Involuntary Hold Research Articles

Interstate Human Trafficking Youth Survivors: Clinical and Forensic Considerations

Child trafficking continues to be underreported due to multiple factors including differences in state laws, lack of a centralized database, and overall under-recognition. The care of such youth often entails forensic as well as significant clinical considerations given their traumatization. We report on our experience with a 14-year-old female who presented to an Emergency Department (ED), brought in by law enforcement after her parents filed a missing person report in a different state, with concerns about human trafficking; the patient expressed suicidal ideation in our ED. The patient was placed under involuntary hold, after obtaining collateral from the her parents. During the hospitalization, legal challenges presented barriers to safe discharge and a need to collaborate for providing care between disciplines and across state lines. At the same time, through validation and support in the therapeutic milieu of an adolescent psychiatric unit, she was able to understand that she had just survived sexual assault and began to process the impact of it. Although no medication changes were made, the patient began to develop insight at the time of discharge to the Child Protective Team.

State Reporting Requirements for Involuntary Holds, Court-Ordered Guardianship, and the US National Firearm Background Check System

Firearm violence is a leading cause of death in the US. There is broad public agreement that individuals at high risk of perpetrating violence should not be allowed to purchase or possess firearms. The National Instant Criminal Background Check System (NICS) is a national system intended to stop firearm purchases or possession by prohibited persons, but there is heterogeneity in how states interact with and report data to NICS. To examine variability in state requirements for NICS reporting for mental health prohibitions. This cross-sectional study in the US reviewed current statutes for all 50 states and the District of Columbia (enacted through the 2021 legislative session) regarding reporting mental health prohibitions to NICS or state systems. Data were analyzed from October 2022 to April 2023. For each state, the following were recorded: reliance on Federal Bureau of Investigation vs state point of contact for NICS checks; regulation requiring or allowing reporting to NICS for 3 hypothetical cases; and details on reporting responsibility and time frame. The number of NICS listings for adjudicated mental health reasons was obtained, and state rates per 1000 population were calculated. To compare states, we developed 3 hypothetical cases of individuals with risk of firearm violence, whether possibly temporary (involuntary commitment for decompensated psychosis, or involuntary short-term psychiatric hold for suicidal ideation) or chronic and progressive (court-appointed guardianship for dementia). A total of 39 states required and 5 allowed reporting to NICS for court-ordered, involuntary psychiatric hospitalization. Thirteen states required and 5 allowed reporting to NICS when a court determines an individual is mentally incompetent to manage their affairs (with or without guardianship). Two states required NICS reporting for short-term emergency psychiatric holds. Five states and the District of Columbia had no legislation explicitly requiring or allowing NICS reporting in the 3 scenarios. In this cross-sectional study of state laws, there was substantial heterogeneity in NICS reporting requirements and lack of clarity around processes. This raises questions about the ability of NICS to be used to block firearm purchases or possession by individuals with court-identified high risk of perpetrating violence toward themselves or others.

WEBB FELLOW: Development and Implementation of an Involuntary Hold for Medical Incapacity in an Academic Hospital: A Quality Improvement Project

WEBB FELLOW: Development and Implementation of an Involuntary Hold for Medical Incapacity in an Academic Hospital: A Quality Improvement Project

357 Implementation of a Behavioral Health Paramedic Program for Crisis Navigation

The heavy burden of behavioral and mental illness on emergency systems is a nationally and internationally recognized problem and can be exacerbated in communities with higher concentrations of people experiencing housing insecurity, psychiatric illness, and substance use disorders. In Alameda County, CA, about ten percent of all EMS encounters result in placement of an involuntary psychiatric hold. Further, patients who at some point required an involuntary hold due to acute exacerbations of their mental illness or substance use (10% of all EMS patients) accounted for a greatly disproportionate fraction (24%) of all EMS encounters.

Youths' and Young Adults' Experiences of Police Involvement During Initiation of Involuntary Psychiatric Holds and Transport.

