Great write up, especially the translation of the legalese. You seem to be coming at this from the direction of loss of freedom as the biggest concern. Most of the worries I see above are in regards to over-committing. The time I have spent working on a psychiatric unit and emergency department and now as a sort of expert witness for civil commitments in Oregon has made me feel like the commitment pendulum has swung too far. I have had countless conversations with families who bring in their young adult child who is manic or psychotic (or both) where I had to tell them that I completely agreed that their child desperately needs involuntary psychiatric care, but the law says they need to be imminently dangerous or will imminently deteriorate. While I love America and our freedoms as much as the rest, I think the most client-centric thing to do is to hold/commit people who clearly aren't thinking clearly. We have all read article after article on addressing the homeless crisis, but I never see the issue of too-narrow commitment criteria and the swing from institutionalization as as proposed cause and solution. Should we improve our inpatient psychiatric treatment centers? Certainly! Do I want commitment to go back to dropping your mother-in-law off on an asylum doorstep and they keep her for life? Of course not. But I do believe many currently homeless folks - I often see my past clients walking the streets - would benefit from more open commitment laws. I would love to hear others' thoughts.
Hey Paul, thanks for your thoughts. Some of mine in response:
1. How confident are you that loosening commitment laws would materially improve outcomes for most of the patients you're thinking of? I can certainly think of a few times where patients have been just out of reach of commitment criteria, but I am not so sure that taking those homeless patients you're thinking about and involuntarily committing them will necessarily improve long-term outcomes.
2. My feeling is that improvement in inpatient facilities needs to come before any loosening of commitment laws. I would say >75% of the psychiatric wards I've been on are not really appropriate for anything but acute stabilization.
3. Your arguments are very focused on being "client-centric," but I think this discussion cannot be had without talking about the broader picture of civil liberties. The question is not just about whether or not this loosening will help patients, but to what extent it might harm non-patients, and to what degree we are comfortable with the general loosening of restrictions on the government around what is essentially involuntary imprisonment.
As a matter of principle, I think that such restrictions should be removed very slowly and carefully, regardless of purported benefit, since I think history shows us that governments (and the people they empower) are plenty happy to abuse the privilege as long as they can convince themselves they are doing things for the "right" reasons.
1. Great but difficult question. I would say that I am not confident. WEAK strength of evidence like those sleeping guidelines a few essays ago. I am a little more confident that the current limited commitment laws cause many to not receive treatment that could stop their active severe mania and/or psychosis. An essential question is what are materially improved outcomes? What does improved quality of life look like? Is improved quality of life worth it with additional limits on civil liberties? Hard questions. Another nuance (and I'm speaking from Oregon's laws) is that I actually saw more issues meeting "hold" criteria in the first place (5 legal day hold) than civil commitment (CC) criteria. Most of the CC patients were the sickest of the sick and were clear cut cases, but many of the patients needing "holds" but not qualifying didn't have that dangerousness listed in the statutes, or they were also actively or intermittently using substances like high potency THC, meth, etc. While often had to give IM antipsychotics for agitation/safety purposes and held some of these patients on intoxication holds, many improved just enough for discharge from the emergency department in 24 hours or so rather than being admitted for a more meaningful stabilization.
And back to whether the homeless folks would be better off in long term care facilities is a tough question. There are major downsides to both options. Clearly the regular or intermittent substance use, victimization due to crime, general misery of the weather without shelter, loss of stable relationships, and lack of clear faculties is significant. But so is the constant monitoring and restriction of a secured residential treatment facility (SRTF) - I am the overseeing medical provider for our local SRTF. And it would be naive for me to say that all the patients in the SRTF with schizophrenia or schizoaffective disorders that are regularly taking antipsychotics are cognitively clear and symptom free. But I do see it as the lessor of the two evils, especially because if they do truly enter a stage of remission, they can move to lower levels of care and regain their civil liberties. This is an important different between our current involuntary system and the asylums of yore.
2. I totally agree that an improvement in psychiatric facilities, long and short term, would be a boon for the SPMI population. I think I read an article or two by Awais Aftab about how because safety and the associated liability risks are the primary concern in the design of psychiatric facilities, and how this leads to a lack of a therapeutic feel, and definitely never allows or something resembling a home. While I get it, that makes me so sad. Seems like a tough battle to fight if the counterpoint is that what makes the facilities nicer also marginally increases liability. I go to the point that there is a reason we all leave our houses and drive and fly and do fun things even when there are risks involved - this is being human. Those with psychiatric issues should be allowed more choice in this regard in my opinion.
