Health promotion

1.  What are the key components to promoting good mental health in individuals, families, and communities?  As you think about these key components, address the issue from one of the three viewpoints below.  Include evidence-based support and guidance in your response.

• If you are an FNP currently providing full-spectrum primary care across the lifespan how do you feel your practice will change as a PMHNP in regards to assuring adequate health promotion, preventive medicine, health protection, anticipatory guidance, counseling, and disease management working with those with mental health issues including those who are severely mentally ill, pregnancy, pediatrics, geriatrics, adults and those with substance abuse issues? What do you envision the barriers to preventive medicine will be and how could you work to enhance primary care/preventive medicine services for your patient population?
• If you are a WHNP, CNM, APN, GNP, or PNP who has predominantly practiced within one specialty area how do you envision integrating full-spectrum care to both men and women providing adequate health promotion, preventive medicine, health protection, anticipatory guidance, counseling and disease management working with those with mental health issues including those who are severely mentally ill, pregnancy, pediatrics, geriatrics, adults, and those with substance abuse issues? What do you envision the barriers to preventive medicine will be and how could you work to enhance primary care/preventive medicine services for your patient population?
• If you are an RN who is not in an advanced practice role, why do you think it is important for a PMHNP to have an eye on health promotion, preventive medicine, health protection, anticipatory guidance, counseling & disease management of mental health issues as well as physical health needs.   How do you feel you could stay up to date with those areas of primary care when your primary focus is psychiatry? 

Step 2:

Look over the following article to identify some important parameters of the involuntary emergency admission process for your state.   You will also look at your IEA process in-depth in the next step.  This article outlines the parameters of involuntary commitment:  

State Laws on Emergency Holds for Mental Health Stabilization

Download State Laws on Emergency Holds for Mental Health Stabilization

Step 3: 

From time to time, patients with severe mental health issues may require a higher level of care than can be provided in the community setting.  This may require the implementation of the emergency admission process.  

It is important to understand the IEA process in your state,  When you are in a crisis situation, you may have to respond quickly to the patient’s need for safety and you will not have time to look up the process for involuntary emergency admission (IEA).  The purpose of this assignment is for you to investigate the process, understand how to initiate the process, and understand the consequences of involuntary commitment in your state.  Please respond to the items below and keep this information as a reference when you begin to practice. 

USE THIS TEMPLATE to record your information

Download USE THIS TEMPLATE to record your information

• Outline the process for involuntary emergency admission, starting with the identification of a patient at risk who is in need of emergency mental health services all the way through admission to the facility, treatment, and discharge.  
• What types of situations would necessitate the initiation of the involuntary emergency admission process?
• What are the resources for follow-up after the patient has been released?  Give an example of how you would implement a health promotion plan for the patient who returns to the community.
• What are your thoughts on the IEA process in your state? Do you think it is reasonable, necessary, and accessible?
• How could you apply the TeamSTEPPS Model before, during, or after commitment to facilitate the best care for the patient? Remember to refer to your readings on TeamSTEPPS to give you some guidance on making your team choices.
• Identify a culture other than your own and discuss the implications of receiving a mental health diagnosis as well as being admitted to a psychiatric facility based on their cultural view of mental health/mental illness.

Health Promotion and the Involuntary Emergency Commitment Process

STATE: _____________________

Health promotion is important in helping patients stay in the community and participate in their care. However, there are times when stress and other factors become too overwhelming for the patient and a higher level of care is required to promote safety and wellness for the patient. This is where the involuntary emergency commitment process may be helpful.

It is important to understand the IEA process in your state. When you are in a crisis situation, you may have to respond quickly to the patient’s need for safety and you will not have time to look up the process. The purpose of this assignment is for you to investigate the process, understand how to initiate the process, and understand the consequences of involuntary commitment in your state.

Please respond to the items below.

1. What are the key components to promoting good mental health in individuals, families, and communities?  As you think about these key components, address the issue from 
one of the three viewpoints below.  Include evidence-based support and guidance in your response.

·
If you are an FNP currently providing full-spectrum primary care across the lifespan how do you feel your practice will change as a PMHNP in regards to assuring adequate health promotion, preventive medicine, health protection, anticipatory guidance, counseling, and disease management working with those with mental health issues including those who are severely mentally ill, pregnancy, pediatrics, geriatrics, adults and those with substance abuse issues? What do you envision the barriers to preventive medicine will be and how could you work to enhance primary care/preventive medicine services for your patient population?

