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Psychiatric Illness and Civil Commitment

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Psychiatric Illness and Civil Commitment 1/20/2021 Psychiatric Illness and Civil Commitment Edward Poa, MD, FAPA Chief of Inpatient Services, The Menninger Clinic Associate Professor, Baylor College of Medicine January 29, 2021 1 Agenda Criteria and definitions Common psychiatric conditions serving as basis for commitment Disorders Dangerousness Treatment Additional considerations Self harm and homicidal ideation Outpatient commitment and informed consent 2 1 1/20/2021 3 types of commitment Inpatient: mentally ill and dangerous Substance abuse: substance abuse and dangerous Outpatient: mentally ill, capable of surviving safely in community, in need of treatment to prevent dangerousness, and unable to seek treatment voluntarily 3 Inpatient commitment An individual with a mental illness Dangerous to self or others 4 2 1/20/2021 Mental illness Diagnostic and Statistical Manual of North Carolina Mental Disorders, Fifth Edition (DSM-V) • Illness • Syndrome characterized by: • Impairs self-control, judgement, and • Clinically significant disturbance in discretion cognition, emotion regulation, or • Treatment is necessary or advisable behavior • Reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning • Usually associated with significant distress in social, occupational, or other important activities 5 Dangerous to self Within the relevant past, the individual: Unable to manage behaviors or care for self, leading to serious physical debilitation in the near future Attempted or threatened suicide, and with reasonable probability of suicide without treatment Attempted or did self-harm, and with reasonable probability of serious self-mutilation without treatment Previous episodes of dangerousness to self may be considered 6 3 1/20/2021 Dangerous to others Within the relevant past, the individual has: Threatened, attempted to inflict, or inflicted serious bodily harm on another Created a substantial risk of serious bodily harm to another Engaged in extreme destruction of property Reasonable probability that this conduct will be repeated Previous episodes of dangerousness to others may be considered 7 Ally vs. adversary Much of the mental health provider’s evaluation is based on self-report and behaviors, which relies on the individual being willing to disclose and not hiding their actions/intentions Evaluation and care are much more successful when the patient and clinician are allied in treatment Process is very difficult if the patient sees the clinician and the health care system as an adversary 8 4 1/20/2021 Depressive disorders Bipolar Psychotic disorders disorders 9 Depressive disorders Hallmarks: Characterized by persistent feelings of sadness severe enough to impact functioning Symptoms beyond what might be expected as a result of life event (mourning, heartbreak) Psychotic symptoms can occur when severe Usually mood congruent (content of delusions or hallucinations are consistent with depressed mood) Examples include delusions of being doomed or damned, or voices telling them they are terrible or cursed 10 5 1/20/2021 Depressive disorders Major depressive disorder Disruptive mood dysregulation disorder Persistent depressive disorder (dysthymia) Premenstrual dysphoric disorder Substance/medication-induced depressive disorder Depressive disorder due to another medical condition Other and Unspecified depressive disorder 11 Major depressive disorder Five of the following for at least two weeks: Depressed mood most of the time Decreased interest or pleasure in activities Appetite or weight changes Sleep disturbances Increase or decrease in physical movement Fatigue or loss of energy Feelings of worthlessness or guilt Problems with thinking or concentration Thoughts of death or suicide 12 6 1/20/2021 Dangerousness Dangerous to self Suicide or self-harm due to mood or hopelessness Suicide or self-harm due to delusion of being doomed/cursed Self-neglect and deterioration as a result of severe neurovegetative symptoms Dangerous to others Result of delusional belief that one needs to save others who are doomed/cursed (parent and child murder suicide) In a role where own suicidality places others at risk (pilot, for example) Lashing out in frustration 13 Treatment Antidepressants – can take several weeks for effect Antipsychotics Electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), ketamine Psychotherapy Bright light therapy (for Seasonal Affective Disorder) 14 7 1/20/2021 Antidepressants Fluoxetine (Prozac) Duloxetine (Cymbalta) TCA’s (Imipramine, Paroxetine (Paxil) Levomilnacipran Amitryptyline, (Fetzima) Clomipramine, Sertraline (Zoloft) Doxepin) Bupropion (Wellbutrin) Citalopram (Celexa) MAOI’s (Phenelzine, Escitalopram Mirtazapine