3. Yes - I am also very concerned about the government having greater levels of control of its people. If I lived in a time where the civil liberties were restrained slightly more, I could easily see myself taking the other side of this. When I read The Center Cannot Hold, so much of what she said resonated with me. I would expect that we would make the loosening very thoughtfully and with frequent glances back at the mistakes of our not-so-distant past. I am not sure I understand what you are referring to when you say how the limitations of civil liberties in this case would harm non-patients. I am sure it would in some ways, for there are almost always unforeseen negative consequences of these things, but I can't think of clear cases in the front of my mind. Also, I'm hoping I didn't come across as taking the higher moral ground (welcome to comments vs an in-person conversation). That definitely was not my goal! And thanks again for taking the time to respond. I wish more of my colleagues cared as much about this as you do!
First off, you definitely do not come across as holier-than-thou at all. Thanks in turn for your thoughtful discussion!
1. I would generally agree that there are many patients who would benefit acutely that are often just "out of reach" of commitment criteria; I do find myself wondering how much it moves the needle in the long-term. i.e. Will treating this acute decompensation do anything more than slap a bandaid on this festering wound? Maybe that's better than nothing, but I'm not sure sometimes.
I actually don't have a problem with the concept of what I think you're describing with the SRTF model. I think there is some segment of the mentally ill that are so sick with no obvious end in sight that an indefinite commitment with the option for step-down is totally appropriate. With very vigorous legal oversight, I think bringing back big state hospitals is one of the most humane things we could do.
2. I've been somewhat heartened to see on the interview trail that many hospitals have built or are building new freestanding psych hospitals that are really, really nice and really take seriously the idea of a therapeutic milieu.
Do they (a mysterious/ambiguous "they") give LAIs with shorter (eg 72-hour) holds? I think sometimes, people would benefit more from a LAI + 72-hour commitment than a LAI + longer commitment.
I guess when clearheaded, people with psychotic disorders can make an "advanced directive" outlining their wishes for involuntary commitment, and let the people they live with and/or interact regularly know these preferences.
Do they wish to be committed whenever they're in acute psychosis? Or only when there's evidence they've recently done something that jeopardizes their relationship/s and/or job?
Eg mine would include, "If I message anyone with paranoid accusations that my family members are harming me or have harmed me in the past, if I damage walls or other property, if I ever hide a knife, and so forth... please don't hesitate to make a call to get me committed."
Theoretically, yes, we can give LAIs during that period. Sometimes we do, but there are some practical considerations.
The most commonly used LAIs require two loading injections -or- oral supplementation to do their job properly. The loading doses typically need to be spaced out more than 72h. There are some exceptions like Uzedy (risperidone, no loading), and Aristada (aripiprazole, loading done in the same day).
In some states (Massachusetts is one) you cannot give antipsychotics over objection as part of routine treatment without a court ordered commitment. So no LAIs during the 72h hold unless the patient consents. My understanding of North Carolina law, however, is that you simply need a second doc to agree with treatment over objection.
Advanced directive stuff is also state dependent, and they're only as effective as state laws let them be. In Massachusetts, you can make them, but they're useless in practice. In North Carolina, my reading of their laws suggest that they're more robust. I think they're mostly for directing treatment while in the hospital, but I don't have a lot of experience with them.
Australian med student here... We're taught that if you have any doubts as a junior doctor, section (commit) first, and then leave it up to the consultant psychiatrist who has to review within... 24-48 hrs (forget which)... to take responsibility for letting them loose, in the coroner's court, if anything untoward goes down afterwards... As someone with a powerful libertarian ethos who believes taking away sometimes human rights should only be done under extreme circumstances (severe psychosis probably makes the cut) this is moral injury territory... and even with extreme psychosis, the fact that our public psych hospitals are such atrocious places for patients... If you're involuntarily committing someone, I think there's a responsibility to do everything to make the conditions you place them in the best possible... I did everything possible to (successfully) keep my daughter out of hospital when she had her first manic episode, because I'm so unimpressed with public psych wards (and we don't have acute private wards here) (fortunately I could access a private psych who saw her 3x a week and played hooky from med school - much to their displeasure - to keep her safe).
Hi Heather! I once felt quite similarly to you and have to share that my opinion changed greatly after a couple of years of practice, as it doesn’t take severe psychosis for somebody to be unable to care for themselves or be at risk to harm others. Be open to changing your mind but I don’t think the commit first mindset is reasonable either. Best of luck in school.