·
If you are a WHNP, CNM, APN, GNP, or PNP who has predominantly practiced within one specialty area how do you envision integrating full-spectrum care to both men and women providing adequate health promotion, preventive medicine, health protection, anticipatory guidance, counseling and disease management working with those with mental health issues including those who are severely mentally ill, pregnancy, pediatrics, geriatrics, adults, and those with substance abuse issues? What do you envision the barriers to preventive medicine will be and how could you work to enhance primary care/preventive medicine services for your patient population?

·
If you are an RN who is not in an advanced practice role, why do you think it is important for a PMHNP to have an eye on health promotion, preventive medicine, health protection, anticipatory guidance, counseling & disease management of mental health issues as well as physical health needs.   How do you feel you could stay up to date with those areas of primary care when your primary focus is psychiatry? 

2. Consider now the patient who requires supportive care for a mental health crisis. You must implement the IEA process to maintain safety. Please respond to these questions related to that process.

· What types of situations would necessitate the initiation of the involuntary emergency admission process?

· How does the process begin? Who can initiate the process? What happens to the patient once the process is initiated?

· After the “hold”, who completes the evaluation for the commitment? How long can the patient be held before the patient must be released or committed?

· Identify a culture other than your own and discuss the implications of receiving a mental health diagnosis as well as being admitted to a psychiatric facility based on their cultural view of mental health/mental illness. 

· What are the resources for follow-up after the patient has been released? Give an example of how you would implement a health promotion plan for the patient who returns to the community. How can the TeamSTEPPS model help maintain health in the community?

· What are your thoughts on the IEA process in your state? Do you think it is reasonable, necessary, and accessible?

State Laws on Emergency Holds for Mental Health
Stabilization
Leslie C. Hedman, J.D., John Petrila, J.D., L.L.M., William H. Fisher, Ph.D., Jeffrey W. Swanson, Ph.D.,
Deirdre A. Dingman, Dr.P.H., Scott Burris, J.D.

Objective: Psychiatric emergency hold laws permit in-
voluntary 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.

Methods: 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 fu-
ture research to accurately capture changes to current laws.

Results: 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.

Conclusions: 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.

Psychiatric Services 2016; 67:529–535; doi: 10.1176/appi.ps.201500205

The reforms in civil commitment statutes that occurred in
the late 1960s and early 1970s led to profound changes in
both substantive and procedural aspects of involuntary
hospitalization (1). One such change, the addition of the
requirement that persons affected bymental illness be either
a danger to themselves or others or gravely disabled, re-
quired that this determination be made before initiation of
long-term commitment proceedings and that evidence of the
determination be available in a commitment hearing (2).
(The term “gravely disabled” refers to a person who, because
of a mental illness, is unable to meet his or her basic needs,
including the ability to meet the need for food, shelter, and
basic self-care.) Toward that end, most states included an
emergency hold period as part of the commitment process,
during which a person could be placed in custody while the
required determinations were made.

Emergency holds potentially play an important role as a
bridge between people in crisis and emergency mental
health services that individuals may not have otherwise been
willing or able to access. Over the past three decades, this
pathway has coexisted with a range of new approaches to
the management of people with mental illnesses, including

the proliferation of police-based crisis intervention models
and other forms of jail diversion (3). This article examines
the current state of emergency hold law and identifies im-
portant questions about the emergency hold mechanism in
contemporary U.S. mental health systems that today bear
little resemblance to the mental health systems in existence
when many of these laws were enacted.

The pathway between people in crisis and the portals of
local mental health services requires critical examination
because of the serious health and social problems worldwide
caused by undertreatment of mental illness (4). In the
United States, 40% of people with a severe mental illness are
untreated (5). People with severe mental illness who do not
receive treatment are the most likely to end up in an acute
mental health crisis in need of emergency hospitalization.
Individuals facing a mental health crisis who do not receive
treatment may go without care or, in the case of violent or
disruptive behavior, be arrested (6).

An emergency hold (also called a 72-hour hold, a pick-up,
an involuntary hold, an emergency commitment, a psychi-
atric hold, a temporary detention order, or an emergency pe-
tition) is a brief involuntary detention of a person presumed to

Psychiatric Services 67:5, May 2016 ps.psychiatryonline.org 529

ARTICLES

http://ps.psychiatryonline.org

have a mental illness in order to determine whether the
individual meets criteria for involuntary civil commitment;
an emergency hold does not necessarily entail involuntary
treatment (7). Under an emergency hold, a person may be
confined in a health care facility at the behest of one or more
categories of requestor. Generally, a requestor must fill out
an affidavit or go before a judge to testify that a person has a
mental illness and meets the state’s specified criteria for a
hold as a result of that mental illness. Neither presentation of
the matter to a judge nor prompt judicial review is uniformly
required. The duration of an emergency hold is typically a
few days, but there is significant variation among states.

