Repair the system used to institutionalize people with psychiatric illness

THIS should be a no-brainer. An idea that could save money for Washington State, make it a much safer state, and allow us to more adequately care for people with severe mental illness: Repair the broken legal system used to commit people with psychiatric illness.

As a psychiatrist and administrator working on both sides of this system (in outpatient community mental health and in involuntary psychiatric hospitals) for 20 years, I've seen both sides of the legal system that gets and keeps people detained. It's in serious need of revision.

In my hospital, at least half of all patients who are committed against their will are discharged by the court against medical advice. Many of these people are very ill, still psychotic and often likely to quickly become a danger to society, their families and themselves. Poignantly, from the outpatient side of the equation because the criteria are so stringent to get people committed, it can take a great deal of time and courage for their families to get them detained in the first place. To see them back where they started — often in three days — is exasperating and heartbreaking.

It's also an incredible waste of money. People discharged against medical advice are often back in the hospital within days if not weeks. This takes resources from law enforcement, jails, hospitals, ambulances and county mental-health professionals, but more than that, it exposes the community to senseless and unpredictable acts of harassment, vandalism and violence. Read the papers. We shouldn't have to wait for a tragedy to fix this system.

There are some studies under way to look at the system. But it needs a great deal of public support to make change happen and to happen sufficiently. Here are a few of my suggestions:

First, stretch out the time of initial commitment from 72 hours to five days, as they do in Oregon, or even a week. Our system was set up as a zealous way to protect the civil rights of people with mental illness (or of those falsely accused of it). Yet, it seems to have gone overboard and is actually violating the rights of people who cannot think rationally in getting the help they need. The days of psychiatric hospitals readily housing the mentally ill against their will for years are as much a relic of the past as female nurses wearing white dresses and hats. The government would do better to involve themselves in overseeing hospital quality and lengths of stay, putting less emphasis on judges and prosecutors who are making what amounts to medical decisions.

Second, implement an outpatient commitment system, so that patients can be more adequately cared for in the community without the only option being hospitalization.

Third, change the criteria — the legal threshold — for civil commitment. For instance, make it less stringent to detain people with psychiatric illness who are dangerous to others, say if they are clearly dangerous but haven't made specific threats or if they kill an animal. Allow more flexibility and deference to treatment teams in hearings about whether to keep someone hospitalized longer, for example, if they are still hostile and potentially a menace but have made no specific threats or acts while in the hospital; or they cannot be discharged without a reasonable place to live or professional follow-up in order to prevent predictable decompensation. Also lessen the criteria for "grave disability" (where someone cannot care for their health and safety) so that they don't have to be so severely incapacitated, in such an immediate risk of death, to be detained.

The offset to increased lengths of hospital stays would be that people would stay out longer — allowing this revolving door to slow down. Savings, safety and quality: a change long overdue.

Jeff Skolnick, MD, PhD., is a psychiatrist working at Navos Psychiatric Hospital in Seattle. The opinions expressed are his and not necessarily those of Navos