Tranycypromine, (Lexapro) (Remeron) Isobaroxazid, Fluovoxamine (Luvox) Trazodone Selegiline) Venlafaxine (Effexor) Vilazodone (Viibryd) Desvenlafaxine Vortioxetine (Trintellix) (Pristiq) 15 Things to keep in mind Unable to will themselves into feeling happier, and friends/families also unable to talk them into it Behavioral activation can help Medications can take several weeks for effect 16 8 1/20/2021 Bipolar disorders “Manic-depressive” Characterized by episodes of abnormally elevated or irritable mood that are persistent and impair functioning (mania) Not in response to external factors More stable than mood instability (rapid fluctuations in mood occurring during course of a day) Psychotic symptoms can occur in both manic and depressive phases (again, usually mood congruent) 17 Bipolar disorders Insight into mania can be limited Even if insight into mania is present, person may not want it to end Sleep is one of the most sensitive markers 18 9 1/20/2021 Bipolar disorders Bipolar I disorder Bipolar II disorder Cyclothymic disorder Substance/medication-induced bipolar and related disorder Bipolar and related disorder due to another medical condition Other and Unspecified bipolar and related disorder 19 Bipolar I disorder – manic episode Abnormal and persistently elevated mood and increased activity/energy Three of the following High self-esteem or grandiosity Decreased sleep Pressured speech Racing thoughts Distractible Increased activity High risk behaviors Most of the day for at last one week 20 10 1/20/2021 Dangerousness Dangerous to self Suicide as a result of depressive phase or mixed state (combination of worst of manic and depressive states) Self-neglect or deterioration due to highly agitated or disorganized manic phase Dangerous to others Potentially due to delusions of grandeur leading to highly hazardous behaviors Aggression can occur when others try to rein in their behaviors 21 Treatment Mood stabilizers Antipsychotics Antidepressants (use with caution) Anxiolytics and sedatives (during acute mania) ECT 22 11 1/20/2021 Mood stabilizers Lithium Valproic acid (Depakote) Carbamazepine (Tegretol) Lamotrigine (Lamictal)* Oxcarbazepine (Trileptal) Topiramate (Topamax) 23 Psychotic disorders Traditionally defined by abnormalities in perceiving and processing reality Abnormalities in at least one of the following domains: Delusions Hallucinations Disorganized thinking Grossly disorganized or abnormal motor behavior Negative symptoms (apathy, decreased emotional expression, low motivation) 24 12 1/20/2021 Psychotic disorders Schizophrenia Delusional disorder Brief psychotic disorder Schizophreniform disorder Schizoaffective disorder Substance/medication-induced psychotic disorder Psychotic disorder due to another medical condition Other or Unspecified schizophrenia spectrum and other psychotic disorder 25 Schizophrenia Two or more of the following for a one month period: Delusions Hallucinations Disorganized speech Disorganized or catatonic behavior Negative symptoms Decline in functioning Signs of disturbance present for at least six months 26 13 1/20/2021 Dangerousness Dangerous to self Catatonia – state of profoundly decreased interaction and responsiveness to others; at high risk due to severe self-neglect Disorganization leading to self-neglect or unintentionally high-risk behaviors Delusions or hallucinations driving urge to self-harm or suicide Dangerous to others Delusions of paranoia or persecution May strike out at others trying to help in unplanned manner 27 Treatment Antipsychotic medications are primary treatment Medications will need time to work, and positive symptoms usually improve faster Recurrence of symptoms does not occur immediately after medication cessation Addition of mood stabilizers may help Persuasion or debate are not effective Certain types of therapy may be helpful (supportive, cognitive behavioral therapy/CBT) 28 14 1/20/2021 Antipsychotics Chlorpromazine Haloperidol (Haldol) Asenapine (Saphris) (Thorazine) Risperidone Iloperidone (Fanapt) Thioridazine (Mellaril) (Risperdal) Clozapine (Clozaril) Loxapine (Loxitane) Olanzapine (Zyprexa) Lurasidone (Latuda) Perphenazine Ziprasidone Paliperidone (Invega) (Trilaphon) (Geodon) Pimavanserin Trifluoperazine Quetiapine (Nuplazid) (Stelazine) (Seroquel) Brexiprazole (Rexulti) Fluphenazine Aripiprazole (Abilify) (Prolixin) Cariprazine (Vraylar) 29 Neurocognitive disorders Memory impairment One or more cognitive disturbances Aphasia (language) Apraxia (motor) Agnosia (recognition) Deficits in executive functioning Deficits cause significant impairment and are a decline from previous functioning 30 15 1/20/2021 Neurocognitive disorders Delirium Waxing and waning level of consciousness, orientation, cognition Usually secondary to a physical condition (infection, injury, metabolic issue)
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