Over the past decade, police involvement in behavioral health crisis response has generated concern and controversy. Despite the salience and timeliness of this topic, the literature on service user experiences of interactions with officers is small and studies of youths and young adults are nonexistent. The authors aimed to investigate youths' and young adults' experiences of police involvement in involuntary psychiatric hold initiation and transport. In-depth interviews were conducted with 40 participants (ages 16-27) who had experienced an involuntary hold; the 28 participants who reported police involvement are the focus of this analysis. Data were inductively coded, and codes were grouped into larger themes. A majority of participants reported negative experiences; major themes characterizing negative encounters were the framing of distress as criminal or of intervention as disciplinary rather than therapeutic, perceived aggression and callousness from police officers, and poor communication. The authors also characterized the positive experiences of officer involvement reported by a minority of participants and youths' perspectives on the degree of control officers could exert over initiation and transport decisions. Findings help center the voices of youths and young adults with mental health challenges and raise important questions about contemporary policies regarding police involvement in crisis response and, more broadly, about coercive responses to distress or emotional crisis.

Different Strokes for Impaired Folks: A Medical-Legal Case Report on Psychosis and Grave Disability following Cerebrovascular Accident

<h3>Introduction</h3> At least 30% of cerebrovascular accident (CVA) survivors suffer from neuropsychiatric symptoms as a direct sequela of their stroke, with poor long-term outcomes due to underdiagnosis and undertreatment. A 2018 systematic review of 76 studies looking at psychotic symptoms following stroke found an increased prevalence in delusional disorders, schizophrenia-like diagnoses, and mood disorders with congruent psychotic features. Right hemispheric lesions accounted for approximately 80% of patients demonstrating subsequent psychotic symptoms in studies with identification of lesion location. Among the many issues arising in management of these patients in addition to behavioral stabilization is decision-making concern should the patient be deemed gravely disabled. In this report, we present a case of a 58-year-old male with psychosis and mood disturbances following right-hemispheric ischemic stroke, and the resulting ethical and legal discussions regarding conservatorship and decision-making capacity. <h3>Methods</h3> Case report: this is the case of a 58-year-old male with psychiatric history of posttraumatic stress disorder, methamphetamine use disorder, cannabis use disorder and medical history pertinent for hypertension, hyperlipidemia, coronary artery disease, and dilated ischemic cardiomyopathy who was hospitalized for subacute onset of altered mental status following ischemic cerebrovascular accident. Magnetic resonance imaging (MRI) two weeks following initial vascular event confirmed right hemispheric ischemic stroke with subsequent hemorrhagic conversion. Additionally, in the two weeks after the initial vascular event, the patient had begun to exhibit significant behavioral changes mostly notable for an increase in psychotic and labile mood symptoms not previously present at patient's baseline mental status. These included auditory hallucinations, disorganized thinking and behavior, avolition, hypersexuality, emotional lability, irritability, and distractibility that persisted over the course of the following six weeks. He did not have a history of a bipolar disorder or a psychotic disorder, and had recently completed rehabilitation of polysubstance use at the West LA Veterans Administration Domiciliary. Urine drug screen was negative. Patient was managed by neurosurgery and neurology, with psychiatry consultation-liaison team providing recommendations for behavioral management. Psychiatry advised an involuntary hold for grave disability owing to patient's ongoing psychotic symptoms following medical stabilization. Of pertinent concern was the degree of to which patient's behavioral symptoms were interfering with his decision-making. Throughout the course of his hospitalization, patient needed repeated encouragement to participate in assessment, vitals, labs, and med administration, all of which he would refuse on a regular basis without appropriate reason. Bioethics review of patient's case affirmed that he lacked capacity to make major decisions regarding his healthcare and that his girlfriend, who held no legal status with relation to the patient, could serve as medical surrogate. Patient's refusal of medical intervention necessitated psychiatry consultation team to file a petition for prolonged involuntary hold as well as court-ordered medication administration. The patient's psychosis was initially managed with increased doses of his home aripiprazole (30mg), which was later tapered and cross-titrated with risperidone (5mg) for management of his psychotic symptoms and impulse control. Following stabilization of acute medical concerns, patient was subsequently transferred to psychiatric unit for persistent psychosis and for continued psychotropic medication management as well as assessment of legal and social status. <h3>Results</h3> N/a, case report. See ‘Conclusion' for discussion of case outcome. <h3>Conclusions</h3> The patient's condition ultimately improved to the point of being able to participate in a capacity declaration, designate a durable power of attorney, and forego the need for probate conservatorship. He continues to be seen by psychiatry for ongoing management of his mood, posttraumatic stress disorder, and mild cognitive impairment stemming from vascular insult. Management of psychiatric and behavioral symptoms following stroke continues to be an important component of the post-cerebrovascular vascular accident treatment plan. In particular, contingency plans need to be anticipated preventively in patients who may have higher risk of considerable decompensation following cerebrovascular stroke. In this particular case, the patient carried several premorbid psychiatric, vascular, and social risk factors that converged into a challenging management scenario post-CVA. Continued assessment and stratification of patients with these types of risk factors should continue to be an essential component to management of the geriatric patient. <h3>Funding</h3> None.

