Congressman Tim Moore (NC-14) highlighted the murder of Iryna Zarutska on Charlotte's light rail in a speech on the U.S. House floor. (Photo: C-SPAN video)
The recent tragic murders of Iryna Zarutska and Zoe Welsh highlight the limitations of the public mental health and public safety systems in managing persons with concurrent mental health and criminal legal problems. Two men with serious mental health conditions and criminal legal involvement committed tragic crimes that we hope could have been averted.
Despite these recent events, recall that violence by persons with mental illness is actually rare and such persons are far more likely to be victims than be perpetrators of violence. Nonetheless, how can we prevent such hard-to-predict events?
Iryna’s Law, passed this fall, hopes to prevent these rare events by allowing judges to order criminal defendants to immediately undergo psychiatric evaluation for involuntary civil commitment when they are thought to be mentally ill.
Under involuntary civil commitment, if a patient is deemed to be at risk for harm to themselves or others, a physician, psychiatrist or other qualified examiner can recommend involuntary commitment for psychiatric hospitalization. While the defendant is involuntarily committed, psychiatrists, with concurrence from another psychiatrist, can authorize involuntary medications to treat delusional thinking, hallucinations or agitation, if the patient could be dangerous or unlikely to improve without medications. As a result, in most cases ,an effective treatment plan can be assured.
Here is the problem: our current involuntary inpatient commitment statutes only apply to patients who are hospitalized and dangerous to themselves or others. When under supervised care in a hospital and taking medication, the risk of dangerous behavior is dramatically reduced. However, in North Carolina there is no way to ensure patients will continue recommended treatment after hospital discharge, and as a result, they may relapse and potentially become dangerous to themselves or others again.
Involuntary outpatient commitment, a law that’s already on the books in North Carolina, is a possible evidence-based remedy that allows providers on an outpatient basis to closely monitor patients at risk for relapse and subsequent dangerous behavior. The American Psychiatric Association recommends this approach, and it has been successfully implemented in several states.
Involuntary outpatient commitment requires that a patient follow a recommended, court-ordered treatment plan — almost always including medication — while keeping appointments and being evaluated on a regular basis. If the patient does not follow the treatment plan and keep appointments, providers can request that law enforcement bring the patient to the clinic or hospital for an immediate re-evaluation with the potential for hospitalization, if needed.
Studies in several states with well-implemented involuntary outpatient programs show it can reduce relapse and dangerous behavior when the commitment order is sustained for six months or more and combined with intensive services.
Although North Carolina was one of the first states to authorize this modern, preventative approach to involuntary outpatient commitment, most observers believe it has fallen into disuse in this state in the wake of mental health reforms that privatized care in the early 2000’s.
Careful implementation of involuntary outpatient commitment requires the will to make it work again in North Carolina. It would likely require some relatively minor statutory changes to enhance its effectiveness, but more importantly, it would require coordination of court processes, reporting systems, the establishment of clear court-ordered treatment plans, careful clinical oversight of the court orders, and oversight to ensure provision of intensive services to individuals in the program. Under these conditions, other states have shown involuntary outpatient commitment can improve treatment compliance, reduce relapse, reduce arrests and improve community functioning.
Recommending a well-implemented program of involuntary outpatient commitment in North Carolina is not a call for more use of involuntary care. In fact, more careful and targeted use can reduce use of involuntary care. Strengthening our involuntary outpatient commitment system is achievable, and it can demonstrably fill gaps in care for patients, use our resources more wisely and enhance public safety.
Megan Pruette M.D. and Marvin Swartz M.D.
Megan Pruette is a psychiatrist in private practice in Durham. Marvin Swartz is a psychiatrist at Duke Health in Durham. This column represents their personal opinions, not the position of any organization.
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