Emergency holds are distinct from civil inpatient or
outpatient commitment, which entails the involuntary
treatment of mental illness over a period of days or weeks.
An emergency hold is the shortest form of civil restriction on
liberty and is often triggered in anticipation of a

commitment

proceeding (8). Emergency holds, and all forms of in-
voluntary commitment, implicate constitutional rights of
autonomy, liberty, and due process. Under the “danger
standard” articulated in the Supreme Court’s 1975 decision
in O’Connor v. Donaldson, a state cannot involuntarily com-
mit people for treatment simply because they have a mental
illness; instead, the state can exercise its police powers to
coerce treatment only when individuals present a danger to
themselves or others (9). O’Connor v. Donaldson established
that the state may not confine a nondangerous individual
who is “capable of surviving safely in freedom by himself or
with the help of willing and responsible family members or
friends.” Because of the short-term, emergency nature of
emergency hold law, however, the statutory requirements
typically differ from those set forth for long-term in-
voluntary commitment (10).

In theory, emergency holds reduce harm and increase
treatment access for people with mental illnesses, but the
actual impact of these policies, applied to tens of thousands
of individuals each year, has not been evaluated. Indeed, it is
not even known reliably how many people are exposed to
this intervention every year. Variation in provisions across

the states constitutes different “conditions” and a natural
experiment for evaluation purposes. This article describes
an available online open-source data set designed for mul-
tistate evaluations of the current state of law governing
emergency holds and raises important research questions.

METHODS

Using the methods set out in Anderson and colleagues (11),
we conducted a comprehensive survey of current emergency
hold laws effective on November 1, 2014. “Emergency hold
laws”weredefined as statutes concerning the length, duration,
criteria, and regulation of involuntary short-term psychiatric
hospitalizations. The researchers worked iteratively and
redundantly to develop a research protocol that reliably
identified the target statutes. The final search terms included
mentally ill, civil commitment, emergency commitment,
emergency hold, mental illness procedures, firearm rights,
and institutionalization procedures. Using Westlaw Next,
the team searched for laws in all 50 states and the District of
Columbia. The team used state legislature Web sites to ob-
tain text of the current law. A coding scheme was developed
to capture key operational features of the law and accom-
modate cross-jurisdictional variation. The team used an it-
erative process of duplicate coding and resolved discrepancies
through discussion. Subject matter experts (JP and JWS)
helped define the variables and the coding scheme and
reviewed changes in the coding scheme. A detailed protocol
is available at www.lawatlas.org. The final coding scheme
consists of 11 variables, including circumstances triggering
emergency hold, duration of emergency hold, who initiates
an emergency hold, whether judicial review of an emergency
hold is required, and the effect of an emergency hold on
firearm rights.

RESULTS

All states and Washington, D.C., allow a person to be placed
and held in a health care facility for treatment, observation,
or stabilization without consent. Current laws vary on how
and for what reason a person can be held, whether or not
judicial review of the emergency hold is required, how long a
hold can last, and the rights to which a person is entitled
during and after the emergency hold. The most prevalent
reason for an emergency hold is being a danger to oneself or
others, and the most common maximum length of time
permitted for the emergency hold is 72 hours (Table 1).

There is considerable variation in the categories of indi-
viduals who may initiate a hold. Police in all jurisdictions
have the authority to detain a person who appears to pose an
imminent danger, and 38 states explicitly authorize police
and peace or parole officers to initiate the emergency hold
process. Police officers are the only legal initiators of
emergency holds in two states (Wisconsin and Kansas). In
31 states mental health practitioners (such as psychologists,
psychiatrists, and mental health workers) can initiate

TABLE 1. Duration of emergency holds and states’ ability to
extend holds without a court order

Duration
No court order

required Court order required

23 hours ND
24 hours AZ, DE, IL, ME, MI, MT, NC,

SC, UT
30 hours MD
48 hours GA, HI, IA DC, TX
72 hours LA, NY, TN, VT, WA AK, AR, CA, CO, CT, FL,

IN, KY, MA, MN, MS, NJ,
NV, OR, VA, WI, WY

96 hours MO, OH
5 days ID, OK, PA, SD
7 days AL, NM
10 days NH, RI
Unspecified KS, NE, WV

530 ps.psychiatryonline.org Psychiatric Services 67:5, May 2016

STATE LAWS ON EMERGENCY HOLDS FOR MENTAL HEALTH STABILIZATION

http://www.lawatlas.org

http://ps.psychiatryonline.org

an emergency hold, in 22
states medical personnel
(including physicians and
nurses) can initiate an emer-
gency hold, and in 22 states
any interested person may ini-
tiate the process. Most states
allow more than one type of
initiator (Table 2).

