key: cord-1041534-wmk0z894
authors: Parker, Carmen Black; Calhoun, Amanda; Davidson, Larry; Ciarleglio, Nicole; Hinchey, Chelsea; Dike, Charles
title: Differentiating Domains of Involuntary Containment for Persons with Severe Psychiatric Impairment and COVID-19
date: 2020-06-18
journal: Psychosomatics
DOI: 10.1016/j.psym.2020.06.010
sha: 5e4637c9a1725a3d356f20ea76cf76b6784c1239
doc_id: 1041534
cord_uid: wmk0z894

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Public health, acute medical, and mental health directives intersect: all permit involuntarily detaining individuals for the "safety of themselves or others." As the vignette illustrates, individuals with COVID-19 and severe psychiatric impairment may risk "danger to others" if psychiatric symptoms and poor insight reduce behavioral capacity to adhere to COVID-19 safety regulations. Or, such individuals may wish to leave the hospital against medical advice while critically ill with COVID-19. Though intersecting, public health, acute medical, and mental health regulatory domains are not interchangeable. Consult-liaison psychiatrists in hospitals and emergency departments serve a critical role in correctly determining which domain of regulations supersedes.

Psychiatric commitment mitigates dangers posed by virtue of mental illness; public health quarantine and isolation mitigate dangers posed by virtue of contagion. 1 The Centers for Disease Control and Prevention governs the detainment of those entering the country or traveling across states, and individual states govern those within their borders. Public health involuntary containment protocols vary extensively across states, as do psychiatric commitment procedures.

Treating individuals with both COVID-19 and severe psychiatric illness traverses public, physical, and mental health. We, the authors, are witnessing some providers default indiscriminately to more familiar mental health mechanisms of involuntary containment for such persons in various settings, from outpatient to hospital psychiatric consults to state administration. Providers are detecting the overlapping public versus physical versus mental health privacy, treatment, and enforcement considerations in this doubly vulnerable population. 2 Though conceptually similar, each domain's parameters for involuntary containment are distinguished.

One key factor determining public versus mental health regulatory domains is stability, not severity, of psychiatric symptomology. Like Mr. A, involuntary psychiatric hospitalization is intended for individuals, with or without COVID-19, experiencing acute deviations from psychiatric baseline that may reasonably benefit from emergency hospitalization. Thus, involuntary psychiatric hospitalization may indirectly alleviate behavioral difficulties adhering with COVID-19 safeguards, thereby circuitously decreasing "harm" (infection) to others. Like Ms. B, however, many acquiring COVID-19 contrastingly have stable, albeit severe, psychiatric disability. Furthermore, inpatient alterations to Ms. B's neuroleptic regimen do not promise increased COVID-19 isolation compliance upon hospital discharge. Given her psychiatric stability, the acuity of her "danger to others" originates in public health contagion, not mental illness.

Consulting psychiatrists also frequently evaluate patients with acute medical illness who lack medical decision-making capacity due to non-psychiatric reasons. There exists precedent within inpatient hospital medicine to utilize involuntary psychiatric holds to restrict such individuals from leaving the hospital against medical advice due to imminent risk of death from medical disease. Though admittedly not an uncommon practice, restricting patients for primarily medical reasons with a psychiatric hold is medically and legally misguided, as thoroughly described by two recently published articles by this journal. 3, 4 Creating hospital policies specifically for medical involuntary holds is proposed. Though COVID-19 is undoubtedly potentially lethal, a positive COVID-19 status does not automatically meet criteria for medical involuntary hold. We must consider whether individuals are asymptomatic, better managed as outpatients, or requiring inpatient medical support. Neither Mr. A nor Ms. B were acutely medically ill from COVID-19, thus their care did not require inpatient medical hospitalization or consequently fall under the domain of medical involuntary holds.

Equating psychiatric symptomatology, or its treatment, with non-adherence to COVID-19 public safety practices is not always appropriate (or correct) and risks discrimination against persons with mental illness. There exists no guarantee that either Mr. A or Ms. B would comply by COVID-19 precautions with reduced psychiatric symptomology, or perhaps no mental illness whatsoever. Rather, mental health regulations direct instances when acutely exacerbated psychiatric symptoms might coincidentally impair behavioral adherence to COVID-19 precautions, thereby suggesting plausible benefit from involuntary inpatient psychiatric medication and management. Patients with stable or no psychiatric impairment may possibly meet criteria for medical involuntary hold if critically medically ill. Beyond these specific instances, involuntary containment for COVID-19-related concerns fall under the authority of public health.

Legal Authorities for Isolation and Quarantine

COVID-19 and the Duty to Protect from Communicable Diseases

The Medical Incapacity Hold: A Policy on the Involuntary Medical Hospitalization of Patients Who Lack Decisional Capacity

A Medical Incapacity Hold Policy Reduces Inappropriate Use of Involuntary Psychiatric Holds While Protecting Patients From Harm