What are the key components to promoting good mental health in individuals, families, and communities?? As you think about these key components, address th
1. What are the key components to promoting good mental health in individuals, families, and communities? As you think about these key components, address the issue from one of the three viewpoints below. Include evidence-based support and guidance in your response.
- If you are an FNP currently providing full-spectrum primary care across the lifespan how do you feel your practice will change as a PMHNP in regards to assuring adequate health promotion, preventive medicine, health protection, anticipatory guidance, counseling, and disease management working with those with mental health issues including those who are severely mentally ill, pregnancy, pediatrics, geriatrics, adults and those with substance abuse issues? What do you envision the barriers to preventive medicine will be and how could you work to enhance primary care/preventive medicine services for your patient population?
- If you are a WHNP, CNM, APN, GNP, or PNP who has predominantly practiced within one specialty area how do you envision integrating full-spectrum care to both men and women providing adequate health promotion, preventive medicine, health protection, anticipatory guidance, counseling and disease management working with those with mental health issues including those who are severely mentally ill, pregnancy, pediatrics, geriatrics, adults, and those with substance abuse issues? What do you envision the barriers to preventive medicine will be and how could you work to enhance primary care/preventive medicine services for your patient population?
- If you are an RN who is not in an advanced practice role, why do you think it is important for a PMHNP to have an eye on health promotion, preventive medicine, health protection, anticipatory guidance, counseling & disease management of mental health issues as well as physical health needs. How do you feel you could stay up to date with those areas of primary care when your primary focus is psychiatry?
Step 2:
Look over the following article to identify some important parameters of the involuntary emergency admission process for your state. You will also look at your IEA process in-depth in the next step. This article outlines the parameters of involuntary commitment: State Laws on Emergency Holds for Mental Health StabilizationDownload State Laws on Emergency Holds for Mental Health Stabilization
Step 3:
From time to time, patients with severe mental health issues may require a higher level of care than can be provided in the community setting. This may require the implementation of the emergency admission process.
It is important to understand the IEA process in your state, When you are in a crisis situation, you may have to respond quickly to the patient’s need for safety and you will not have time to look up the process for involuntary emergency admission (IEA). The purpose of this assignment is for you to investigate the process, understand how to initiate the process, and understand the consequences of involuntary commitment in your state. Please respond to the items below and keep this information as a reference when you begin to practice. USE THIS TEMPLATE to record your information Download USE THIS TEMPLATE to record your information
- Outline the process for involuntary emergency admission, starting with the identification of a patient at risk who is in need of emergency mental health services all the way through admission to the facility, treatment, and discharge.
- What types of situations would necessitate the initiation of the involuntary emergency admission process?
- What are the resources for follow-up after the patient has been released? Give an example of how you would implement a health promotion plan for the patient who returns to the community.
- What are your thoughts on the IEA process in your state? Do you think it is reasonable, necessary, and accessible?
- How could you apply the TeamSTEPPS Model before, during, or after commitment to facilitate the best care for the patient? Remember to refer to your readings on TeamSTEPPS to give you some guidance on making your team choices.
- Identify a culture other than your own and discuss the implications of receiving a mental health diagnosis as well as being admitted to a psychiatric facility based on their cultural view of mental health/mental illness.
Health Promotion and the Involuntary Emergency Commitment Process
STATE: _____________________
Health promotion is important in helping patients stay in the community and participate in their care. However, there are times when stress and other factors become too overwhelming for the patient and a higher level of care is required to promote safety and wellness for the patient. This is where the involuntary emergency commitment process may be helpful.
It is important to understand the IEA process in your state. When you are in a crisis situation, you may have to respond quickly to the patient’s need for safety and you will not have time to look up the process. The purpose of this assignment is for you to investigate the process, understand how to initiate the process, and understand the consequences of involuntary commitment in your state.
Please respond to the items below.
1. What are the key components to promoting good mental health in individuals, families, and communities? As you think about these key components, address the issue from one of the three viewpoints below. Include evidence-based support and guidance in your response.
· If you are an FNP currently providing full-spectrum primary care across the lifespan how do you feel your practice will change as a PMHNP in regards to assuring adequate health promotion, preventive medicine, health protection, anticipatory guidance, counseling, and disease management working with those with mental health issues including those who are severely mentally ill, pregnancy, pediatrics, geriatrics, adults and those with substance abuse issues? What do you envision the barriers to preventive medicine will be and how could you work to enhance primary care/preventive medicine services for your patient population?
