What is a 5150 (involuntary psychiatric) hold?

What is a 5150 Hold?

A 5150 hold (also called a "psychiatric hold") is a legal mechanism that allows physicians to involuntarily admit a patient to a psychiatric facility for evaluation and treatment, typically for up to 72 hours, when the patient has a mental disorder and poses an immediate risk of harm to themselves or others, or is "gravely disabled." 1

Legal Criteria for Initiating a 5150 Hold

The specific criteria that must be met include:

• The patient must have a mental disorder that requires immediate psychiatric treatment 1, 2
• The patient must meet at least one of the following conditions:
  • Presents an immediate risk of harm to themselves (e.g., active suicidal intent with a plan, recent high-lethality suicide attempt) 1, 2
  • Presents an immediate risk of harm to others (e.g., violent behavior, threats during acute psychosis or mania) 1, 3
  • Is "gravely disabled," meaning unable to provide for basic needs such as food, clothing, or shelter due to mental illness 1, 2, 4

Duration and Legal Framework

• Initial hold duration varies by state, typically ranging from 1 to 30 days, though most commonly 72 hours 1, 2, 5
• After the initial hold period expires, if the patient or guardian continues to object to hospitalization, the psychiatric facility must obtain a court order for civil commitment to continue involuntary treatment 1, 5
• State-specific laws govern the exact procedures, so clinicians should familiarize themselves with the involuntary commitment statutes in their jurisdiction 1

Clinical Situations Warranting a 5150 Hold

High-Risk Suicidal Presentations

• Active suicidal intent with a specific plan and access to lethal means 3
• Recent suicide attempts with high lethality or clear expectation of death 3, 2
• Persistent desire to die combined with inability to engage in safety planning 3, 2
• Severe hopelessness combined with psychotic symptoms 3

Acute Psychotic or Manic Episodes

• Florid psychosis with severe agitation, paranoia, or command hallucinations 3
• Psychotic symptoms during manic episodes with confusion or disorganization 3
• Aggressive behavior or threats during manic episodes 3
• Mixed episodes with concurrent manic and depressive symptoms 3

Functional Impairment

• Marked behavioral dyscontrol with inability to maintain basic self-care 3
• Patient cannot provide for basic needs due to mental illness (gravely disabled) 3, 2
• Degree of crisis too great for family to manage safely 3

Important Clinical Considerations

The decision to place a psychiatric hold should only be made after determining that less restrictive options have failed or are impractical 2. This is not simply a matter of convenience—the hold represents a significant restriction of patient autonomy and should be used judiciously 6.

Common Pitfalls to Avoid

• Do not confuse medical incapacity with psychiatric criteria: Civil commitment statutes were designed for psychiatric illness, not medical conditions that impair decision-making capacity 7
• The "gravely disabled" criterion is often misapplied: This should refer specifically to inability to meet basic needs due to mental illness, not simply homelessness or poverty 4
• Mental illness alone does not equal lack of capacity: The presence of psychiatric symptoms does not automatically justify overriding patient autonomy 6

Assessment Process

When evaluating whether a 5150 hold is appropriate:

• Conduct a thorough mental status examination assessing thought process, thought content, mood, affect, and insight/judgment 2
• Obtain collateral information from caregivers or others with knowledge of the patient's mental state 2
• Evaluate for medical conditions that could mimic psychiatric symptoms, as many medical illnesses present with behavioral manifestations 2
• Document specific risk factors including continued endorsement of desire to die or harm others, persistent agitation, severe hopelessness, or inability to engage in safety planning 2

Safety Measures During the Hold

While arranging admission or during the hold:

• Place patients in a safe environment, removing access to medical equipment, sharps, medications, and potential weapons 3
• Maintain continuous 1:1 observation and never leave high-risk patients alone 3
• Search patients and their belongings for potential means of harm when suicide risk is identified 3
• Attempt verbal de-escalation first before considering more restrictive interventions like physical or chemical restraint 1, 5

Special Populations

• Youth with early-onset bipolar disorder often require more intensive inpatient treatment due to chronic and refractory course 3
• Adolescents with mania frequently present with psychotic symptoms requiring stabilization 3
• People who inject drugs with co-occurring mental illness and homelessness are at particularly high risk for psychiatric holds 8
• Patients with substance use disorders, particularly methamphetamine use, have increased odds of experiencing psychiatric holds 8