Oct 23, 2019
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
- This week in Psychiatry (00:37)
- Masterclass lecture (02:00)
- Dr. RK (40:50)
This week in Psychiatry:
Duloxetine 'sprinkle' launches
for patients with difficulty swallowing
by Christopher Palmer
Drizalma Sprinkle (duloxetine delayed-release capsule) has
launched for the treatment of various neuropsychiatric and pain
disorders in patients with difficulty swallowing.
Overview of the involuntary commitment
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
- Second, as involuntary beds decrease, there is no place for
- 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
- The final controversy addresses a patient’s right to refuse
treatment with medication.
Groups hold wide-ranging positions along policy
- 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
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
stance in support of outpatient commitment on a limited
- 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
- 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
- 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.
- 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
- Involuntary care would be less necessary if voluntary care were
easier to access earlier in an illness to avoid crisis and
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.
(Edgmont). 2010 Oct;7(10):30-40.
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