The Issue with Involuntary Psychiatric Holds: a call for patient-centered mental health treatment
Nearly an eighth of the world population struggles with a diagnosable mental illness. Most folks with psychological disorders do not have access to adequate care due to a lack of services and supports, capacity issues, accessibility issues, cost issues, or widespread stigma that discourages people from seeking help. Cultural perspectives, language, and idiomatic expressions all contribute to whether or not people seek psychological help. These factors also affect whether people identify their own or another’s issues as being related to mental health.
According to the World Health Organization (WHO), “coverage for care of psychosis worldwide is estimated to be as low as 29%”, suggesting that approximately 700 million people across the globe spend their lives with an untreated mental illness. This number would create uproar if it pertained to physical illness (i.e. what has transpired in light of the ongoing COVID-19 pandemic), but in the words of Freeman (2022), “it has become clichéd to say that mental health is undervalued, that little is done to promote mental health or prevent mental health conditions from occurring, that mental health services fail to meet need in almost all countries, and that human rights are often abused”. Although decades of research, data collection, advocacy and awareness programs have led to some change, so-called “progressive” areas of the world such as New York City still employ insufficient, antiquated, and often abusive forms of treatment.
The following is a case example written by a psychiatric social worker of a large public hospital in Brooklyn, NY:
Ms. T was brought to the emergency department by her mother, who informed providers that she had been acting strange for a couple weeks, not taking her bipolar medication, and was recently involved in a physical altercation with her stepsister. Upon encounter, the patient was seen barking and making animal noises at a male officer from hospital police. The psychiatric resident executed a verbal de-escalation technique that involved approaching Ms. T with a broad smile and speaking in a low volume—the resident asked permission to speak with her, to enter her exam room, and to ask her questions. Ms. T responded agreeably and, though her presentation suggested active mania, there was no evidence or suspicion of potential violence from the patient. The resident reported their findings to the attending physician in the emergency department, who immediately ordered an involuntary psychiatric hold (IPH) in the Comprehensive Psychiatric Emergency Program (CPEP). Then the attending pushed what we call a “5:2” (5mg of Haldol, an antipsychotic; 2mg of Ativan, a benzodiazepine). In essence, the attending deemed the patient to “lack capacity”, which relinquishes them of their right to consent to treatment, and then prescribed a sedative cocktail, which makes the patient easier to transfer to a carceral psychiatric ward in a crowded and understaffed public hospital.
The hospital with which the social worker is employed is the most-sued establishment in NYC’s healthcare system. According to the NYC Comptroller’s Annual Claims Report for the Fiscal Year 2021, the city paid out over 30% of the medical malpractice claims against them, totaling over $63 million in settlements (Lander, 2022).
According to Cheung et. al. (2017), “there are no laws that address th[e] matter [of IPHs] directly…in many jurisdictions”. Subsequently, psychiatrists are expected to issue a “civil commitment” in order to safeguard patients who “pose a danger to themselves or others, or who are gravely disabled, specifically as the result of a mental illness” (Cheung et. al., 2017). IPHs are routine in NYC public hospitals; they are integral to the protocol in its healthcare system because of the reasons aforementioned by the social worker. Heldt et. al. (2019) argue that while the use of IPHs to detain patients who lack the capacity to make health care decisions may prevent harm, “it also deprives civil liberties, risks liability for false imprisonment, and may hinder disposition”. How then, do medical professionals ensure that IPHs are exercised in justified efforts to save lives, as opposed to preventing patients of sound orientation from leaving against medical advice?
Researchers suggest a potential solution in the utilization of a medical incapacity hold (MIH) as an alternative, which “establish[es] institutional criteria for detaining patients who lack capacity but do not meet criteria for an IPH” (Heldt et. al., 2019). The key to their study was ensuring inter-rate reliability, which mandates that a hold may be placed on a patient only after they are examined by three independent physician reviewers and deemed to lack capacity by each of them. This methodology yielded a drop in wrongful IPH implementation from 17.6% to 3.9% following successful MIH implementation—Cohen’s kappa coefficient (κ) = 0.72; as a result, “no instances of patient elopement, grievances, or litigation” were filed throughout the duration of the study (Heldt et. al., 2019).
MIH policies serve both the safety of patients who lack capacity and the healthcare systems responsible for protecting them, and mitigate the frequency of inappropriate uses of IPHs. There must be a clear, universal policy for when a patient is deemed to lack capacity. Consent is too easily bypassed when every effort should be made to keep it paramount. These policies must be written by a team comprising of providers who approach the case from varied perspectives (medical, behavioral, social, etc.), instead of relying on state and/or local municipalities to uphold the responsibility, as they have historically operated through a lens of cost efficiency over safety and ethics. These policies must also be enforced by similar care teams as opposed to law enforcement officers, as they are less trained in de-escalation techniques and more trained in “social control functions” and “managing deviant behavior”, which poses a greater risk of harm to patients (Rosenheck, 1988).
The importance of these policies (and the ethical management of them) increases exponentially in public healthcare settings such as the one Ms. T experienced, where approximately 90% of patients—4.82 million people in the Fiscal Year 2021—identify as Black, Hispanic, Native American, Asian/Native Hawaiian/Pacific Islander, or something other than “white” (NYC Health+Hospitals, 2022). The same report outlines the payor mix of patients served by NYC’s public healthcare organizations, suggesting an approximate 60% coverage from Medicare/Medicaid, and a staggering <19% of patients that engage in any form of self-pay. Therefore, in a system that services a majority impoverished, BIPOC population, patient advocacy should be centered above all to ensure the injustice reported in Ms T.’s case not be repeated.
*Identifying details have been changed to protect patient confidentiality.
*This article was originally published in Mixed Mag, an online multimedia publication promoting creatives of color and celebrating multiethnic/multicultural stories. I am honored to have been invited to author this piece for the advocacy and politics section of Mixed Mag, spearheaded by Elizabeth T.
Cheung, E.H.; Heldt, J.; Strouse, T.; Schneider, P. (2018). The Medical Incapacity Hold: A Policy on the Involuntary Medical Hospitalization of Patients Who Lack Decisional Capacity. Psychosomatics, 59(2), p. 169-176. doi: 10.1016/j.psym.2017.09.005. Epub 2017 Sep 21. PMID: 29096914.
Freeman, M. (2022). The World Mental Health Report: transforming mental health for all. World Psychiatry, 21(3), p. 391-392. doi: 10.1002/wps.21018. PMID: 36073688; PMCID: PMC9453907.
Heldt, J.P.; Zito, M.F.; Seroussi, A.; Wilson, S.P.; Schneider, P.L.; Strouse, T.B.; Cheung, E.H. (2019). A Medical Incapacity Hold Policy Reduces Inappropriate Use of Involuntary Psychiatric Holds While Protecting Patients From Harm. Psychosomatics, 60(1), p. 37-46. doi: 10.1016/j.psym.2018.06.002. Epub 2018 Jun 14. PMID: 30064729.
Lander, B. (2022). “Annual Claims Report Fiscal Year 2021”. New York City Office of the Comptroller.
NYC Health+Hospitals (2022). “Community Health Needs Assessment 2022.” NYC Health and Hospitals Corporation’s Board of Directors. http://www.nychealthandhospitals.org/chna.
Rosenheck, R. (1988). System Dynamics in Complex Psychiatric Treatment Organizations. Psychiatry, 51(2), p. 211-220. doi:10.1080/00332747.1985.11024286.
World Health Organization (2022). World Mental Health Report: transforming mental health for all. Geneva.