Gravely Disabled from Depression

[heyjack70]

Hi,

How gravely disabled does a depressed person need to be to qualify for involuntary psych admission in your opinion. I'm curious about a non-suicidal patient, non-psychotic depression, where there is low risk of suicide or danger to others.

It seems all states require danger to self, others, and some form of gravely disabled (or being unable to provide for basic life necessities, health, etc). In the past, I've run into problems with the "imminence" of the risk preventing psychiatric commitment. If a depressed person is eating minimally and drinking minimally, and steadily and slowly losing weight, moving slowly, and not showering, is that enough to commit them? How long would this have to go on before they would be meet involuntary admission criteria? How much weight loss? What would you be arguing to get this person detained?

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[nitemagi]

There's no specific numbers, since you're trying to convince a court.

In my experience when there are clear lab abnormalities showing problems (renal insufficiency from dehydration, low albumin from malnutrition), that helps the case.

A better question is IF someone is involuntarily detained for depression and refuses treatment (medications), then what can you do, really? Invol ECT sounds extreme, but my point being that unlike psychosis with IM medications for the untreated psychosis, we have no such treatment for depression (alternatives to pill form).

 

[notdeadyet]

Agree with nitemagi. It varies by state, but in California, there is a much higher threshold necessary to keep someone involuntarily held on grounds of Grave Disability than danger to self or others.

If a depressed person is eating minimally and drinking minimally, and steadily and slowly losing weight, moving slowly, and not showering, is that enough to commit them?

No. The grave disability means they can not access food, clothing, or shelter due to impairment from mental illness. Someone who can formulate a plan for eating but decides to do so minimally does not really meet criteria for GD. If someone is depressed and says they don't want to eat anymore because they're worried about aliens putting arsenic in their food, that's GD. If someone is depressed and says they don't want to eat anymore because they're tired of living, that's DTS. Minimal PO intake due to depression and amotivation would be a very tough sell. If it's severe and (as nitemagi pointed out) you have good medical grounds to show that they are actively killing themselves, you have a good shot at a hold, but it would be under DTS grounds.

 

[heyjack70]

There's no specific numbers, since you're trying to convince a court.

In my experience when there are clear lab abnormalities showing problems (renal insufficiency from dehydration, low albumin from malnutrition), that helps the case.

A better question is IF someone is involuntarily detained for depression and refuses treatment (medications), then what can you do, really? Invol ECT sounds extreme, but my point being that unlike psychosis with IM medications for the untreated psychosis, we have no such treatment for depression (alternatives to pill form).

Agreed. I think for depression, the much loved 'milieu' therapy would be the initial intervention. Just being around people, motivating to shower and eat regularly, that would lead to improvement. Then you could work on rapport and start meds. Then the issue is what psych unit do you know is going to keep someone like this for 2-3 weeks to start improving? What will likely happen is the patient will continue to worsen outpatient, until it becomes an actual medical issue due to poor nutrition/hydration, and they'll get admitted to a med floor, then psych will be the dispo when their depression is absolutely terrible.

Notdead, I agree it is DTS in the case of someone refusing food as an avenue to death (like someone totally not eating) but I do not agree if someone simply has no appetite or energy due to the depression. They are not accessing food as necessary for their health, which in my opinion is gravely disabled. I think the DTS argument is incorrect in this case, though you could stretch the case to fit, and it may carry more weight in court.

 

[notdeadyet]

Notdead, I agree it is DTS in the case of someone refusing food as an avenue to death (like someone totally not eating) but I do not agree if someone simply has no appetite or energy due to the depression. They are not accessing food as necessary for their health, which in my opinion is gravely disabled.

Might be a regional thing. You will not meet criteria for GD due to poor appetite and not showering out my way.

 

[whopper]

How gravely disabled does a depressed person need to be to qualify for involuntary psych admission in your opinion. I'm curious about a non-suicidal patient, non-psychotic depression, where there is low risk of suicide or danger to others.

It depends on two main factors that can be further subdivided.

1) Can this person be involuntarily admitted on a 72 hour hold? This all depends on the wording in your state on doing such.

If someone is "gravely" disabled. they likely will fall under this category. Since the wording varies per state, you need to read up on the laws in your state.

2) If the person cannot be involuntarily admitted, can they be admitted as a voluntary patient? Where I did residency, virtually anyone that wanted in as a voluntary patient got one unless the hospital was filled or close to filled so the beds could be prioritized to the sicker patients or if we believed the patient had some type of BS agenda such as malingering.

