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dateTime="2024-08-06T14:02:13.873">August 6, 2024</time></div><div class="flex items-center"><p class="text-gray-500 mt-[1px]">Psychiatric Times</p></div><div class="flex flex-wrap max-h-[24px] text-gray-500 mb-2"><span class="text-gray-500">Vol 41, Issue 8<div class="inline-block h-[16px] border-l-2 border-gray-400 mt-1 mx-1 relative top-[3px]"></div>Volume<span class="font-bold "></span></span></div><h1 class="text-[26px] font-medium leading-8">Outpatient Civil Commitment: A Look at Maryland’s New Legislation</h1><div class="py-3 text-gray-600 md:flex flex-col md:justify-between"><div class="flex flex-col xs:flex-row"><p class="mr-1 self-start">Author(s):</p><div class="flex flex-col xs:flex-row mb-3 md:mb-0"><div class="flex flex-wrap"><span class="text-md mr-2"><a class="text-author text-gray-500 hover:text-primary underline hover:no-underline decoration-gray-400" href="/authors/dinah-miller-md">Dinah Miller, MD</a></span></div></div></div><div class="max-w-full"><div class="flex 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cursor-pointer"><svg id="print" xmlns="http://www.w3.org/2000/svg" width="24" height="24" fill="currentColor" class="print bi bi-printer" viewBox="0 0 16 16"> <path d="M2.5 8a.5.5 0 1 0 0-1 .5.5 0 0 0 0 1z"></path> <path d="M5 1a2 2 0 0 0-2 2v2H2a2 2 0 0 0-2 2v3a2 2 0 0 0 2 2h1v1a2 2 0 0 0 2 2h6a2 2 0 0 0 2-2v-1h1a2 2 0 0 0 2-2V7a2 2 0 0 0-2-2h-1V3a2 2 0 0 0-2-2H5zM4 3a1 1 0 0 1 1-1h6a1 1 0 0 1 1 1v2H4V3zm1 5a2 2 0 0 0-2 2v1H2a1 1 0 0 1-1-1V7a1 1 0 0 1 1-1h12a1 1 0 0 1 1 1v3a1 1 0 0 1-1 1h-1v-1a2 2 0 0 0-2-2H5zm7 2v3a1 1 0 0 1-1 1H5a1 1 0 0 1-1-1v-3a1 1 0 0 1 1-1h6a1 1 0 0 1 1 1z"></path></svg></a></div><style> .print-wrap { width: 32px; height: 32px; background: #7F7F7F; border-radius: 100%; } .print { background: #7F7F7F; color: white; padding: 2px; border-radius: 100%; } </style></div></div></div></div><div class=" lg:w-full flex flex-col lg:flex-row lg:items-center lg:justify-end"></div><p class="py-2 mb-2 text-sm italic text-gray-600">Outpatient civil commitment in Maryland will go into effect in July 2025. Learn more here.</p><div class="py-2"><div class="blockText_blockContent__TbCXh"><div class=""><div style="width:50%;float:left;max-width:525px;margin:0 1.5rem 1.5rem 0;clear:both;cursor:" class=" figure"><div class="flex-none relative text-center"><span style="box-sizing:border-box;display:inline-block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative;max-width:100%"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;max-width:100%"><img style="display:block;max-width:100%;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0" alt="" aria-hidden="true" src="data:image/svg+xml,%3csvg%20xmlns=%27http://www.w3.org/2000/svg%27%20version=%271.1%27%20width=%275075%27%20height=%272956%27/%3e"/></span><img alt="gavel" title="gavel" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain"/><noscript><img alt="gavel" title="gavel" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F4d243418f9da71148bfca30eed0d60641701e4cb-5075x2956.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=3840&q=75 1x" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F4d243418f9da71148bfca30eed0d60641701e4cb-5075x2956.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=3840&q=75" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain" loading="lazy"/></noscript></span></div><div id="image-caption" class="text-gray-500 italic"><div class="blockText_blockContent__TbCXh"><p class="pb-2">Kreatiw/AdobeStock</p></div></div><div class="top-[-100%] block w-[1px] transition-opacity duration-500 ease-in-out opacity-0 overflow-hidden"><img class="m-auto absolute inset-0 max-w-[0%] max-h-[0%] border-[3px] border-solid border-white shadow-[0px_0px_8px_rgba(0,0,0,0.3)] box-border transition ease-in-out duration-500" src="https://cdn.sanity.io/images/0vv8moc6/psychtimes/4d243418f9da71148bfca30eed0d60641701e4cb-5075x2956.jpg?fit=crop&auto=format"/></div></div><style> #image-caption p{ font-size: 12px; max-width: 525px; margin: 0 auto; text-align: center; } </style></div><p class="pb-2"><strong>COMMENTARY</strong></p><p class="pb-2">Outpatient civil commitment is one of those polarizing topics where many individuals are adamantly for or against legislation and where emotions are high on both sides. Advocates are often the parents of adult children with untreated mental illness, while patient and civil rights groups argue for the right to medical autonomy.