Older adults on involuntary hold status in the emergency department.

As the United States' population ages, the health care system will experience overall change. This study aims to identify factors in the older adult that may contribute to involuntary hold status in the ED. This study is a retrospective review conducted at a suburban acute-care hospital ED of adult patients evaluated while on involuntary hold from January 1, 2014, through November 30, 2015. Older adults (patients born on or before 06/31/1964) were compared to younger adults (born on or after 07/01/1964) according to demographic and clinical variables including medical comorbidity, ED length of stay, reason for involuntary hold, psychiatric disorder, suicide attempt, substance use disorder, serum alcohol level, urine drug testing, medical comorbidity, violence in the ED, 30-day ED readmission, and 30-day mortality. Of 251 patients, 90 (35.9%) were older adults. The most common reason for involuntary hold in both cohorts was suicidal ideation. Medical comorbidities were more prevalent in older adults [60 (66.7%) vs. 64 (39.8%), P≤.0001]. Older adults were less likely to report current drug abuse [31 (34.4%) vs. 77 (47.8%), P=.04]. The most commonly misused substance in both groups was alcohol; however, despite similar rates, blood alcohol levels (BAC) and urine drug screen (UDS) were performed less often in older adults. Cohorts were not significantly different with respect to sex, race, violence in the ED, psychiatric diagnosis, and ED LOS. Involuntary older adult patients present with medical comorbidities that impact mental health. In the ED, they are less likely report substance use, and drug screening may be underutilized. Medical needs make their care unique and may present challenges in transfer of care to inpatient psychiatric facilities.

178 Behavioral Emergencies, Involuntary Holds, and Restraint Use Among Pediatric Patients Transported by Emergency Medical Services in Alameda County, 2011-2016

Emergency department (ED) visits for behavioral emergencies are common in the United States, and approximately 74% arrive by ambulance. However, national datasets provide little insight into details of out-of-hospital management of these emergencies. In Alameda County, CA, police and EMS respond to most behavioral health crises. Although ambulances transport most children to a general ED for medical clearance, Alameda County EMS workers use a screening protocol to identify a subset of children over age 12 that may be directly transported to a pediatric psychiatric emergency service. We aimed to describe the patients, visits, and safety outcomes associated with these behavioral emergency ambulance encounters. We obtained data for all pediatric (age<18) EMS encounters between November 1, 2011, and November 1, 2016, using Alameda County’s standardized data set. After unique patient identification and linkage to data from Alameda County Vital Statistics, we describe the dataset at the patient level and at the encounter level. During the study period, EMS treated 29,123 unique patients, and 17.2 % (N=5,022) had at least one behavioral emergency. 554 patients were transported 3 or more times, and accounted for 35% (N=2,771) of all behavioral emergency encounters. There were 6 deaths (0.1%) among children transported for at least one behavioral emergency, but none were within 60 days of a visit for a behavioral emergency. The median age for a behavioral health emergency was 15.1 (IQR: 13.1 - 16.6). There were a total of 37,888 total EMS encounters, and 21.0% (N=7,938) were for behavioral emergencies, making them the second most common reason for ambulance transport after traumatic injuries (25.1%, N=9,506). Behavioral emergencies frequently occured at home (44.4%), at school (30.8%), and in a number of other public places (24.9%). Overall, 6.9% of children were placed in handcuffs by police prior to EMS arrival, and 15.3% of patients were placed in physical restraints during transport. Behavioral emergency transports originating at school resulted in a lower rate of physical restraint placement by EMS (9.0%) as compared to those originating at home (15.6%, RR: 1.7, 95% CI: 1.5 - 2.0) or in other public locations (22.5%, RR: 2.5, 95% CI: 2.1 - 2.9).2,941 (37.0%) behavioral emergency encounters met protocol criteria and were transported directly to the pediatric psychiatric emergency service. From a safety perspective, only 13 (0.4%) patients had a secondary transport to a general ED within 12 hours of arrival to the psychiatric facility. None of these patients required any critical EMS intervention. Behavioral health emergencies are the second most common reason for transport of pediatric patients. Direct transportation to a pediatric psychiatric emergency service is safe, and the need for general ED transport for all patients is likely unnecessary. Even in the long-term, death is rare in pediatric patients after EMS transport for a behavioral emergency. Use of handcuffs and restraints by police and EMS is common, but varies based on the location in which the emergency occurred. Further research should be conducted to better understand the out-of-hospital management of pediatric behavioral emergencies.