· If you are a WHNP, CNM, APN, GNP, or PNP who has predominantly practiced within one specialty area how do you envision integrating full-spectrum care to both men and women providing adequate health promotion, preventive medicine, health protection, anticipatory guidance, counseling and disease management working with those with mental health issues including those who are severely mentally ill, pregnancy, pediatrics, geriatrics, adults, and those with substance abuse issues? What do you envision the barriers to preventive medicine will be and how could you work to enhance primary care/preventive medicine services for your patient population?
· If you are an RN who is not in an advanced practice role, why do you think it is important for a PMHNP to have an eye on health promotion, preventive medicine, health protection, anticipatory guidance, counseling & disease management of mental health issues as well as physical health needs. How do you feel you could stay up to date with those areas of primary care when your primary focus is psychiatry?
2. Consider now the patient who requires supportive care for a mental health crisis. You must implement the IEA process to maintain safety. Please respond to these questions related to that process.
· What types of situations would necessitate the initiation of the involuntary emergency admission process?
· How does the process begin? Who can initiate the process? What happens to the patient once the process is initiated?
· After the “hold”, who completes the evaluation for the commitment? How long can the patient be held before the patient must be released or committed?
· Identify a culture other than your own and discuss the implications of receiving a mental health diagnosis as well as being admitted to a psychiatric facility based on their cultural view of mental health/mental illness.
· What are the resources for follow-up after the patient has been released? Give an example of how you would implement a health promotion plan for the patient who returns to the community. How can the TeamSTEPPS model help maintain health in the community?
· What are your thoughts on the IEA process in your state? Do you think it is reasonable, necessary, and accessible?
,
State Laws on Emergency Holds for Mental Health Stabilization Leslie C. Hedman, J.D., John Petrila, J.D., L.L.M., William H. Fisher, Ph.D., Jeffrey W. Swanson, Ph.D., Deirdre A. Dingman, Dr.P.H., Scott Burris, J.D.
Objective: Psychiatric emergency hold laws permit in- voluntary admission to a health care facility of a person with an acute mental illness under certain circumstances. This study documented critical variation in state laws, identified important questions for evaluation research, and created a data set of laws to facilitate the public health law research of emergency hold laws’ impact on mental health outcomes.
Methods: The research team built a 50-state, open-source data set of laws currently governing emergency holds. A protocol and codebook were developed so that the study may be replicated and extended longitudinally, allowing fu- ture research to accurately capture changes to current laws.
Results: Although every state and the District of Columbia have emergency hold laws, state law varies on the duration of emergency holds, who can initiate an emergency hold,
the extent of judicial oversight, and the rights of patients during the hold. The core criterion justifying an involuntary hold is mental illness that results in danger to self or others, but many states have added further specifications. Only 22 states require some form of judicial review of the emergency hold process, and only nine require a judge to certify the commitment before a person is hospitalized. Five states do not guarantee assessment by a qualified mental health professional during the emergency hold.
Conclusions: The article highlights variability in state law for emergency holds of persons with acute mental illness. How this variability affects the individual, the treatment system, and law enforcement behavior is unknown. Research is needed to guide policy making and implementation on these issues.
Psychiatric Services 2016; 67:529–535; doi: 10.1176/appi.ps.201500205
The reforms in civil commitment statutes that occurred in the late 1960s and early 1970s led to profound changes in both substantive and procedural aspects of involuntary hospitalization (1). One such change, the addition of the requirement that persons affected bymental illness be either a danger to themselves or others or gravely disabled, re- quired that this determination be made before initiation of long-term commitment proceedings and that evidence of the determination be available in a commitment hearing (2). (The term “gravely disabled” refers to a person who, because of a mental illness, is unable to meet his or her basic needs, including the ability to meet the need for food, shelter, and basic self-care.) Toward that end, most states included an emergency hold period as part of the commitment process, during which a person could be placed in custody while the required determinations were made.
Emergency holds potentially play an important role as a bridge between people in crisis and emergency mental health services that individuals may not have otherwise been willing or able to access. Over the past three decades, this pathway has coexisted with a range of new approaches to the management of people with mental illnesses, including
the proliferation of police-based crisis intervention models and other forms of jail diversion (3). This article examines the current state of emergency hold law and identifies im- portant questions about the emergency hold mechanism in contemporary U.S. mental health systems that today bear little resemblance to the mental health systems in existence when many of these laws were enacted.