Eight triggering criteria
appear with varying frequency
across jurisdictions. Forty-five
states and the District of Co-
lumbia allowemergency holds
when a person is a danger to
him- or herself or to others
due tomental illness. The five
remaining states allow an
emergency hold when a per-
son is a danger to self or
others without specifying that
the danger is due to mental
illness. Nineteen states al-
low an emergency hold if the
person is gravely disabled or
unable to meet his or her ba-
sic needs. Five states specify
that a person who has re-
cently attempted suicide may
be held, even in the absence
of ongoing suicidal ideation.
Georgia is an outlier: the only
criterion for an emergency
hold is having amental illness
and being in need of treat-
ment (Table 3).

Twenty-two states require judicial approval for an
emergency hold (Figure 1). In nine of these states, judicial
approval is required before the admission, and whoever
initiates the commitment must show probable cause before
a judge or magistrate that the emergency commitment
criteria have been met. The hearing may be conducted ex
parte (that is, without the person subject to the hold
being represented or present). If the judge or magistrate
believes that there is probable cause to believe that the
person meets one or more criteria for a hold, the judge in-
structs the police to bring the person into custody and to a
hospital where he or she will be examined. If the health care
professional believes that the person meets the criteria, the
person is placed under an emergency hold. In the other 13
states, judicial review and approval are required after ad-
mission. These hearings are conducted ex parte and are
based primarily on observations of the patient since his or her
hospitalization. If the health care practitioner does not report
satisfaction of the hold criteria, then the judge orders the
immediate release of the patient.

The length of emergency holds varies by state (Table 2).
The maximum time a person can be held ranges from
23 hours (N=1) to ten days (N=2). Twenty-two states have a
72-hour hold. In eight states, practitioners can extend an
emergency hold without a court order.

Kansas, Nebraska, and West Virginia do not specify a
maximum length for an emergency hold (Table 1). Kansas
requires a health care professional to evaluate the patient
within 17 hours and either release the individual or initiate
involuntary commitment proceedings. InNebraska, a person
who is taken into custody must be seen by a health pro-
fessional within 48 hours. If the health care professional
finds commitment to be medically justified, he or she will
notify the county attorney, and long-term commitment
procedures may begin; otherwise, the person must be re-
leased. West Virginia requires a commitment hearing within
24 hours of the person’s being placed on an emergency hold.

Every state but Utah has emergency hold statutes that
guarantee specific rights for a person being detained
(Table 4). Twenty-one states require the hospital to allow

TABLE 2. Who can initiate emergency commitment and judicial review requirements, by state

Initiator No requirement
Predetention ex
parte hearing

Postdetention ex
parte hearing

Any interested person AZ, DE, LA, MA, MN, MO, NC,
SD, UT, WV

AR, CO, MD,
MS, VA, VT

IA, IN, ME, NH, TX

Relative AZ, OK MS, NY NV
Friend AZ
Police officer AL, CT, DE, FL, HI, LA, MA,

MO, MT, OH, RI, WI
NY KS, NV, TN, WY

Peace officer AK, AZ, CA, CO, DE, IL, KY,
LA, MD, MI, MT, NE, NM,
OK, OR, PA, SD, TX, UT

NY ME, MI, NH

Parole officer OH
Physician AK, AZ, CT, DE, FL, GA, HI, KY,

LA, MA, MD, MO, MN, NC,
NJ, OH, OR, PA, RI, UT

NV DC, ND, NH, NV,
TN, WY

Nurse AZ, MA, MO, NJ, RI CO, FL, NY ND
Advanced practice

registered nurse
CT, GA, HI, LA, MD, MN NH, WY

Physician assistant HI, MN WY
Psychologist AK, CT, DE, GA, HI, LA, MA,

MD, MN, MO, NC, NJ,
OH, RI

FL, NY DC, ND, NV, TN, WY

Psychiatrist AK, AZ, DE, HI, MO, NJ, OH,
RI, UT

VA ND, NV, WY

Mental health professional AL, CA, CO, DE, GA, HI, MA,
MD, MN, MO, NE, RI,
UT, WA