Great write up, especially the translation of the legalese. You seem to be coming at this from the direction of loss of freedom as the biggest concern. Most of the worries I see above are in regards to over-committing. The time I have spent working on a psychiatric unit and emergency department and now as a sort of expert witness for civil commitments in Oregon has made me feel like the commitment pendulum has swung too far. I have had countless conversations with families who bring in their young adult child who is manic or psychotic (or both) where I had to tell them that I completely agreed that their child desperately needs involuntary psychiatric care, but the law says they need to be imminently dangerous or will imminently deteriorate. While I love America and our freedoms as much as the rest, I think the most client-centric thing to do is to hold/commit people who clearly aren't thinking clearly. We have all read article after article on addressing the homeless crisis, but I never see the issue of too-narrow commitment criteria and the swing from institutionalization as as proposed cause and solution. Should we improve our inpatient psychiatric treatment centers? Certainly! Do I want commitment to go back to dropping your mother-in-law off on an asylum doorstep and they keep her for life? Of course not. But I do believe many currently homeless folks - I often see my past clients walking the streets - would benefit from more open commitment laws. I would love to hear others' thoughts.
Hey Paul, thanks for your thoughts. Some of mine in response:
1. How confident are you that loosening commitment laws would materially improve outcomes for most of the patients you're thinking of? I can certainly think of a few times where patients have been just out of reach of commitment criteria, but I am not so sure that taking those homeless patients you're thinking about and involuntarily committing them will necessarily improve long-term outcomes.
2. My feeling is that improvement in inpatient facilities needs to come before any loosening of commitment laws. I would say >75% of the psychiatric wards I've been on are not really appropriate for anything but acute stabilization.
3. Your arguments are very focused on being "client-centric," but I think this discussion cannot be had without talking about the broader picture of civil liberties. The question is not just about whether or not this loosening will help patients, but to what extent it might harm non-patients, and to what degree we are comfortable with the general loosening of restrictions on the government around what is essentially involuntary imprisonment.
As a matter of principle, I think that such restrictions should be removed very slowly and carefully, regardless of purported benefit, since I think history shows us that governments (and the people they empower) are plenty happy to abuse the privilege as long as they can convince themselves they are doing things for the "right" reasons.
1. Great but difficult question. I would say that I am not confident. WEAK strength of evidence like those sleeping guidelines a few essays ago. I am a little more confident that the current limited commitment laws cause many to not receive treatment that could stop their active severe mania and/or psychosis. An essential question is what are materially improved outcomes? What does improved quality of life look like? Is improved quality of life worth it with additional limits on civil liberties? Hard questions. Another nuance (and I'm speaking from Oregon's laws) is that I actually saw more issues meeting "hold" criteria in the first place (5 legal day hold) than civil commitment (CC) criteria. Most of the CC patients were the sickest of the sick and were clear cut cases, but many of the patients needing "holds" but not qualifying didn't have that dangerousness listed in the statutes, or they were also actively or intermittently using substances like high potency THC, meth, etc. While often had to give IM antipsychotics for agitation/safety purposes and held some of these patients on intoxication holds, many improved just enough for discharge from the emergency department in 24 hours or so rather than being admitted for a more meaningful stabilization.
And back to whether the homeless folks would be better off in long term care facilities is a tough question. There are major downsides to both options. Clearly the regular or intermittent substance use, victimization due to crime, general misery of the weather without shelter, loss of stable relationships, and lack of clear faculties is significant. But so is the constant monitoring and restriction of a secured residential treatment facility (SRTF) - I am the overseeing medical provider for our local SRTF. And it would be naive for me to say that all the patients in the SRTF with schizophrenia or schizoaffective disorders that are regularly taking antipsychotics are cognitively clear and symptom free. But I do see it as the lessor of the two evils, especially because if they do truly enter a stage of remission, they can move to lower levels of care and regain their civil liberties. This is an important different between our current involuntary system and the asylums of yore.
2. I totally agree that an improvement in psychiatric facilities, long and short term, would be a boon for the SPMI population. I think I read an article or two by Awais Aftab about how because safety and the associated liability risks are the primary concern in the design of psychiatric facilities, and how this leads to a lack of a therapeutic feel, and definitely never allows or something resembling a home. While I get it, that makes me so sad. Seems like a tough battle to fight if the counterpoint is that what makes the facilities nicer also marginally increases liability. I go to the point that there is a reason we all leave our houses and drive and fly and do fun things even when there are risks involved - this is being human. Those with psychiatric issues should be allowed more choice in this regard in my opinion.
