Clinicians who treat patients with severe mental illness are at odds with each other, and the attorneys who represent those patients, over the current process for deciding whether to hospitalize and medicate people against their will.
Those divisions came into focus Wednesday during more than three hours of testimony before the Senate Health and Welfare and Judiciary committees on a bill, S.287, that would overhaul the rules for judicial review of those decisions.
Some said the system is broken. The amount of time it takes to make a decision causes psychiatric patients to suffer without medication that could improve their condition, and occasionally results in violent episodes that are difficult to predict.
Others expressed fear that the proposed changes will foster a medical culture of knee-jerk involuntary medication, instead of encouraging therapeutic relationships with patients that induce voluntary participation in treatment.
The closing of the Vermont State Hospital in the aftermath of Tropical Storm Irene has complicated the debate by forcing hospitals across the state to treat patients with severe psychiatric conditions. Overnight, care for acute patients was decentralized and the system’s capacity for providing treatment was dramatically reduced. Patients are sent to facilities that are less equipped to meet the needs of severely mentally ill patients, while some sit in emergency rooms under police supervision.
Patients often wait in emergency rooms beyond the legal 72-hour period a person can be held against their will. Within that time frame, courts are supposed to hold a hearing to determine whether the patients should be committed involuntarily.
At any given time there are eight people waiting in correctional facilities or emergency rooms for a hospital bed in an acute care facility, said Paul Dupre, commissioner of the Department of Mental Health.
Of the 584 people that received an emergency examination in 2013, roughly 20 percent — 119 patients — waited more than 72 hours before being admitted to an inpatient facility, according to figures from the mental health department.
The expected opening this summer of the 25-bed Vermont Psychiatric Care Center in Berlin will reduce the number of patients in limbo at emergency rooms, officials said. But the new state hospital will only increase capacity by 10 beds because the acute care patients at Fletcher Allen Health Care and the temporary psychiatric facility in Morrisville will be transferred to Berlin — and that’s if the new hospital opens at capacity.
But concerns about involuntary treatment predate Irene, as do reform efforts.
The issue has come up repeatedly during his decades of involvement with Vermont’s mental health system, Dupre said, but changes have often been derailed by the fraught emotions on either side.
Society has already decided as a matter of public policy that people with serious mental illness should in certain cases be hospitalized and treated involuntarily, he said.
For Dupre, the question is then, “How long do we leave someone who is suffering from an illness before that illness is treated?”
But compressing the judicial review process, as S.287 proposes, will inevitably result in more patients being treated involuntarily, said Dr. Craig Van Tuinen, a psychiatrist with more than 25 years of experience with mentally ill patients in Vermont.
It takes time to develop a trust with clinicians that will result in participation in treatment, Van Tuinen said.
“We can get a shorter-term response on an acute case (through involuntary treatment), but I think we also have to look at what the long-term effect is on the individual and their relationship with treatment providers,” he added.
However, those considerations must be pushed aside when a patient is assaultive or attempting to hurt themselves, said Dr. W. Gordon Frankle, chief of psychiatry at Rutland Regional Medical Center.
Frankle described the case of a patient in his 20s diagnosed with chronic paranoid-schizophrenia, who was experiencing psychotic symptoms, but was not taking medication.
The patient was cooperating with staff, but was having delusions that he was involved with street gangs, he said.
At one point, he walked up behind a staff member and struck him in the head without warning, knocking him to the ground before striking him again, Frankle said.
The attack left the staff member with a traumatic brain injury.
The patient was already in the judicial process to be involuntarily medicated, but before his case could be heard he attacked another staff member, Frankle said.
The episode illustrates the need for an option to expedite involuntary medication requests for dangerous patients that S.287 would create, he said.
Frankle said patients are held in Vermont with no legal determination longer than they should be. In several other states where he’s worked, the process moves more quickly.
Jack McCullough, director of the Mental Health Law Project for Vermont Legal Aid, bristled at Frankle’s suggestion that his office places ideology before a patient’s medical needs.
“I don’t think Vermont should be apologetic in being solicitous to protect people’s rights,” said McCullough, whose office represents virtually all patients in involuntary treatment proceedings. “A person gets a much greater allotment of due process in our cases here in Vermont.”
Both the U.S. Supreme Court and the Vermont Supreme Court have affirmed that involuntary treatment is what McCullough termed a deprivation of liberty.
The state’s current system aims to limit coercion in psychiatric treatment, and the proposed changes would increase reliance on involuntary medication, he said.
There is already a sea-change afoot, McCullough said, pointing to figures from the the courts that show involuntary medication filings have increased more than 150 percent from 26 in 2008 to 66 in 2013.
Lawmakers must also consider how amending the judicial review process would impact court resources.
Currently close to 70 percent of involuntary treatment cases are dismissed prior to a hearing, said Justice Amy Davenport, administrator for the Vermont trial courts.
She expressed concern that streamlining the process would reduce opportunities for cases to be resolved without a judge’s ruling, thereby placing a heavier burden on the courts’ time.
