What is required for a psychiatric hold?

Requirements for a Psychiatric Hold

A psychiatric hold can only be implemented when a patient presents an immediate risk of harm to self or others, or is gravely disabled due to a mental disorder, and less restrictive options have failed or are impractical. 1

Core Criteria for Involuntary Hospitalization

• The patient must have a mental disorder that requires immediate treatment 1
• The patient must present an immediate risk of harm to self or others, or in some states, be "gravely disabled" 1
• Less restrictive treatment options must have failed or be deemed impractical 1
• The decision must prioritize patient autonomy and dignity to the greatest extent possible while ensuring safety 1

Assessment Process

• Conduct thorough evaluation including mental status examination to assess thought process, thought content (hallucinations/delusions), mood, affect, and insight/judgment 1
• Obtain collateral information from caregivers or others who have knowledge about the patient's state of mind, as patients often minimize symptom severity 1
• Interview patients both with and separately from caregivers, explaining limits of confidentiality 1
• Evaluate for medical conditions that could mimic psychiatric symptoms, as many medical illnesses can present with behavioral or psychiatric manifestations 1

Risk Assessment Factors

• Continued endorsement of desire to die or harm others 1
• Persistent agitation or severe hopelessness 1
• Inability to engage in safety planning discussions 1
• Inadequate support system or inability to be monitored 1
• Recent high-lethality suicide attempt or attempt with clear expectation of death 1
• Additional risk factors including substance abuse and high levels of anger or impulsivity 1

Legal Considerations

• Duration of initial psychiatric holds varies by state, typically ranging from 1-30 days (most commonly 72 hours) 1
• After the initial hold period, psychiatric facilities must obtain a court order for continued involuntary treatment if the patient/guardian still objects 1
• Healthcare providers should familiarize themselves with specific state laws regarding involuntary commitment procedures 1
• For medical conditions requiring hospitalization in patients lacking decisional capacity, some institutions have established "medical incapacity hold" policies separate from psychiatric holds 2

Implementation Requirements

• The order for seclusion or restraint must be obtained from a licensed independent practitioner within 1 hour of initiation 1
• In Medicare/Medicaid-funded programs, a physician or licensed independent practitioner must conduct a face-to-face evaluation within 1 hour of initiating restraint or seclusion 1
• Time limits for verbal and written orders are age-dependent: 1 hour for children under 9 years and 2 hours for individuals aged 9-17 1
• The patient's family should be informed of the use of seclusion or restraint 1

Common Pitfalls to Avoid

• Psychiatric holds should never be used as punishment, for staff convenience, or to compensate for inadequate staffing 1
• Avoid implementing holds without proper training or documentation 1
• Do not assume dangerousness based on demographic factors like race or culture 1
• Recognize that clinical assessment of dangerousness relies on behavioral indicators rather than demographic characteristics 3
• Be aware that psychiatric holds for dangerousness may create barriers to treatment and potentially stigmatize mentally ill patients 4

Discharge Planning

• Develop a safety plan that includes identification of warning signs, coping strategies, healthy distraction activities, social supports, and professional contacts 1
• Provide means restriction counseling, particularly important as many suicide attempts are impulsive 1
• Emphasize the importance of follow-up care, as the greatest risk of suicide reattempt is in the months following an initial attempt 1
• Address potential barriers to subsequent treatment 1