The pathway between people in crisis and the portals of local mental health services requires critical examination because of the serious health and social problems worldwide caused by undertreatment of mental illness (4). In the United States, 40% of people with a severe mental illness are untreated (5). People with severe mental illness who do not receive treatment are the most likely to end up in an acute mental health crisis in need of emergency hospitalization. Individuals facing a mental health crisis who do not receive treatment may go without care or, in the case of violent or disruptive behavior, be arrested (6).
An emergency hold (also called a 72-hour hold, a pick-up, an involuntary hold, an emergency commitment, a psychi- atric hold, a temporary detention order, or an emergency pe- tition) is a brief involuntary detention of a person presumed to
Psychiatric Services 67:5, May 2016 ps.psychiatryonline.org 529
ARTICLES
have a mental illness in order to determine whether the individual meets criteria for involuntary civil commitment; an emergency hold does not necessarily entail involuntary treatment (7). Under an emergency hold, a person may be confined in a health care facility at the behest of one or more categories of requestor. Generally, a requestor must fill out an affidavit or go before a judge to testify that a person has a mental illness and meets the state’s specified criteria for a hold as a result of that mental illness. Neither presentation of the matter to a judge nor prompt judicial review is uniformly required. The duration of an emergency hold is typically a few days, but there is significant variation among states.
Emergency holds are distinct from civil inpatient or outpatient commitment, which entails the involuntary treatment of mental illness over a period of days or weeks. An emergency hold is the shortest form of civil restriction on liberty and is often triggered in anticipation of a commitment proceeding (8). Emergency holds, and all forms of in- voluntary commitment, implicate constitutional rights of autonomy, liberty, and due process. Under the “danger standard” articulated in the Supreme Court’s 1975 decision in O’Connor v. Donaldson, a state cannot involuntarily com- mit people for treatment simply because they have a mental illness; instead, the state can exercise its police powers to coerce treatment only when individuals present a danger to themselves or others (9). O’Connor v. Donaldson established that the state may not confine a nondangerous individual who is “capable of surviving safely in freedom by himself or with the help of willing and responsible family members or friends.” Because of the short-term, emergency nature of emergency hold law, however, the statutory requirements typically differ from those set forth for long-term in- voluntary commitment (10).
In theory, emergency holds reduce harm and increase treatment access for people with mental illnesses, but the actual impact of these policies, applied to tens of thousands of individuals each year, has not been evaluated. Indeed, it is not even known reliably how many people are exposed to this intervention every year. Variation in provisions across
the states constitutes different “conditions” and a natural experiment for evaluation purposes. This article describes an available online open-source data set designed for mul- tistate evaluations of the current state of law governing emergency holds and raises important research questions.
METHODS
Using the methods set out in Anderson and colleagues (11), we conducted a comprehensive survey of current emergency hold laws effective on November 1, 2014. “Emergency hold laws”weredefined as statutes concerning the length, duration, criteria, and regulation of involuntary short-term psychiatric hospitalizations. The researchers worked iteratively and redundantly to develop a research protocol that reliably identified the target statutes. The final search terms included mentally ill, civil commitment, emergency commitment, emergency hold, mental illness procedures, firearm rights, and institutionalization procedures. Using Westlaw Next, the team searched for laws in all 50 states and the District of Columbia. The team used state legislature Web sites to ob- tain text of the current law. A coding scheme was developed to capture key operational features of the law and accom- modate cross-jurisdictional variation. The team used an it- erative process of duplicate coding and resolved discrepancies through discussion. Subject matter experts (JP and JWS) helped define the variables and the coding scheme and reviewed changes in the coding scheme. A detailed protocol is available at www.lawatlas.org. The final coding scheme consists of 11 variables, including circumstances triggering emergency hold, duration of emergency hold, who initiates an emergency hold, whether judicial review of an emergency hold is required, and the effect of an emergency hold on firearm rights.