Telemedicine is associated with rapid transfer and fewer involuntary holds among patients presenting with suicidal ideation in rural hospitals: a propensity matched cohort study

ObjectiveThe purpose of this study was to evaluate the impact of telemedicine in clinical management and patient outcomes of patients presenting to rural critical access hospital emergency departments (EDs) with...

Patients Threatening Harm to Others Evaluated in the Emergency Department under the Florida Involuntary Hold Act (Baker Act).

This study describes the specific threats of harm to others that led to the use of the Baker Act, the Florida involuntary hold act for emergency department (ED) evaluations. The study also summarizes patient demographics, concomitant psychiatric diagnoses, and emergent medical problems. This is a retrospective review of 251 patients evaluated while on involuntary hold from January 1, 2014 through November 30, 2015 at a suburban acute care hospital ED. The data that were collected included demographic information, length of stay, reason for the involuntary hold, psychiatric disorder, substance use, medical illness, and violence in the ED. The context of the homicidal threat also was collected. We found that 13 patients (5.2%) were homicidal. Three patients had homicidal ideations alone, whereas 10 made homicidal threats toward others. Of the 10 making homicidal threats, 7 named a specific person to harm. Ten of the 13 homicidal patients (76.9%) also were suicidal. Eleven patients (84.6%) had a psychiatric disorder: 9 patients (69.2%) had a depressive disorder and 8 patients (61.5%) had a substance use disorder. Eight patients had active medical problems that required intervention in the ED. We found that three-fourths of patients expressing homicidal threats also were suicidal. The majority of patients making threats of harm had a specific plan of action to carry out the threat. It is important to screen any patient making homicidal threats for suicidal ideation. If present, there is a need to implement immediate management appropriate to the level of the suicidal threat, for the safety of the patient. Eighty-five percent of patients making a homicidal threat had a previously documented psychiatric disorder, the most common being a depressive disorder. This finding differs from previous studies in which psychosis predominated. More than 60% of homicidal patients had an unrelated medical disorder requiring intervention. It is important not to overlook these medical disorders while focusing on the psychiatric needs of the patient; most of our homicidal patients proved to be cooperative in the ED setting.

Comparison of youth suicide with involuntary hold criteria and inpatient capacity

BackgroundBoarding in emergency departments pending psychiatric admission significantly impacts both the patient and system. Current recommendations suggest increasing available inpatient beds, yet involuntary psychiatric admissions have not been widely correlated with improved patient outcomes. MethodsWe compared state-by-state youth suicide data clustered into 3-year intervals from 1999 to 2016 to psychiatric inpatient bed numbers and stringency on involuntary hold criteria using Poisson regression models. ResultsNo significant association was found between suicide rates and bed availability or hold criteria. ConclusionsWhile individual holds can be valuable in prevention of danger to self, on a population basis, the incident rate ratio of inpatient bed number and that of stringency of hold criteria was not significant when relevant variables were controlled. A focus on preventative strategies is imperative, given the equipoise for this current avenue of treatment.

Discontinuing involuntary mental health holds for children: Does psychiatrist specialty matter? A pilot study

BackgroundInvoluntary mental health detainments should only be utilized when less restrictive alternatives are unavailable and should be discontinued as soon as safety can be ensured. The study objective was to determine if child and adolescent psychiatrists discontinue a greater proportion of involuntary holds than general psychiatrists for similar pediatric patients. MethodsRetrospective analysis of consecutive patients under 18 years placed on an involuntary hold in the prehospital setting presenting over a 1-year period to one high-volume emergency department (ED) where youth on involuntary holds are seen by child and adolescent psychiatrists when available and general psychiatrists otherwise. The primary outcome of interest was hold discontinuation after initial psychiatric consultation. The key predictor of interest was psychiatrist specialty (child and adolescent vs. general). We conducted multivariate logistic regression modeling adjusting for patient characteristics and time of arrival. ResultsChild and adolescent psychiatrists discontinued 27.4% (51/186) of prehospital holds while general psychiatrists discontinued only 10.6% (22/207). After adjusting for observable confounders, holds were over 3 times as likely to be discontinued in patients evaluated by child and adolescent psychiatrists rather than general emergency psychiatrists (adjusted OR 3.2, 95% CI 1.7–5.9, p < 0.001). ConclusionsChild and adolescent psychiatrists are much more likely to discontinue prehospital involuntary mental health holds compared with general emergency psychiatrists. While inappropriate hold discontinuation places patients at risk of harm, prolonged hold continuation limits patients' rights and potentially increases psychiatric boarding in EDs. Earlier access to child and adolescent psychiatry may facilitate early hold discontinuation and standardize patient care.