FL, KY DC, ME, ND, NV, WY

Medical directors CA, OR
Hospital staff ID
Attorney HI MS
Judge HI, IL, NJ FL, VA
Social worker CT, GA, IL, HI, MA, MN, NJ, RI CO, FL, NY ND, NV, WY
Clergy HI
Government employee DE, HI
County-appointed

professional
HI, MD, MS, PA TN

Mental health program MO, NJ
Guardian ID, OK MS, NY NV, TX

Psychiatric Services 67:5, May 2016 ps.psychiatryonline.org 531

HEDMAN ET AL.

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the patient to make phone calls, 26 states offer the held
person the ability to see an attorney, 12 states require that a
hospital allow the refusal of treatment, and eight states
guarantee the right to appeal the emergency hold. Twenty-
nine states require the hospital to provide written notifica-
tion of the reason for the hold. Ten state laws require
discharge transportation for the patient after the hold.

The full LawAtlas data set,
the text of the law, and the
report, codebook, and research
protocol are available for pub-
lic use at http://lawatlas.org/
query?dataset=short-term-civil-
commitment. The LawAtlas
Web site includes a “contact
us” feature, and people are
encouraged to make contact
in regard to errors found or
updates needed.

DISCUSSION

Every state and the District
of Columbia provide for tem-
porary, involuntary hospitali-
zation of people suffering
from acute mental illness.
The legitimacy and value of
these interventions depend
on several factors: the statu-
tory criteria and their appli-
cation, the accuracy of the
process for triggering an
emergency hold, the degree
to which the intervention
facilitates (or interferes with)
access to care, and the re-
lationship of holds and hold
procedures to health and
treatment outcomes. There
is little research aimed at
measuring these factors.
This survey of mental health
laws creates the foundation
for studies to evaluate how
emergency hold laws are
being used and to assess the
impact of the laws on care,
community safety, and the
treatment system.

The results of the study
demonstrate the diversity of
criteria that justify holds
under state law. Current law
generally reflects the stan-

dard established in O’Connor v. Donaldson that people
cannot be forced into treatment unless they are at risk of
serious harm or of seriously harming another (12). Many
states initially defined dangerousness quite narrowly in state
commitment laws. However, over time, concern about lack of
treatment has led some policy makers to call for a less
stringent standard for involuntary commitment generally,