RESULTS
All states and Washington, D.C., allow a person to be placed and held in a health care facility for treatment, observation, or stabilization without consent. Current laws vary on how and for what reason a person can be held, whether or not judicial review of the emergency hold is required, how long a hold can last, and the rights to which a person is entitled during and after the emergency hold. The most prevalent reason for an emergency hold is being a danger to oneself or others, and the most common maximum length of time permitted for the emergency hold is 72 hours (Table 1).
There is considerable variation in the categories of indi- viduals who may initiate a hold. Police in all jurisdictions have the authority to detain a person who appears to pose an imminent danger, and 38 states explicitly authorize police and peace or parole officers to initiate the emergency hold process. Police officers are the only legal initiators of emergency holds in two states (Wisconsin and Kansas). In 31 states mental health practitioners (such as psychologists, psychiatrists, and mental health workers) can initiate
TABLE 1. Duration of emergency holds and states’ ability to extend holds without a court order
Duration No court order
required Court order required
23 hours ND 24 hours AZ, DE, IL, ME, MI, MT, NC,
SC, UT 30 hours MD 48 hours GA, HI, IA DC, TX 72 hours LA, NY, TN, VT, WA AK, AR, CA, CO, CT, FL,
IN, KY, MA, MN, MS, NJ, NV, OR, VA, WI, WY
96 hours MO, OH 5 days ID, OK, PA, SD 7 days AL, NM 10 days NH, RI Unspecified KS, NE, WV
530 ps.psychiatryonline.org Psychiatric Services 67:5, May 2016
STATE LAWS ON EMERGENCY HOLDS FOR MENTAL HEALTH STABILIZATION
an emergency hold, in 22 states medical personnel (including physicians and nurses) can initiate an emer- gency hold, and in 22 states any interested person may ini- tiate the process. Most states allow more than one type of initiator (Table 2).
Eight triggering criteria appear with varying frequency across jurisdictions. Forty-five states and the District of Co- lumbia allowemergency holds when a person is a danger to him- or herself or to others due tomental illness. The five remaining states allow an emergency hold when a per- son is a danger to self or others without specifying that the danger is due to mental illness. Nineteen states al- low an emergency hold if the person is gravely disabled or unable to meet his or her ba- sic needs. Five states specify that a person who has re- cently attempted suicide may be held, even in the absence of ongoing suicidal ideation. Georgia is an outlier: the only criterion for an emergency hold is having amental illness and being in need of treat- ment (Table 3).
Twenty-two states require judicial approval for an emergency hold (Figure 1). In nine of these states, judicial approval is required before the admission, and whoever initiates the commitment must show probable cause before a judge or magistrate that the emergency commitment criteria have been met. The hearing may be conducted ex parte (that is, without the person subject to the hold being represented or present). If the judge or magistrate believes that there is probable cause to believe that the person meets one or more criteria for a hold, the judge in- structs the police to bring the person into custody and to a hospital where he or she will be examined. If the health care professional believes that the person meets the criteria, the person is placed under an emergency hold. In the other 13 states, judicial review and approval are required after ad- mission. These hearings are conducted ex parte and are based primarily on observations of the patient since his or her hospitalization. If the health care practitioner does not report satisfaction of the hold criteria, then the judge orders the immediate release of the patient.
The length of emergency holds varies by state (Table 2). The maximum time a person can be held ranges from 23 hours (N=1) to ten days (N=2). Twenty-two states have a 72-hour hold. In eight states, practitioners can extend an emergency hold without a court order.
Kansas, Nebraska, and West Virginia do not specify a maximum length for an emergency hold (Table 1). Kansas requires a health care professional to evaluate the patient within 17 hours and either release the individual or initiate involuntary commitment proceedings. InNebraska, a person who is taken into custody must be seen by a health pro- fessional within 48 hours. If the health care professional finds commitment to be medically justified, he or she will notify the county attorney, and long-term commitment procedures may begin; otherwise, the person must be re- leased. West Virginia requires a commitment hearing within 24 hours of the person’s being placed on an emergency hold.
