State lawmakers are considering legislation to repair the under-resourced process by which doctors have the authority to hold a person against their will for emergency psychiatric treatment.
House Bill 1013, already passed by the House, would assemble a task force to address the lack of infrastructure and mental health specialists who treat patients for involuntary psychiatric hospitalizations. It is now being deliberated in the Senate.
Colloquially referred to as an MH-1, involuntary emergency psychiatric treatments occur when police transport people considered to pose a danger to themselves or others — but have not committed a crime — to a hospital to receive care. These patients — either mentally ill or in a state of crisis — cannot be held against their will by doctors for more than 48 hours.
Often these interventions are inadequate.
A report published last year through collaboration of the Honolulu Police Department and health care agencies shows that hundreds of so-called MH-1 patients on Oahu go on to experience repeated hospitalizations and brushes with law enforcement, sometimes just days after their release.
The report’s conclusion: People with the most severe cases of mental illness aren’t getting the help they need. Instead, they are funneled through a revolving door of short-term hospitalizations.
The doctor’s job in these situations is to pull the patient out of the throes of crisis. But for people with persistent mental illness, it can be all too easy to fall back into crisis again.
The issue is further complicated by the fact that many of these patients are adamant in their refusal of mental health services.
Each time a mental health intervention falls short, research shows the person becomes sicker, more difficult to treat and more likely to engage in serious criminal behavior.
Meanwhile, repeat MH-1 patients are overwhelming emergency medicine departments. And they are raising questions about the state’s lack of mental health resources, as well as the merits of protecting a person’s civil liberty to refuse psychiatric treatment — even when they’re too sick to recognize they are suffering from mental illness.
“If we feel they have insight and awareness to make decisions, then we can’t forcefully hold them against their will — even if they have chronic mental illness and they’re always delusional,” said Howie Klemmer, chief of emergency medicine at The Queen’s Medical Center.
“It’s a free country, you’re allowed to think what you want to think and you’re allowed to do what you want to do, as long as you don’t break laws.”
In one remarkable example, a woman was struck and killed by a pickup last summer while walking in the middle of the fast lane on Interstate H-2. Her death occurred less than two weeks after police hospitalized her against her will for wandering around naked and shouting about demons in the middle of a congested road.
Although cases that end in death are rare, many situations risk the safety of the public or the person who’s sick.
The challenge, according to Institute for Human Services Clinical Director Jerry Coffee, is finding a way to provide patients with substantial treatment despite a lack of resources and a legal environment that prohibits doctors from treating people without their consent for longer than two days. In many cases, he said, doctors are releasing people on the brink of reverting to crisis.
“They’ll give them a shower, give them an egg salad sandwich, give them a Gatorade and as soon as they contract for safety and they get linear and they get rehydrated, they say, ‘I don’t want any services,’ and the hospital will let them go,” Coffee said. “That’s typically what happens.”
In HB 1013, lawmakers are seeking to improve access to treatment under the MH-1 process for people who either have a mental illness or are in a state of crisis while reducing the number of patients admitted for emergency psychiatric care who could more appropriately be served by another hospital unit.
The task force that would examine this and other problems with the MH-1 process would include in its membership state Health Director Bruce Anderson, Hawaii Attorney General Clare Connors, Dean of the John A. Burns School of Medicine Jerris Hedges, the chief of police for each county, key lawmakers and mental health advocates.
In 2018, Queen’s hospital admitted more than 1,700 MH-1 patients for mental health evaluations. Approximately 85 percent of them did not require specialized psychiatric treatment and could have been seen by another emergency department, according to testimony to lawmakers last month.
Queen’s treats more MH-1 patients than anywhere else in the state, but it has only six psychiatric beds in its emergency department.
“Although we have six dedicated patient rooms for treating those with psychiatric illnesses,” Queen’s executive vice president Paula Yoshioka said in written testimony, “we have experienced times when these rooms were full, leaving us to find space in our (emergency department) to evaluate and treat. This creates an unsafe environment and stresses an already over-capacity (emergency department) that the community relies on.”
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