TABLE 3. Reasons for emergency commitment, by state

State

Danger
to self

Danger
to others

Mentally
ill

Danger to
self due to
mental
illness

Danger to
others
due to
mental
illness

Recently
attempted
suicide

Gravely
disabled

Unable
to meet
basic
needs

AK ✓ ✓ ✓

AL ✓ ✓

AR ✓ ✓

AZ ✓ ✓

CA ✓ ✓ ✓

CO ✓ ✓ ✓

CT ✓ ✓ ✓

DC ✓ ✓

DE ✓ ✓

FL ✓ ✓ ✓

GA ✓

HI ✓ ✓

IA ✓ ✓

ID ✓ ✓ ✓

IL ✓ ✓

IN ✓ ✓

KS ✓ ✓ ✓

KY ✓ ✓

LA ✓ ✓ ✓

MA ✓ ✓

MD ✓ ✓

ME ✓ ✓

MI ✓ ✓ ✓

MN ✓ ✓ ✓

MO ✓ ✓ ✓ ✓

MS ✓ ✓

MT ✓ ✓ ✓

NC ✓ ✓ ✓ ✓

ND ✓ ✓ ✓

NE ✓ ✓

NH ✓ ✓ ✓ ✓

NJ ✓ ✓

NM ✓ ✓ ✓

NV ✓ ✓

NY ✓ ✓

OH ✓ ✓

OK ✓ ✓

OR ✓ ✓

PA ✓ ✓ ✓ ✓

RI ✓ ✓

SC ✓ ✓

SD ✓ ✓

TN ✓ ✓

TX ✓ ✓

UT ✓ ✓

VA ✓ ✓ ✓

VT ✓ ✓

WA ✓ ✓ ✓

WI ✓ ✓ ✓

WV ✓ ✓

WY ✓ ✓

532 ps.psychiatryonline.org Psychiatric Services 67:5, May 2016

STATE LAWS ON EMERGENCY HOLDS FOR MENTAL HEALTH STABILIZATION

http://lawatlas.org/query?dataset=short-term-civil-commitment

http://lawatlas.org/query?dataset=short-term-civil-commitment

http://lawatlas.org/query?dataset=short-term-civil-commitment

http://ps.psychiatryonline.org

such as “lacking the capacity to consent to
treatment,” based on the assumption that the
longer people go without treatment after a
first episode of psychosis, the worse their
illness will become (12). The data presented
here document the expansion of emergency
hold criteria outside of the danger standard.
Nineteen states allow emergency holds when
a person is “gravely disabled” or unable to
meet basic needs, which allows the emer-
gency hospitalization of people who do not
present an immediate danger to themselves.
Most of these additional criteria are consis-
tent with the standard in O’Connor, but both
legal and clinical questions remain unan-
swered. One study of commitment decisions
made in California general hospital emer-
gency rooms suggests that clinicians generally
adhere to statutory criteria in their decisions
(13), but there is no research on how criteria
are being applied and whether the available
criteria are influencing the incidence or ap-
propriateness of emergency holds (and longer-
term commitment).

Whether the criteria have an impact on future access to
treatment is also unknown. Emergency holds are applied in
an environment of chronic deficiencies in treatment capac-
ity. Because there are far more people whomeet criteria for a
psychiatric hold than there is space to accommodate them in
short-term psychiatric facilities (14–16), it is certain that the
hold process cannot be counted on (or justified) as a reliable
gateway to treatment. A lack of short-term inpatient capacity
invites the question of whether statutory provisions in many
states’ involuntary hold laws can be implemented under
these conditions.

Emergency hold laws also may influence community
safety. States differ on who can initiate a hold, with police
officers, trained mental health professionals, judges, and
lay people among the choices.Whomaymake the decision to
hold someone may in turn result in different interpretations
of whether a person constitutes a danger to self or others.
The effect of these differences on incidence of holds, the
hold process, or hold outcomes has not been objectively
evaluated. Similar knowledge gaps concern the required
procedures and the rights of individuals subject to a hold.
Available research suggests that if individuals believe they
have been treated fairly and given a voice, their satisfaction
and willingness to adhere to treatment may be enhanced
(17–19), but the comparative effect on public safety is largely
unexplored.

The effectiveness of the emergency hold as a tool to sta-
bilize acute symptoms of mental illness also is largely un-
known. Ideally, a patient placed on an emergency hold is
discharged with a long-term care strategy. Unfortunately,
many patients on emergency holds are discharged without a
mental health care strategy or lack the resources to follow

through on the plan advised and find themselves in a cycle
of crisis care (20). Emergency hold laws do not require the
implementation of a long-term treatment strategy, and,
remarkably, Alabama, Arkansas, Colorado, and Utah do
not mandate that a person on an emergency hold be seen by
a health care professional at all. Notably, Pennsylvania does
not require an evaluation by a health care professional but
mandates that a physician certify the treatment, which
must be based on an assessment either before or during the
hospitalization.

The difficulty of measuring these statutes in a scientifically
valid manner has long presented a barrier to rigorous evalu-
ation of emergency hold policy and, more broadly, of
involuntary civil commitment. This research provides an
open-source, regularly updated database for capturing the
variation in these laws across states. The protocol and coding
scheme may be used to create longitudinal data to facilitate
quasi-experimental designs with a capacity to support
credible causal inferences (21). The database facilitates future
scientific research exploring these myriad, highly important,
although presently uninvestigated, documented variations.

Optimal use of involuntary hold laws involves the balance of
competing concerns: the welfare of adults with incapacitating
mental health conditions, the civil rights of such adults, the
public’s concern with safety, the high direct cost of acute
inpatient psychiatric services, and the (perhaps even higher)
indirect, deferred cost of not providing such services in a
timely way to the people who need them. Finding
such a balance may implicate public policies and en-
cumber resources at the interface of behavioral health,
law enforcement, civil courts, and criminal justice systems.
That the features of the relevant state laws vary state by state,

FIGURE 1. State variation in requiring judicial approval before emergency holds

Judicial approval required (N=22)
AR, CO, DC, FL, IA, ID, IN, KS, KY, MD, ME, MS, ND, NH, NV, NY,

SC, TN, TX, VA, VT, WY

Postdetention adversarial hearing (N=13)
DC, IA, ID, IN, KS, ME, ND, NH, NV,

SC, TN, TX, WY

Predetention ex parte hearing (N=9)
AR, CO, FL, KY, MD, MS, NY, VA, VT

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HEDMAN ET AL.