Where I'm at now, we virtually never admit voluntary patients unless those patients already meet the criteria to be involuntarily admitted because we fill up almost all the time and need to prioritize those beds to the sicker patients.

In short, #2 depends on specific hospital factors.

 

[heyjack70]

It depends on two main factors that can be further subdivided.

1) Can this person be involuntarily admitted on a 72 hour hold? This all depends on the wording in your state on doing such.

If someone is "gravely" disabled. they likely will fall under this category. Since the wording varies per state, you need to read up on the laws in your state.

.

Beyond danger to self or others, the gravely disbaled part of the statute reads: "Unable to provide for basic personal needs and is not receiving such care as is necessary for health or safety." I think a person with extremely low energy, losing weight, not eating, and no appetite falls under this. I think danger to self is a stretch. If you look at gravely disabled from a reductionist perspective, gravely disabled is really just an indirect danger to self. Danger from neglect, rather than danger from action.

My current location has a huge under supply of psych beds, so I doubt such a patient would be taken as a voluntary admission. And if she was admitted voluntarily or even commited, she would probably be released in a week with no improvement on a brand name med no insurance will pay for.

 

[billypilgrim37]

Beyond danger to self or others, the gravely disbaled part of the statute reads: "Unable to provide for basic personal needs and is not receiving such care as is necessary for health or safety." I think a person with extremely low energy, losing weight, not eating, and no appetite falls under this. I think danger to self is a stretch. If you look at gravely disabled from a reductionist perspective, gravely disabled is really just an indirect danger to self. Danger from neglect, rather than danger from action.

The only thing that REALLY matters is how the court officers in your county interpret the statute. For example, on my side of the state, that would probably qualify for an involuntary commitment. On the other side of my state, I'm told by friends that trained out there that involuntary commitment proceedings were very adversarial and overturned all the time if they were ever approved to begin with. I've heard varying standards in the surrounding rural counties. So there's no absolute standard. There are just lots of local standards with 30-50 years of history interpreting dangerousness to self and others.

 

[strangeglove]

If nutritional status can be used as a basis for involuntary admission, then what about eating disorders? My guess is that most anorexics have lower albumin than the most severely depressed patients who aren't eating. And yet they usually do not meet criteria for involuntary hospitalization.

 

[michaelrack]

If nutritional status can be used as a basis for involuntary admission, then what about eating disorders? My guess is that most anorexics have lower albumin than the most severely depressed patients who aren't eating. And yet they usually do not meet criteria for involuntary hospitalization.

http://psychiatryonline.org/data/Journals/AJP/3718/1806.pdf

http://www.eatingdisordersreview.com/nl/nl_edr_12_2_1.html

Don't have much experience in this area, but the above articles suggest they sometimes do meet criteria. Also, many with anorexia are under 18 and in some states (I think) the parents can hospitalize them against their will.

 

[heyjack70]

If nutritional status can be used as a basis for involuntary admission, then what about eating disorders? My guess is that most anorexics have lower albumin than the most severely depressed patients who aren't eating. And yet they usually do not meet criteria for involuntary hospitalization.

Referring back whopper's comment about more npatient capacity easing voluntary admission, the grumblings from older psychiatrists is that with loss of beds, the bar for involuntary admission/commitment has been raised because the resources aren't there. So some places an eating disorder patient would be easily admitted, because the judge is not under pressure to keep the system unclogged.

 

[billypilgrim37]

If nutritional status can be used as a basis for involuntary admission, then what about eating disorders? My guess is that most anorexics have lower albumin than the most severely depressed patients who aren't eating. And yet they usually do not meet criteria for involuntary hospitalization.

In my locale, <80% IBW is commitable, <85% IBW required (without other medical abnormalities) for insurance to pay for voluntary. I just admitted a schizoaffective teenager of mine (who probably has an IQ of 145) to our ED unit because as soon as we got her homicidal delusions (which, at her and her mother's begging, I did not commit her for) under control she relapsed on ED and lost about 15 pounds in two weeks (2-600 cal/day w/ exercise designed to burn off exactly as much as she consumed). She was passing out, and given the rate of decompensation she would have been easily commitable in our area despite being only about 83% IBW at the time of admission.

 

[CounselortoMD]

Where I used to work, these determinations always came down to what kind of insurance the patient had.

Sad, but quite true...