We Need to Rethink Involuntary Hospitalization during This Pandemic

For millions of Americans detained by law, the COVID-19 pandemic may be especially distressing. As of April 8, more than 1,300 COVID-19 cases had been reported at jails and prisons in the U.S., raising questions about the rights of people who have limited ability to protect themselves from infection. Policy makers have explored different options to prevent the spread of coronavirus in correctional facilities, including eliminating cash bail, reducing arrest rates and releasing people early who were incarcerated for non-violent crimes.

Yet there is another population of Americans who may be detained under law and face risks related to COVID-19: patients held in psychiatric units.

Every state in the United States has laws that authorize involuntary psychiatric hospitalization in specific situations, most often when someone poses a danger to self or others because of mental illness. It’s difficult to know how many people are held for psychiatric care at a given time, although estimates suggest more than one million involuntary psychiatric detentions take place each year in the United States.

Involuntary hospitalization can be lifesaving for patients grappling with suicidal thoughts, delusions, mania or other symptoms of mental illness, and not all people brought to emergency departments under these laws are admitted against their wishes. Some patients might decide they want to receive care and ask to be admitted on a voluntary basis. In other cases, health professionals in emergency departments evaluate patients, help address their symptoms, and set up community supports that enable patients to obtain care outside of hospitals.

Still, the COVID-19 pandemic has worrisome implications for patients needing involuntary psychiatric care.

Patients with serious mental illness are already part of a vulnerable population that may be grappling with unstable housing, poverty, addiction, other medical conditions and limited health literacy. As a result, they may be at increased risk for acquiring and developing complications from COVID-19. Further, the set-up of inpatient psychiatry units, which typically includes open interactions between patients and staff, group therapy and communal meals, could increase the risks of infectious disease transmission. According to one estimate, there had been more than 1,450 COVID-19 cases in state mental health facilities across 23 states and the District of Columbia as of April 16. Other countries, such as Canada, China and South Korea, have also grappled with COVID-19 outbreaks in mental health facilities.

When our laws bring people against their will into hospitals, we all have a duty to protect these patients, particularly during a pandemic.

First, mental health facilities can take steps to protect patients and staff from COVID-19. Decreasing the risks of infectious disease transmission requires comprehensive measures, such as encouraging handwashing, practicing physical distancing, providing masks to patients and staff, limiting in-person group therapy, screening patients and staff for COVID-19 symptoms, asking staff with symptoms to stay home and expanding testing for patients and staff in these settings. Since psychiatry units may be particularly susceptible to infectious disease outbreaks, staff should weigh these risks when considering admitting patients and discharge patients as soon as can be safely done. Patients who test positive may need to be temporarily transferred to separate units to decrease risks of viral transmission.

Second, we need to be vigilant about protecting patients’ rights during this pandemic. Hospitals are banning visitors to reduce infection risks, but patients who lean on family and friends for support might struggle to recover, to understand their treatment, or to make informed decisions about their care. Similarly, mental health advocates may not be able to meet with patients in person, which could impede patients’ access to legal counsel during involuntary hospitalization. Hospitals should set up telephone and videoconferencing options not only so patients can communicate with loved ones, but also for coordinating legal proceedings with courts.

Third, supporting access to mental health services during this pandemic is key. Some mental health systems, such as the California Department of State Hospitals, have recently suspended admissions and discharges for patients. Some community facilities and programs will not accept patients unless they have negative SARS-CoV-2 tests upon discharge from hospitals. While potentially limiting the spread of COVID-19, these policies could exacerbate shortages of psychiatric beds, prolong emergency department waits for patients who need admission, or prevent discharge for patients no longer needing hospitalization.

Expanding reimbursement and use of telepsychiatry may be one way to help. By providing ongoing psychotherapy, medication access or case management for people in the community, telepsychiatry might help keep them well and out of hospitals. Although less well studied in hospital settings, telepsychiatry in hospitals could facilitate access to mental health professionals in emergency departments, prevent unnecessary admissions and support treatment on psychiatric units while limiting in-person interactions.

Mental health care is too often under-resourced and ignored, and COVID-19 will place further strain on these systems. Patients receiving involuntary psychiatric care are especially vulnerable during this pandemic, and we need to act quickly to support them.



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