</p><p class="pb-2">Outpatient commitment is often touted as something that can protect both the patient and society from the ravages of untreated psychiatric disorders. It is seen as a means to prevent violence by individuals with psychiatric disorders as well as <a target="_blank" href="https://www.psychiatrictimes.com/view/im-homeless-and-i-have-ptsd">homelessness</a>, incarceration, inpatient hospitalization, family estrangement, and the inadvertent overuse of the health care system.</p><p class="pb-2">As the coauthor of a book on involuntary psychiatric care, I have not found a reason to be supportive of outpatient commitment for any but the very sickest of patients, and I do not feel it should be used in place of providing comprehensive, easy-to-access, voluntary treatment. When we mandate care, we remove the patient’s agency in their own treatment, risk setting up an adversarial relationship with those we treat, divert funds away from an underfunded mental health system for others, and frighten people away from seeking voluntary services for fear that they too might be court ordered to treatment.</p><p class="pb-2">Maryland is 1 of only 3 states that had not had civil outpatient commitment, also called assisted outpatient treatment (AOT). Legislation has been repeatedly proposed over the last 23 years, often spearheaded by the Treatment Advocacy Center (TAC),<sup class="text-inherit">1</sup> a Virginia-based advocacy group. Until this year, the legislation has always been defeated. </p><p class="pb-2">This year was different: In the final days of the 2024 Maryland General Assembly session, an outpatient commitment legislation bill passed.<sup class="text-inherit">2</sup> Senate Bill 453/House Bill 576<sup class="text-inherit">3</sup> requires that all 23 counties in Maryland have outpatient commitment, and if a county does not implement it, the Maryland Department of Health is required to do so. The bill had bipartisan sponsorship and the strong support of Maryland Gov. Wes Moore.</p><p class="pb-2">The implementation of outpatient commitment is difficult, and in many places with legislation, it is not used at all. New York devoted funding to the program, and its AOT program was held as a standard. Recently, however, a <em>New York Times</em> article<sup class="text-inherit">4</sup> discussed difficulties the program is having.</p><p class="pb-2">Maryland may be the first state to require a statewide rollout, with the specific requirement for a care coordination team—specified as a psychiatrist, a case manager, and a certified peer specialist—and a $3 million fiscal note.<sup class="text-inherit">2</sup> The Maryland Association of County Health Officers has estimated that each county will spend from $250,000 to up to $5 million annually on associated costs.<sup class="text-inherit">5,6 </sup>The hope is that this will be a mechanism for offering services more than forcing care and that the state will bear the burden if the counties cannot.</p><p class="pb-2">“I have been directing the emergency department for 10 years now, and the tools that are currently in place are failing our patients miserably. There is no mechanism to help those who suffer from symptoms that prevent them from appreciating the need to help themselves,” said Cynthia Major Lewis, MD, director of <a target="_blank" href="https://www.psychiatrictimes.com/view/critical-care-psychiatry-the-value-of-psychiatrists-in-the-icu">psychiatric emergency services</a> at Johns Hopkins Hospital, in Baltimore, Maryland, who is an avid supporter of legislation for outpatient commitment. “At the end of the day, many of my patients remain homeless, estranged from their families, are being dragged into the emergency department on emergency petitions that further impact their rights, and many are dying early deaths. If there was more appreciation for which population of patients AOT is trying to target, I believe there would be less misinformation and more support for this program.”</p><p class="pb-2">The group Social Work Advocates for Social Change opposed the legislation,<sup class="text-inherit">7</sup> noting, “Each county would be compelled to establish AOT programs, with the Maryland Office of the Public Defender (MOPD) tasked with providing representation in related proceedings. Some of these provisions will cause considerable harm by causing increased involuntary treatment, overburdening the already strained mental health system, and negatively impact the relationships between mental health care providers and clients.” The group further noted that two-thirds of Maryland counties have shortages of mental health professionals.