Every state but Utah has emergency hold statutes that guarantee specific rights for a person being detained (Table 4). Twenty-one states require the hospital to allow
TABLE 2. Who can initiate emergency commitment and judicial review requirements, by state
Initiator No requirement Predetention ex parte hearing
Postdetention ex parte hearing
Any interested person AZ, DE, LA, MA, MN, MO, NC, SD, UT, WV
AR, CO, MD, MS, VA, VT
IA, IN, ME, NH, TX
Relative AZ, OK MS, NY NV Friend AZ Police officer AL, CT, DE, FL, HI, LA, MA,
MO, MT, OH, RI, WI NY KS, NV, TN, WY
Peace officer AK, AZ, CA, CO, DE, IL, KY, LA, MD, MI, MT, NE, NM, OK, OR, PA, SD, TX, UT
NY ME, MI, NH
Parole officer OH Physician AK, AZ, CT, DE, FL, GA, HI, KY,
LA, MA, MD, MO, MN, NC, NJ, OH, OR, PA, RI, UT
NV DC, ND, NH, NV, TN, WY
Nurse AZ, MA, MO, NJ, RI CO, FL, NY ND Advanced practice
registered nurse CT, GA, HI, LA, MD, MN NH, WY
Physician assistant HI, MN WY Psychologist AK, CT, DE, GA, HI, LA, MA,
MD, MN, MO, NC, NJ, OH, RI
FL, NY DC, ND, NV, TN, WY
Psychiatrist AK, AZ, DE, HI, MO, NJ, OH, RI, UT
VA ND, NV, WY
Mental health professional AL, CA, CO, DE, GA, HI, MA, MD, MN, MO, NE, RI, UT, WA
FL, KY DC, ME, ND, NV, WY
Medical directors CA, OR Hospital staff ID Attorney HI MS Judge HI, IL, NJ FL, VA Social worker CT, GA, IL, HI, MA, MN, NJ, RI CO, FL, NY ND, NV, WY Clergy HI Government employee DE, HI County-appointed
professional HI, MD, MS, PA TN
Mental health program MO, NJ Guardian ID, OK MS, NY NV, TX
Psychiatric Services 67:5, May 2016 ps.psychiatryonline.org 531
HEDMAN ET AL.
the patient to make phone calls, 26 states offer the held person the ability to see an attorney, 12 states require that a hospital allow the refusal of treatment, and eight states guarantee the right to appeal the emergency hold. Twenty- nine states require the hospital to provide written notifica- tion of the reason for the hold. Ten state laws require discharge transportation for the patient after the hold.
The full LawAtlas data set, the text of the law, and the report, codebook, and research protocol are available for pub- lic use at http://lawatlas.org/ query?dataset=short-term-civil- commitment. The LawAtlas Web site includes a “contact us” feature, and people are encouraged to make contact in regard to errors found or updates needed.
DISCUSSION
Every state and the District of Columbia provide for tem- porary, involuntary hospitali- zation of people suffering from acute mental illness. The legitimacy and value of these interventions depend on several factors: the statu- tory criteria and their appli- cation, the accuracy of the process for triggering an emergency hold, the degree to which the intervention facilitates (or interferes with) access to care, and the re- lationship of holds and hold procedures to health and treatment outcomes. There is little research aimed at measuring these factors. This survey of mental health laws creates the foundation for studies to evaluate how emergency hold laws are being used and to assess the impact of the laws on care, community safety, and the treatment system.
The results of the study demonstrate the diversity of criteria that justify holds under state law. Current law generally reflects the stan-
dard established in O’Connor v. Donaldson that people cannot be forced into treatment unless they are at risk of serious harm or of seriously harming another (12). Many states initially defined dangerousness quite narrowly in state commitment laws. However, over time, concern about lack of treatment has led some policy makers to call for a less stringent standard for involuntary commitment generally,
TABLE 3. Reasons for emergency commitment, by state
State Danger to self
Danger to others
Mentally ill
Danger to self due to mental illness
Danger to others due to mental illness
Recently attempted suicide
Gravely disabled
Unable to meet basic needs
AK ✓ ✓ ✓
AL ✓ ✓
AR ✓ ✓
AZ ✓ ✓
CA ✓ ✓ ✓
CO ✓ ✓ ✓
CT ✓ ✓ ✓
DC ✓ ✓
DE ✓ ✓
FL ✓ ✓ ✓
GA ✓
HI ✓ ✓
IA ✓ ✓
ID ✓ ✓ ✓
IL ✓ ✓
IN ✓ ✓
KS ✓ ✓ ✓
KY ✓ ✓
LA ✓ ✓ ✓
MA ✓ ✓
MD ✓ ✓
ME ✓ ✓
MI ✓ ✓ ✓
MN ✓ ✓ ✓
MO ✓ ✓ ✓ ✓
MS ✓ ✓
MT ✓ ✓ ✓
NC ✓ ✓ ✓ ✓
ND ✓ ✓ ✓
NE ✓ ✓
NH ✓ ✓ ✓ ✓
NJ ✓ ✓
NM ✓ ✓ ✓
NV ✓ ✓
NY ✓ ✓
OH ✓ ✓
OK ✓ ✓
OR ✓ ✓
PA ✓ ✓ ✓ ✓
RI ✓ ✓
SC ✓ ✓
SD ✓ ✓
TN ✓ ✓
TX ✓ ✓
UT ✓ ✓
VA ✓ ✓ ✓
VT ✓ ✓
WA ✓ ✓ ✓
WI ✓ ✓ ✓
WV ✓ ✓
WY ✓ ✓
532 ps.psychiatryonline.org Psychiatric Services 67:5, May 2016
STATE LAWS ON EMERGENCY HOLDS FOR MENTAL HEALTH STABILIZATION