3. Yes - I am also very concerned about the government having greater levels of control of its people. If I lived in a time where the civil liberties were restrained slightly more, I could easily see myself taking the other side of this. When I read The Center Cannot Hold, so much of what she said resonated with me. I would expect that we would make the loosening very thoughtfully and with frequent glances back at the mistakes of our not-so-distant past. I am not sure I understand what you are referring to when you say how the limitations of civil liberties in this case would harm non-patients. I am sure it would in some ways, for there are almost always unforeseen negative consequences of these things, but I can't think of clear cases in the front of my mind. Also, I'm hoping I didn't come across as taking the higher moral ground (welcome to comments vs an in-person conversation). That definitely was not my goal! And thanks again for taking the time to respond. I wish more of my colleagues cared as much about this as you do!
First off, you definitely do not come across as holier-than-thou at all. Thanks in turn for your thoughtful discussion!
1. I would generally agree that there are many patients who would benefit acutely that are often just "out of reach" of commitment criteria; I do find myself wondering how much it moves the needle in the long-term. i.e. Will treating this acute decompensation do anything more than slap a bandaid on this festering wound? Maybe that's better than nothing, but I'm not sure sometimes.
I actually don't have a problem with the concept of what I think you're describing with the SRTF model. I think there is some segment of the mentally ill that are so sick with no obvious end in sight that an indefinite commitment with the option for step-down is totally appropriate. With very vigorous legal oversight, I think bringing back big state hospitals is one of the most humane things we could do.
2. I've been somewhat heartened to see on the interview trail that many hospitals have built or are building new freestanding psych hospitals that are really, really nice and really take seriously the idea of a therapeutic milieu.
Do they (a mysterious/ambiguous "they") give LAIs with shorter (eg 72-hour) holds? I think sometimes, people would benefit more from a LAI + 72-hour commitment than a LAI + longer commitment.
I guess when clearheaded, people with psychotic disorders can make an "advanced directive" outlining their wishes for involuntary commitment, and let the people they live with and/or interact regularly know these preferences.
Do they wish to be committed whenever they're in acute psychosis? Or only when there's evidence they've recently done something that jeopardizes their relationship/s and/or job?
Eg mine would include, "If I message anyone with paranoid accusations that my family members are harming me or have harmed me in the past, if I damage walls or other property, if I ever hide a knife, and so forth... please don't hesitate to make a call to get me committed."
Theoretically, yes, we can give LAIs during that period. Sometimes we do, but there are some practical considerations.
The most commonly used LAIs require two loading injections -or- oral supplementation to do their job properly. The loading doses typically need to be spaced out more than 72h. There are some exceptions like Uzedy (risperidone, no loading), and Aristada (aripiprazole, loading done in the same day).
In some states (Massachusetts is one) you cannot give antipsychotics over objection as part of routine treatment without a court ordered commitment. So no LAIs during the 72h hold unless the patient consents. My understanding of North Carolina law, however, is that you simply need a second doc to agree with treatment over objection.
Advanced directive stuff is also state dependent, and they're only as effective as state laws let them be. In Massachusetts, you can make them, but they're useless in practice. In North Carolina, my reading of their laws suggest that they're more robust. I think they're mostly for directing treatment while in the hospital, but I don't have a lot of experience with them.
Australian med student here... We're taught that if you have any doubts as a junior doctor, section (commit) first, and then leave it up to the consultant psychiatrist who has to review within... 24-48 hrs (forget which)... to take responsibility for letting them loose, in the coroner's court, if anything untoward goes down afterwards... As someone with a powerful libertarian ethos who believes taking away sometimes human rights should only be done under extreme circumstances (severe psychosis probably makes the cut) this is moral injury territory... and even with extreme psychosis, the fact that our public psych hospitals are such atrocious places for patients... If you're involuntarily committing someone, I think there's a responsibility to do everything to make the conditions you place them in the best possible... I did everything possible to (successfully) keep my daughter out of hospital when she had her first manic episode, because I'm so unimpressed with public psych wards (and we don't have acute private wards here) (fortunately I could access a private psych who saw her 3x a week and played hooky from med school - much to their displeasure - to keep her safe).
Hi Heather! I once felt quite similarly to you and have to share that my opinion changed greatly after a couple of years of practice, as it doesn’t take severe psychosis for somebody to be unable to care for themselves or be at risk to harm others. Be open to changing your mind but I don’t think the commit first mindset is reasonable either. Best of luck in school.