Involuntary patient length-of-stay at a suburban emergency department

BackgroundPatients who may be a danger to themselves or others often are placed on involuntary hold status in the Emergency Department (ED). Our primary objective was to determine if there are demographic and/or clinical variables of involuntary hold patients which were associated with an increased ED LOS. MethodsRecords of ED patients evaluated while on involuntary hold from January 1, 2014 through November 30, 2015 at a suburban acute-care hospital ED were reviewed. Data collected included demographics information, LOS, suicidal or homicidal ideation, suicide attempt, blood alcohol concentration (BAC), urine drug test (UDT), psychiatric disorder, substance use, medical illness, violence in the ED, and hospital admission. Linear regression based on the log of LOS was used to identify factors associated with increased LOS. ResultsTwo-hundred and fifty-one patients were included in the study. ED LOS (median) was 6 h (1, 49). Linear regression analysis showed increased LOS was associated with BAC (p = 0.05), urine drug test (UDT) (p = 0.05) and UDT positive for barbiturates (p = 0.01). There was no significant difference in ED LOS with respect to age, gender, housing, psychiatric diagnosis, suicidal or homicidal ideation, suicide attempt, violence, medical diagnosis, or admission status. ConclusionsInvoluntary hold patients had an increased ED LOS associated with alcohol use, urine drug test screening, and barbiturate use. Protocol development to help stream-line ED evaluation of alcohol and drug use may improve ED LOS in this patient population.

Patients on Involuntary Hold Status in the Emergency Department.

Patients requiring involuntary holds are frequently seen in the emergency department (ED). Much of what is known comes from studies of patients at urban academic centers. Our aim was to describe the demographic and clinical characteristics of patients who were evaluated while on involuntary status at a suburban ED. The medical records of patients seen in the ED requiring involuntary hold status between January 1, 2014 and November 30, 2015 were reviewed. Demographic and clinical variables including medical and psychiatric comorbidity were collected. A subanalysis was performed comparing patients who attempted suicide with all other involuntary patients. Two hundred fifty-one patient records were reviewed; 215 patients (85.3%) had psychiatric disorders-depression was the most common (57%)-and 108 patients (43%) had substance use disorders. Only 13 patients (5.2%) had neither a psychiatric disorder nor a history of substance use. Twenty-two patients (8.8%) were violent in the ED. Thirteen patients (5.2%) were readmitted, and 1 patient died within 30 days of discharge from the ED. One hundred twenty-four patients (49.4%) had medical disorders. Suicidal ideation was the most common reason for involuntary hold (n = 185, 73.7%); 63 patients (25.1%) attempted suicide. Compared with other involuntary patients, the patients who attempted suicide were less likely to use opiates (odds ratio 0.27, 95% confidence interval 0.08-0.94, P = 0.04) and to have medical disorders (odds ratio 0.52, 95% confidence interval 0.28-0.98, P = 0.04). Patients in this study differed from those in urban centers with respect to sex and psychiatric disorder; however, substance misuse was common in both settings. Suicidal ideation including suicide attempt was the most common reason for involuntary status. Patients who attempted suicide were similar to other patients on involuntary hold with respect to demographic and clinical variables.

