The legal side of psychiatry

Most of the inpatient psychiatry patients I have seen were admitted voluntarily. But some patients can be held involuntarily if they meet certain criteria: 1) They pose a threat to themselves, 2) They pose a threat to others, and 3) They have grave disability. Those first two are self-explanatory; "grave disability" just means that a patient's psychiatric illness impairs his or her ability to properly care for themselves. Think food, clothes, and shelter.

A mental health hold (MHH) is the shortest involuntary hold at 72 hours. Its purpose is to further evaluate a patient's mental state according to the above three criteria. There are important legal implications of the MHH. Most importantly, since the purpose of the MHH is fact-finding, the psychiatrist is allowed to obtain medical records from other institutions, and talk with the patient's friends and family, without the patient's consent. This means that if a patient is initially admitted on a MHH then switches to voluntary status, the psychiatrist is no longer able to get that information if the patient doesn't agree to it. I saw this happen a few times.

Short-term certification, which lasts for 3 months, is the next step of involuntary hospitalization. By the end of a 72 hour of a MHH, the psychiatrist must convince a judge that short-term certification is necessary, again demonstrating that the patient poses a threat to himself or others or has grave disability. Long-term certification lasts an additional 6 months and also has to be argued before a judge to be granted.

Lastly, there are involuntary medications (i-meds), which are exactly what they sound like. Typically, a patient flies out of control after refusing voluntary medications, emergency medications (e-meds) are given to control the patient in the short-term, then the case is brought before a judge to grant power to administer i-meds. Concern for the physical safety of fellow patients and staff is often cited as justification for requesting i-meds.

The gravity of depriving a person of freedom is not lost on me.

Going to court

One particularly memorable patient took his case to court. Among other problems, this patient had delusions of grandeur that led to increasingly serious run-ins with the law.

The patient was shackled and escorted to the courthouse by a sheriff, while the rest of us piled into a government-issued van for a field trip. The intern would be testifying, a first for him. He practiced his testimony on the ride over, and the attending prepared him for what to expect. "The public defender is going to try to discredit you as an expert witness. Don't worry: It's not personal, and the judge will likely rule in your favor."

That's exactly what happened. My intern became a newly-minted "expert" with the privilege of providing testimony related to the matter of placing our patient on a short-term certification. He stood at the podium with his hands clasped tightly behind him, so tightly in fact that his fingertips were white. His back was straight, his shoulders squared, his head held high, and in that pose he answered questions thoroughly but succinctly in a clear and certain voice. I was very impressed.

After some back-and-forth questioning from the public defender and city attorney, the patient/defendant had the opportunity to address the court. It turned out that our patient sealed his own fate with a diatribe that clearly demonstrated to the judge that he poses a threat to himself and suffers grave disability. We won short-term certification and the ability to administer involuntary medications.

Observing the legal process in action was fascinating, a valuable component of my psychiatry education.


Update: This patient is now doing fairly well. My intern writes:

The patient became less and less resistant to medications as he become more linear and logical. He never quite thanked us for forcing medication on him, but he did start saying positive things about the way he was thinking. Before he left, he actually became quite socially appropriate, responding to social cues, which previously he had not been able to do. He started telling jokes, some pretty funny and some bizarre. But he would occasionally follow a bizarre comment with reality testing saying, "Does that sound crazy?" and then laugh it off. At discharge, he was nervous to go home and thought it was happening too fast. Last I checked, he was making his outpatient appointments. His home visits have found him pleasant; he has been very welcoming to his case worker and showing off how clean and organized his apartment is, as well as new writings he has been working on.