year of community exposure while in CONREP programs (6).
- Mentally Disordered Offenders had low rates of rearrest while in CONREP treatment, 10.6% during one year of community CONREP exposure, but after leaving CONREP almost 40% were rearrested within two years (compared with less than 15% of NGI’s at two years post-CONREP) (8).
What accounts for differences in performance between the more successful (NGI) and less successful (MDO and IST) CONREP legal categories?
- California’s experience in the forensic mental health field suggests that in order to achieve the best outcomes, substantial treatment in state hospitals is followed by substantial treatment in community outpatient settings. This concept is more fully realized, due to law and consequent durations of treatment, with NGI patients than with MDO and IST clients.
- NGI patients spend substantial amounts of time in state hospital inpatient treatment (average = 4.25 years) prior to CONREP placement (9);
- NGI patients also remain in community CONREP aftercare treatment for considerable lengths of time (average = 3.5 years) (10);
- MDO and IST clients spend briefer periods of time in state hospitals and in community CONREP programs than do NGI patients.
- The average MDO length of state hospital stay is only 1.35 years as compared to 4.25 years among NGI’s (9);
- IST clients stay an average of less than one year in state hospitals (9);
- Community CONREP lengths-of-stay for IST as well as MDO clients average less than one year compared with over three years among NGI’s (10).
- CONREP is charged by law with limited goals with the two latter categories and is given less decision-making authority than is the case with NGI’s.
- For IST’s the goal is trial competence rather than becoming restored to sanity.
- For MDO’s the goal is safely maintaining clients in the community until CONREP jurisdiction ends due to remission from psychiatric symptoms or release from California Department of Corrections parole. (MDO patients can also be civilly committed, and treated by state hospitals and/or CONREP, if at the end of parole the essential clinical and dangerousness conditions of MDO still apply.)
How long do patients stay in state hospitals before release to community CONREP programs?
- Average state hospital stays prior to CONREP by legal class are:
- NGI’s = 4.25 years in state hospitals (9);
- MDO’s = 1.35 years
- MDSO’s = 5.46 years
- IST’s = 0.94 years
How long do patients stay in state hospitals during a revocation-stay?
- Average lengths of stay during a revocation-hospitalization was found in a 1999 analysis to be (11):
- NGI = 2.71 years
- MDO = 1.46 years
- (MDSO and IST patients have insufficient numbers for meaningful calculation.)
How much does CONREP cost?
- The cost per patient in the last complete fiscal year (2001-02) was $20,100.
- This cost is approximately 1/5 the per-patient annual cost of state hospital placement.
How have the clients of today changed in social and psychiatric functioning compared to the clients in CONREP in 1993 and 1999?
- CONREP therapists rate all clients’ social and psychiatric functioning at time of entry to CONREP and at anniversaries of entry. From these ratings, scores on adjustment scales are computed (3).
- Clients who entered CONREP in 2002 had slightly poorer functioning in the areas of Employment, Social Supports, Substance Abuse, and Risk/Dangerousness than clients admitted in 1999. In these four adjustment areas there was a steady downward trend in initial functioning scores from 1993 to 1999, and from 1999 to 2002.
- In other adjustment areas, trends in functioning scores of entering clients were more complex across years, average scores either increasing a few points after a 1993-1999 decrease, or decreasing a few points after a 1993-1999 increase.
- Regarding client gains after treatment in CONREP, two of the three scales in which there were significant statewide gains by clients during their first year of CONREP treatment in the 1993 and 1999 analyses, Employment and Social Supports, also showed statistically significant first-year gains in 2002.
- In 2002 there was also a statistically significant improvement in client functioning in Substance Abuse (that is, less substance abuse) between program entry and one year in the program.
How do consumers of CONREP services rate the program and its staff?
- A 1998 doctoral dissertation research project, conducted by Robin Zasio with the assistance of Department of Mental Health research staff, surveyed active CONREP patients to get their perceptions of the services they had received.
- Nine programs serving 30 different counties in various regions of the state participated in this project.
- A total of 224 active CONREP patients who had been in the program for at least six months were asked to complete an anonymous questionnaire, put it in a stamped addressed envelope, and mail it to the researcher. Of this number, 102 questionnaires were returned.
- On the questionnaire, thirty-four items asked for the extent of agreement to statements concerning therapists (e.g., “My therapist understands my problems” “My therapist helps me find resources in the community”), while three questions asked for overall levels of satisfaction.
- Patients expressed high overall satisfaction with their programs and therapists.
- When asked, “Overall, how much do you feel you have been helped while under the supervision of the Conditional Release Program?” 38% responded Extremely, 35% Quite a Bit, 10% Moderately, 11% Somewhat, 6% Not at All.
- Patients also gave high ratings to their therapists. Asked, “Overall, how satisfied are you with your therapist?” 50% responded Extremely, 24% Quite a Bit, 13% Moderately, 8% Somewhat, and 5% Not at All satisfied.