such as “lacking the capacity to consent to treatment,” based on the assumption that the longer people go without treatment after a first episode of psychosis, the worse their illness will become (12). The data presented here document the expansion of emergency hold criteria outside of the danger standard. Nineteen states allow emergency holds when a person is “gravely disabled” or unable to meet basic needs, which allows the emer- gency hospitalization of people who do not present an immediate danger to themselves. Most of these additional criteria are consis- tent with the standard in O’Connor, but both legal and clinical questions remain unan- swered. One study of commitment decisions made in California general hospital emer- gency rooms suggests that clinicians generally adhere to statutory criteria in their decisions (13), but there is no research on how criteria are being applied and whether the available criteria are influencing the incidence or ap- propriateness of emergency holds (and longer- term commitment).
Whether the criteria have an impact on future access to treatment is also unknown. Emergency holds are applied in an environment of chronic deficiencies in treatment capac- ity. Because there are far more people whomeet criteria for a psychiatric hold than there is space to accommodate them in short-term psychiatric facilities (14–16), it is certain that the hold process cannot be counted on (or justified) as a reliable gateway to treatment. A lack of short-term inpatient capacity invites the question of whether statutory provisions in many states’ involuntary hold laws can be implemented under these conditions.
Emergency hold laws also may influence community safety. States differ on who can initiate a hold, with police officers, trained mental health professionals, judges, and lay people among the choices.Whomaymake the decision to hold someone may in turn result in different interpretations of whether a person constitutes a danger to self or others. The effect of these differences on incidence of holds, the hold process, or hold outcomes has not been objectively evaluated. Similar knowledge gaps concern the required procedures and the rights of individuals subject to a hold. Available research suggests that if individuals believe they have been treated fairly and given a voice, their satisfaction and willingness to adhere to treatment may be enhanced (17–19), but the comparative effect on public safety is largely unexplored.
The effectiveness of the emergency hold as a tool to sta- bilize acute symptoms of mental illness also is largely un- known. Ideally, a patient placed on an emergency hold is discharged with a long-term care strategy. Unfortunately, many patients on emergency holds are discharged without a mental health care strategy or lack the resources to follow
through on the plan advised and find themselves in a cycle of crisis care (20). Emergency hold laws do not require the implementation of a long-term treatment strategy, and, remarkably, Alabama, Arkansas, Colorado, and Utah do not mandate that a person on an emergency hold be seen by a health care professional at all. Notably, Pennsylvania does not require an evaluation by a health care professional but mandates that a physician certify the treatment, which must be based on an assessment either before or during the hospitalization.
The difficulty of measuring these statutes in a scientifically valid manner has long presented a barrier to rigorous evalu- ation of emergency hold policy and, more broadly, of involuntary civil commitment. This research provides an open-source, regularly updated database for capturing the variation in these laws across states. The protocol and coding scheme may be used to create longitudinal data to facilitate quasi-experimental designs with a capacity to support credible causal inferences (21). The database facilitates future scientific research exploring these myriad, highly important, although presently uninvestigated, documented variations.
Optimal use of involuntary hold laws involves the balance of competing concerns: the welfare of adults with incapacitating mental health conditions, the civil rights of such adults, the public’s concern with safety, the high direct cost of acute inpatient psychiatric services, and the (perhaps even higher) indirect, deferred cost of not
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