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in ways that would seem to require correspondingly varying
policy solutions and legislative reforms, amounts to a strong
argument for more solid state-comparative research on the ef-
fectiveness and fairness of emergency commitment practices
and their legal underpinnings. The legal database described
herein makes such research possible, feasible, and imperative.

This study focused on state
statutes dictating the explicit
standards regulating emer-
gency hold law. A notable
limitation of this study is that
it considered only emergency
hold laws and did not address
the relationship between
emergency hold law criteria
and statutory criteria for
longer-term involuntary com-
mitment. We are developing a
database to codify involuntary
commitment statutes beyond
the emergency hold criteria,
which will make this type of
analysis possible in the future.
Hospital protocols and local
law enforcement practices
also have a significant effect
on whether an emergency
hold takes place (7). Court
cases related to emergency
hold standards may inform,
or even control, how the le-
gal standards are applied.
Understanding the impact
of state law on local practices
is a key area of future re-
search. In order to map out
trends, the research team
created categories that nec-
essarily lost some finer dis-
tinctions in the law; to address
this limitation, the database
includes a detailed protocol
capturing the assumptions
the coders implanted dur-
ing the research phase.

CONCLUSIONS

Recent events, such as mass
shootings, highlight the need
for both acute and long-term
mental health care, espe-
cially as a means to prevent
escalation of harm during
mental health crises. Emer-
gency holds may be one of

the portals through which people with untreated mental
illnesses receive stabilizing and consistent mental health
services. This study highlights the variability in state law and
the acute lack of research on variations in law and practice
that influence the incidence and outcomes of emergency
holds. In addition, this article illustrates the methods by

TABLE 4. Rights of persons under emergency commitment, by state

State

Right to know
reason for

commitment

Right to
refuse

medication

Right to
refuse

treatment

Right to
make a
phone
call

Right to
see an
attorney

Right to see
a health care
professional

for an
assessment

Right to
appeal the
emergency
commitment

AK ✓ ✓ ✓ ✓ ✓ ✓ ✓

AL ✓

AR ✓ ✓

AZ ✓ ✓ ✓

CA ✓ ✓ ✓ ✓ ✓

CO ✓ ✓

CT ✓ ✓ ✓

DC ✓

DE ✓ ✓ ✓

FL ✓

GA ✓ ✓ ✓ ✓

HI ✓ ✓

IA ✓ ✓ ✓

ID ✓

IL ✓ ✓ ✓ ✓

IN ✓

KS ✓ ✓

KY ✓ ✓

LA ✓ ✓ ✓ ✓

MA ✓ ✓ ✓ ✓

MD ✓

ME ✓ ✓ ✓

MI ✓ ✓ ✓

MN ✓ ✓ ✓ ✓ ✓ ✓

MO ✓ ✓ ✓ ✓

MS ✓ ✓ ✓ ✓

MT ✓ ✓ ✓ ✓

NC ✓ ✓ ✓ ✓

ND ✓ ✓ ✓

NE ✓ ✓ ✓

NH ✓ ✓ ✓ ✓

NJ ✓ ✓ ✓ ✓

NM ✓ ✓ ✓ ✓

NV ✓

NY ✓ ✓ ✓

OH ✓ ✓ ✓ ✓ ✓

OK ✓ ✓ ✓

OR ✓ ✓ ✓

PA ✓ ✓

RI ✓ ✓ ✓ ✓

SC ✓

SD ✓ ✓ ✓

TN ✓

TX ✓ ✓ ✓ ✓

UT
VA ✓ ✓

VT ✓ ✓

WA ✓

WI ✓ ✓ ✓ ✓ ✓

WV ✓ ✓

WY ✓ ✓ ✓ ✓

534 ps.psychiatryonline.org Psychiatric Services 67:5, May 2016

STATE LAWS ON EMERGENCY HOLDS FOR MENTAL HEALTH STABILIZATION

http://ps.psychiatryonline.org

which comprehensive, systematic legal data sets can be
created.

AUTHOR AND ARTICLE INFORMATION

Mrs. Hedman is with Legal Science, LLC (e-mail: leslie@legalscience.io),
and Dr. Dingman and Mr. Burris are with Public Health Law Research
and Policy Surveillance Programs, Temple University Beasley School of
Law, Philadelphia. Mr. Petrila is with the Department of Health Policy and
Management, College of Public Health, University of South Florida,
Tampa. Dr. Fisher is with the School of Criminology and Justice Studies,
University of Massachusetts, Lowell. Dr. Swanson is with the Department
of Psychiatry and Behavioral Sciences, Duke University School of
Medicine, Durham, North Carolina.

