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Standards Unclear As Colorado's Mental Health Holds Rise

Joe Mahoney
Rocky Mountain PBS I-News
An empty patient room in the emergency psychiatric services ward at Denver Health in Denver on Nov. 11, 2013. More Coloradans are being put into involuntary mental-health treatment, but the standards for these holds are unclear.

In 2013, more than 31,000 Coloradans were held involuntarily because they were thought to pose a danger to themselves or others, or were gravely disabled, because of a mental illness.

What constitutes a danger? It depends whom you ask.

A recent survey of practitioners in Denver, conducted by the city attorney’s office, found a wide disparity in the interpretation of the “imminent danger” required to place people in a three-day hold.

Those surveyed defined “imminent” as anything from 24 hours to two weeks, city attorney Michael Stafford told members of a task force that met May 19.

An ongoing investigation into the state’s behavioral health care system by Rocky Mountain PBS I-News has found that for the one in four adults who have a mental health issue in any given year, help can be hard to find. More Coloradans are reaching the point of crisis, putting the burden on first responders, emergency rooms doctors and jail staff to make tough decisions about their treatment.

A new law, passed in the wake of the 2012 mass shooting in Aurora and coming into effect July 1, was intended to make the rules on holds easier to understand and follow. It added a definition of “danger to self or others” that included examples of what police, doctors and social workers should look for when placing a suicidal or homicidal person on a hold – threatened or attempted suicide, for example, or recent violent behavior.

But a month before the new rules are due to launch, experts in the field are still debating what they mean.

Members of the civil commitment statute review task force, comprised of legislators, health officials, psychiatrists and advocates, have asked state Attorney General John Suthers to publish guidelines clarifying whether or how the new rules change the threshold for involuntary holds.

The number of people put into emergency holds grew dramatically - around 21 percent - in the fiscal year that ended June 30, 2013 compared with a year earlier, according to a recently published state report.

It’s unclear whether the new “danger to self or others” definition applies to 72-hour holds. That precise phrase doesn’t appear in forms that law enforcement, physicians, psychologists and social workers must fill out when they’re deciding whether to put someone on a hold. Instead, they’re asked to determine whether a person poses an “imminent danger to others or to himself/herself.”

It’s a subtle distinction. But it raises questions about whether the new definition applies at all, Don Mares, CEO of the advocacy organization Mental Health America of Colorado, told the task force.

The confusion among members of the task force – which was convened in 2013 as part of the same law that revised the civil commitment statute – highlights disparities and confusion on the ground over the rules for putting someone on a hold.

These rules have been the subject of contentious debate, with some critics arguing that Colorado makes it too difficult to confine potentially violent people, while others defend the standard.

The task force ratified the new standards in November. Some of its members also supported bills proposed in the latest legislative session that would have further defined the requirements for 72-hour holds, and scratched the need for “imminent” danger.

But those bills didn’t make it to a vote by the legislature. They were defeated in part by pressure from the Rocky Mountain Gun Owners, which argued that the bills were a “gun grab” that would make it easier for court-ordered mental health treatment to land people on a federal background check list.

The Legal Center for People with Disabilities and Older People, which advocates for people with mental illnesses and other disabilities, also opposed taking out the word “imminent.” Emergency holds represent “a massive curtailment of civil rights,” said the center’s managing attorney Mark Ivandick, and a high threshold is appropriate.

Ivandick noted that training isn’t mandatory for law enforcement and health providers that make the decisions every day to place people on holds.

Emergency holds are intended to provide protection against a mental-health crisis. Most of these holds – about 67 percent in fiscal year 2013, according to state data – are placed on people who are believed to be at risk of hurting themselves. The holds are meant to provide a chance for mental-health professionals to evaluate and treat people in crisis.

Dr. Elizabeth Lowdermilk is a psychiatrist at Denver Health, and represents the Colorado Psychiatric Society on the task force. She has expressed frustration about the lack of clarity on the ground when it comes to putting people on holds.

“I’ve seen a lot of bad holds,” she told the task force.

People who might be depressed but don’t seem to pose any real danger can be hospitalized against their will, Lowdermilk explained later. She blamed a lack of experience among law enforcement or others tasked with making a quick decision in a high-pressure situation.

Valerie Schlecht believes she was the victim of an inappropriate hold in September. She says a housemate called 911, believing mistakenly that Schlecht had swallowed pills in a suicide attempt.

Credit Joe Mahoney / Rocky Mountain PBS I-News
Rocky Mountain PBS I-News
A bed with restraints in a patient room in the emergency psychiatric services ward at Denver Health in Denver on Nov. 11, 2013. More Coloradans are being put into involuntary mental-health treatment, but the standards for holds are unclear.

Schlecht says she was roused from bed on a Friday night and brought to Porter Adventist Hospital in an ambulance wearing her pajamas and without her eyeglasses. She underwent a series of tests that showed she had no drugs in her system apart from the ones she was prescribed.

She was released three hours later, at 2:30 a.m. on a Saturday morning, alone and with no ride home.

“It was horrible,” says Schlecht. “It has affected me since then. How do I describe it? It terrorized me.”

The number of people put into emergency holds grew dramatically – around 21 percent – in the fiscal year that ended June 30, 2013 compared with a year earlier, according to a recently published state report.

Dr. Patrick Fox, an official with the Colorado Department of Human Services, said it’s not clear why more people were put on holds last year. There was no policy change.

One possibility, says Lowdermilk, is that more people are accessing services as they enroll in health insurance, leading them to the attention of doctors who might place them on a hold. Around 14.3 percent of Coloradans were uninsured in 2013, down from 15.8 percent in 2011.

Another factor, Lowdermilk adds, may be the increased attention to mass violence in recent years, which is putting more pressure on the mental-health profession to take action when somebody is thought to be a risk to others.

Around 7 percent of the emergency holds in the fiscal year 2013 were placed on people believed to be a danger to others. That category that wasn’t among the top three reasons for putting people on holds in 2012, when around 4 percent of holds were because of a perceived “danger to self and others.”

The Attorney General’s office is expected to offer guidance on the new rules soon.

In the meantime, those whose job it is to decide when to put someone on a hold are left to make decisions in the best way they can. Lowdermilk, who is helping Denver Health train its staff on the newest standards, says she won’t wait for state guidance.

This report appears in partnership with Rocky Mountain PBS I-News. Contract Kristin Jones at kristinjones@rmpbs.org.

I-News is the public service journalism arm of Rocky Mountain PBS and works in collaboration with news media throughout Colorado.
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