Management of a stable atlas fracture in a patient with comorbid schizophrenia and alcohol use disorder

To our knowledge, there are no existing case reports documenting how to treat a fracture of the high cervical spine in a nonadherent patient. In this case report, we present an adult male with longstanding diagnoses of schizophrenia and alcohol use disorder who originally presented with neck pain after a fall due to alcohol intoxication. He had already been placed in a cervical neck brace (C-collar) at presentation. Preliminary imaging revealed a fracture of the left lateral mass of C1 extending into the left transverse process of the odontoid, without significant widening of the joint, no involvement of the dens, and no vascular compromise. The C-collar remained in place and the patient was transferred to the intensive care unit (ICU) for monitoring of his fracture and alcohol withdrawal. The patient was admitted to the psychiatric unit nine days later through an involuntary hold to ensure proper initial care for the atlas fracture and address his primary psychotic disorder. The patient was ultimately lost to follow up. Because of the sensitive nature of the fracture, and the nonadherence of the patient due to his comorbid schizophrenia and alcohol use, orthopedic surgeons instituted a unique care plan to best suit this individual patient’s needs. In the management of stable high cervical fractures in patients with questionable adherence, conservative measures are more safe, plausible, and effective than surgical intervention.

Emergency Medical Services Use Among Patients Receiving Involuntary Psychiatric Holds and the Safety of an Out-of-Hospital Screening Protocol to “Medically Clear” Psychiatric Emergencies in the Field, 2011 to 2016

Patients with acute psychiatric emergencies who receive an involuntary hold often spend hours in the emergency department (ED) because of a deficit in inpatient psychiatric beds. One solution to address the lack of prompt psychiatric evaluation in theED has been to establish regional stand-alone psychiatric emergency services. However, patients receiving involuntary holds still need to be screened and evaluated to ensure that their behavior is not caused by an underlying and life-threatening nonpsychiatric illness. Although traditional regional emergency medical services (EMS) systems depend on the medical ED for this function, a field-screening protocol can allow EMS to directly transport a substantial portion of patients to a stand-alone psychiatric emergency service. The purpose of this investigation is to describe overall EMS use for patients receiving involuntary holds, compare patients receiving involuntary holds with all EMS patients, and evaluate the safety of field medical clearance of an established field-screening protocol in Alameda County, CA. We obtained data for all EMS encounters between November 1, 2011, and November 1, 2016, using Alameda County's standardized data set. After unique patient identification, we describe the data at the patient level and at the encounter level. At the patient level, we compare "involuntary hold patients" (≥1 involuntary hold during the study period) with those who were "never held." Additionally, we assess the safety of out-of-hospital medical clearance by calculating the rate of failed diversion, defined as retransport of a patient to a medical ED within 12 hours of transport to the psychiatric emergency services by EMS. Of the 541,731 total EMS encounters in Alameda County during the study period, 10% (N=53,887) were identified as involuntary hold encounters. Of these involuntary hold patient encounters, 41% (N=22,074) resulted in direct transport of the patient to the stand-alone psychiatric emergency service for evaluation; 0.3% (N=60) failed diversion and required retransport within 12 hours. At the patient level, Alameda County EMS encountered 257,625 unique patients, and 10% (N=26,283) had at least one encounter for an involuntary hold during the study period. These "involuntary hold patients" were substantially younger, more likely to be men, and less likely to be insured. Additionally, they had higher overall EMS use: "involuntary hold patients" accounted for 24% of all encounters (N=128,003); 53,887 of these encounters were for involuntary holds, whereas an additional 74,116 were for other reasons. Similarly, 4% of "involuntary hold patients" had 20 or more encounters, whereas only 0.4% of "never held" patients were in this category. Last, the 7% of "involuntary hold patients" (N=1,907) who received greater than or equal to 5 involuntary holds during the study period accounted for 39% of all involuntary holds and 9% of all EMS encounters. Ten percent of all EMS encounters were for involuntary psychiatric holds. With an EMS-directed screening protocol, 41% of all such patient encounters resulted in direct transport of the patient to the psychiatric emergency service, bypassing medical clearance in the ED. Overall, only 0.3% of these patients required retransport to a medical ED within 12 hours of arrival to psychiatric emergency services. We found that 24% of all EMS encounters in Alameda County were attributable to "involuntary hold patients," reinforcing the importance of the effects of mental illness on EMS use.

Case-controlled Analysis of Patient-based Risk Factors for Assault in the Healthcare Workplace.