The study was funded by the Public Health Law Research and Policy
Surveillance Programs, both of which are funded by the Robert Wood
Johnson Foundation.

The authors report no financial relationships with commercial interests.

Received May 26, 2015; revision received August 25, 2015; accepted
October 6, 2015; published online March 1, 2016.

REFERENCES
1. Fisher WH, Grisso T: Commentary: civil commitment statutes:

40 years of circumvention. Journal of the American Academy of
Psychiatry and the Law Online 38:365–368, 2010

2. Brooks RA: Psychiatrists’ opinions about involuntary civil com-
mitment: results of a national survey. Journal of the American
Academy of Psychiatry and the Law Online 35:219–228, 2007

3. Bonnie RJ, Reinhard JS, Hamilton P, et al: Mental health system
transformation after the Virginia Tech tragedy. Health Affairs 28:
793–804, 2009

4. Kessler RC, Berglund PA, Bruce ML, et al: The prevalence and
correlates of untreated serious mental illness. Health Services
Research 36:987–1007, 2001

5. Bijl RV, de Graaf R, Hiripi E, et al: The prevalence of treated and
untreated mental disorders in five countries. Health Affairs 22:
122–133, 2003

6. Lamb HR, Weinberger LE: Persons with severe mental illness in
jails and prisons: a review. Psychiatric Services 49:483–492, 1998

7. Faulkner LR, McFarland BH, Bloom JD: An empirical study of
emergency commitment. American Journal of Psychiatry 146:
182–186, 1989

8. Testa M, West SG: Civil commitment in the United States.
Psychiatry 7:30–40, 2010

9. O’Connor v Donaldson. United States Reports: US; 1975. p 563
10. Lamb HR, Mills MJ: Needed changes in law and procedure for the

chronically mentally ill. Hospital and Community Psychiatry 37:
475–480, 1986

11. Anderson E, Tremper C, Thomas S, et al: Measuring statutory law
and regulations for empirical research; in Public Health Law Re-
search: Theory and Methods. Edited by Wagenaar A, Burris S. San
Francisco, Jossey-Bass, 2013

12. Large MM, Ryan CJ, Nielssen OB, et al: The danger of danger-
ousness: why we must remove the dangerousness criterion from
our mental health acts. Journal of Medical Ethics 34:877–881, 2008

13. Segal SP, Laurie TA, Segal MJ: Factors in the use of coercive
retention in civil commitment evaluations in psychiatric emer-
gency services. Psychiatric Services 52:514–520, 2001

14. Bloom JD, Krishnan B, Lockey C: The majority of inpatient psy-
chiatric beds should not be appropriated by the forensic system.
Journal of the American Academy of Psychiatry and the Law 36:
438–442, 2008

15. Lamb HR, Weinberger LE: The shift of psychiatric inpatient care
from hospitals to jails and prisons. Journal of the American
Academy of Psychiatry and the Law 33:529–534, 2005

16. Liptzin B, Gottlieb GL, Summergrad P: The future of psychiatric
services in general hospitals. American Journal of Psychiatry 164:
1468–1472, 2007

17. Cascardi M, Poythress NG, Hall A: Procedural justice in the con-
text of civil commitment: an analogue study. Behavioral Sciences
and the Law 18:731–740, 2000

18. Fondacaro M, Frogner B, Moos R: Justice in health care decision-
making: patients’ appraisals of health care providers and health
plan representatives. Social Justice Research 18:63–81, 2005

19. Murphy-Berman V, Cross T, Fondacaro M: Fairness and health
care decision making: testing the group value model of procedural
justice. Social Justice Research 12:117–129, 1999

20. Christy A, Petrila J, McCranie M, et al: Involuntary outpatient
commitment in Florida: case information and provider experience
and opinions. International Journal of Forensic Mental Health 8:
122–130, 2009

21. Wagenaar AC, Komro KA: Natural experiments: research design
elements for optimal causal inference without randomization; in
Public Health Law Research: Theory and Methods. Edited by
Wagenaar A, Burris S. San Francisco, Jossey-Bass, 2013

Psychiatric Services 67:5, May 2016 ps.psychiatryonline.org 535

HEDMAN ET AL.

mailto:leslie@legalscience.io

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