Dinah Miller, MD, returns to the MDedge Psychcast, this time to do a Masterclass lecture on involuntary commitment.

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care.” She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, both in Baltimore. In addition, Dr. Miller is a columnist for Clinical Psychiatry News and serves on the editorial advisory boards of CPN and MDedge Psychiatry.

Timestamps:

• This week in Psychiatry (00:37)
• Masterclass lecture (02:00)
• Dr. RK (40:50)

This week in Psychiatry:

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Overview of the involuntary commitment debate

Four main controversies surround involuntary treatment

• First, standards for involuntary commitment vary by state; most states require that a person be diagnosed with a mental illness and is imminently dangerous to self or others. Some states extend their parameters to include those who are “gravely disabled” or need of psychiatric treatment.
• Second, as involuntary beds decrease, there is no place for involuntary treatment.
• Third, involuntary treatment includes outpatient civil commitment (OCC), and policy groups differ in their opinions of involuntary inpatient and outpatient treatments. Laws defining the need and amount of mandated outpatient services vary, based on geographical area. Also, outpatient commitment is difficult to enforce.
• The final controversy addresses a patient’s right to refuse treatment with medication.

Groups hold wide-ranging positions along policy spectrum

• The Treatment Advocacy Center is a strong proponent of involuntary hospitalization. The group advocates for more state hospital beds in the United States, monitors the number of state hospital beds, proposes an involuntary standard of based on need for treatment, and argues that anosognosia justifies involuntary hospitalization.
• The National Alliance on Mental Illness (NAMI) is a grassroots organization founded by parents of individuals with serious mental illness (SMI) and initially represented a view in favor of involuntary hospitalization based on protecting those with SMI. However, as NAMI has grown to represent a broad swath of people with mental illness, the organization has struggled with whether it represents the interests of people with SMI only or a broader group of people with any mental illness.
• The American Psychiatric Association holds the middle ground, identifying dangerousness as the standard of involuntary care. In 2015, the APA released a carefully worded stance in support of outpatient commitment on a limited basis.
• Organizations strongly against involuntary treatment include the Bazelon Center for Mental Health Law, whose mission is to protect and advance the rights of adults and children with mental illness. The Bazelon Center opposes anything that restricts the rights of people with mental illness.
• The recovery movement, which developed as a backlash against the perceived paternalism of psychiatry, prioritizes the mental health consumer’s autonomy with an emphasis on peer support and being proactive in health care choices.
• On the antipsychiatry spectrum are the groups MindFreedom International and the Citizens Commission on Human Rights. Both of those groups oppose involuntary treatment.

Violence and mental illness

• In the community, psychiatric illness is thought to be responsible for 4% of total violence and 7%-10% of murders.
• The MacArthur Foundation investigated rates of violence in people with mental illness 10 weeks after an inpatient hospitalization. It found that, compared with community samples, people with mental illness following hospitalization have higher rates of violence. The rate of violence was 8% for people with schizophrenia, 15% for bipolar disorder, 18% for depression, and 23% for personality disorder. Twenty weeks after discharge, patients with more treatment contacts were less likely to be violent.
• Mental illness does not belong in conversations about violence prevention because violence is more strongly correlated with substance use, anger, and early exposure to violence. Thus, mass murder cannot be prevented with forced care or institutionalization.
• The case is less clear for involuntary treatment for suicide prevention. For example, we know that two-thirds of gun deaths are suicides; however, we do not have statistics to elucidate whether involuntary hospitalization would prevent suicides.

Final thoughts

• Involuntary hospitalization should be the treatment choice of last resort. A psychiatrist should pursue careful assessment with as many sources as possible and strongly suggest alternatives, such as voluntary hospitalization.
• Involuntary hospitalization could be less traumatizing by implementing steps such as reducing forced treatments, minimizing seclusion and restraints, asking patients for feedback at the end of their stays, and acknowledging that involuntary treatment is difficult.
• Involuntary care would be less necessary if voluntary care were easier to access earlier in an illness to avoid crisis and hospitalization.

 

References

Miller D and Hanson A. “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016).

Torrey EF et al. The MacArthur Violence Risk Study revisited: Two views ten years after its initial publication. Psychiatr Serv. 2008 Feb 1;59(2):147-52.

Testa M and West SG. Civil commitment in the United States. Psychiatry (Edgmont). 2010 Oct;7(10):30-40.

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