IntroductionViolence against healthcare workers in the medical setting is common and associated with both physical and psychological adversity. The objective of this study was to identify features associated with assailants to allow early identification of patients at risk for committing an assault in the healthcare setting.MethodsWe used the hospital database for reporting assaults to identify cases from July 2011 through June 2013. Medical records were reviewed for the assailant’s (patient’s) past medical and social history, primary medical complaints, ED diagnoses, medications prescribed, presence of an involuntary psychiatric hold, prior assaultive behavior, history of reported illicit drug use, and frequency of visits to same hospital requesting prescription for pain medications. We selected matched controls at random for comparison. The primary outcome measure(s) reported are features of patients committing an assault while undergoing medical or psychiatric treatment within the medical center.ResultsWe identified 92 novel visits associated with an assault. History of an involuntary psychiatric hold was noted in 52%, history of psychosis in 49%, a history of violence in the ED on a prior visit in 45%, aggression at index visit noted in the ED chart in 64%, an involuntary hold (or consideration of) for danger to others in 61%, repeat visits for pain medication in 9%, and history of illicit drug use in 33%. Compared with matched controls, all these factors were significantly different.ConclusionPatients with obvious risk factors for assault, such as history of assault, psychosis, and involuntary psychiatric holds, have a substantially greater chance of committing an assault in the healthcare setting. These risk factors can easily be identified and greater security attention given to the patient.

Violent behavior by emergency department patients with an involuntary hold status

BackgroundViolence against health care workers has been increasing. Health care workers in emergency departments (EDs) are highly vulnerable because they provide care for patients who may have mental illness, behavioral problems, or substance use disorders (alone or in combination) and who are often evaluated during an involuntary hold. Our objective was to identify factors that may be associated with violent behavior in ED patients during involuntary holds. MethodsRetrospective review of patients evaluated during an involuntary hold at a suburban acute care hospital ED from January 2014 through November 2015. ResultsOf 251 patients, 22 (9%) had violent incidents in the ED. Violent patients were more likely to have a urine drug screen positive for tricyclic antidepressants (18.2% vs 4.8%, P=0.03) and to present with substance misuse (68.2% vs 39.7%, P=0.01), specifically with marijuana (22.7% vs 9.6%, P=0.06) and alcohol (54.5% vs 24.9%, P=0.003). ED readmission rates were higher for violent patients (18.2% vs 3.9%, P=0.02). No significant difference was found between violent patients and nonviolent patients for sex, race, marital status, insurance status, medical or psychiatric condition, reason for involuntary hold, or length of stay. ConclusionViolent behavior by patients evaluated during an involuntary hold in a suburban acute care hospital ED was associated with tricyclic antidepressant use, substance misuse, and higher ED readmission rates.

State Laws on Emergency Holds for Mental Health Stabilization.

Psychiatric emergency hold laws permit involuntary admission to a health care facility of a person with an acute mental illness under certain circumstances. This study documented critical variation in state laws, identified important questions for evaluation research, and created a data set of laws to facilitate the public health law research of emergency hold laws' impact on mental health outcomes. The research team built a 50-state, open-source data set of laws currently governing emergency holds. A protocol and codebook were developed so that the study may be replicated and extended longitudinally, allowing future research to accurately capture changes to current laws. Although every state and the District of Columbia have emergency hold laws, state law varies on the duration of emergency holds, who can initiate an emergency hold, the extent of judicial oversight, and the rights of patients during the hold. The core criterion justifying an involuntary hold is mental illness that results in danger to self or others, but many states have added further specifications. Only 22 states require some form of judicial review of the emergency hold process, and only nine require a judge to certify the commitment before a person is hospitalized. Five states do not guarantee assessment by a qualified mental health professional during the emergency hold. The article highlights variability in state law for emergency holds of persons with acute mental illness. How this variability affects the individual, the treatment system, and law enforcement behavior is unknown. Research is needed to guide policy making and implementation on these issues.

Understanding and helping people with hallucinations based on the theory of negative legacy emotions.

This article applies the new concept of negative legacy emotions to understanding and helping people suffering with psychosis and hallucinations. The theory of negative legacy emotions proposes that guilt, shame, and anxiety result from biological evolution, specifically to inhibit human self-assertion, willfulness, and aggression in personal and family relationships. Because human beings are so violent, the species would have destroyed itself if natural selection had not favored individual humans with inhibitory or restraining emotional reactions in personal relationships. Unfortunately, negative legacy emotions are crude responses that can worsen aggression and fail to provide adequate guidelines for ethical adult living. Hallucinations share many qualities with guilt, shame, and anxiety, including a seemingly involuntary hold over individuals, making them compliant with them. Painful or disabling hallucinations are driven by guilt, shame, or anxiety. Rather than viewing hallucinations as essentially pa...