<sup class="text-inherit">4</sup></p><p class="pb-2">Outpatient civil commitment in Maryland will go into effect in July 2025. Although AOT is aimed at the sickest of patients who have repeated relapses because of nonadherence to psychiatric treatment, this legislation has a low bar for inclusion. Any interested party—a family member, a treating clinician, a roommate, an employer—can petition the court to place someone on outpatient commitment. The patient must have had 2 psychiatric admissions in a 36-month period, including very brief voluntary admissions. There is not a requirement that the patient have ever been committed to a hospital. The patient must have a severe and persistent mental illness and be nonadherent to treatment, and any relapses must include a level of dangerousness to the patient or others, which may include credible threats of violence or suicide.<sup class="text-inherit">3</sup> There are no set definitions of “severe and persistent,” and there are many individuals who could be captured with these criteria.</p><p class="pb-2">Although the inclusion criteria for AOT are wide, the logistics are neither easy nor clear. The hearings will be held in a public courthouse as a judicial matter, not in a hospital conference room by an administrative law judge. The treating psychiatrist must testify at the court hearing to present the treatment plan, and it is not clear how this will transpire if the patient refuses the evaluation and does not attend the court hearing. If the patient agrees to the stipulations of the treatment plan, the hearing will be canceled and the patient will not be placed on outpatient commitment.</p><p class="pb-2">There is also no obvious recourse if the patient then does not comply. For those who have AOT orders, failure to abide by them will not result in a contempt order or in hospitalization. So, there is a low bar that enables many individuals to be eligible for petition and a logistically complicated hearing process, and it is easily skirted by patients who want to avoid treatment.</p><p class="pb-2">The issue came up in the Maryland General Assembly as to what types of treatment the legislation specifically permits. The attorney general’s comments reportedly left it wide open: Outpatient commitment could include any type of medical care. Sen. Clarence Lam, MD, a physician, filed an amendment to limit the extent of what could be ordered, and that amendment was not passed.</p><p class="pb-2">In a live streamed meeting, the finance committee specifically discussed involuntary outpatient <a target="_blank" href="https://www.psychiatrictimes.com/view/electroconvulsive-therapy-in-individuals-with-behavioral-and-psychological-symptoms-of-dementia">electroconvulsive therapy (ECT)</a>, implanted contraception, the off-label use of medications, and the discontinuation of medications used to treat substance use disorder. Written documentation of these meetings is difficult to find. The Maryland General Assembly’s office noted that legal interpretations are not available to the public or the media, and the live streamed meeting of the finance committee hearing is no longer available.</p><p class="pb-2">Psychiatrists in Maryland do not perform involuntary ECT on hospitalized patients, with the possible exception of catatonic patients who are under guardianship, so there is no reason to believe it will be used on outpatients. Involuntary implanted contraception is not in psychiatry’s purview, and it is hard to imagine a treatment plan that orders a patient to stop methadone or suboxone.</p><p class="pb-2">I listened to the finance committee’s hearing, and I felt like our legislators have very little understanding of what it is we do. I also had the sense that they were talking about individuals they saw as “other,” not about humans who have conditions to which they, or people they know, could be susceptible.</p><p class="pb-2">One concern is that such laws will cause individuals to shy away from voluntary treatment, and especially hospitalizations during crises, for fear of being court ordered to care, whether that fear is well founded or not. Another concern is that it might divert resources away from those who want care.</p><p class="pb-2">Legislation that limits civil rights for psychiatric patients has gone very wrong in the past, and while one hopes that only the most disabled of patients are captured and helped by this legislation, there are risks. For example, performer Britney Spears wrote of the abuses of her psychiatric guardianship in her memoir, <em>The Woman in Me</em>.<sup class="text-inherit">8</sup> In the book, she notes that she was well enough to perform a grueling schedule of concerts for years, yet she was required to pay a court-appointed attorney, and her guardian made decisions for her on many basic aspects of her life. Her guardianship lasted for 13 years, and there was a “Free Britney” movement of protestors.</p><p class="pb-2">The intent of Maryland legislation for AOT is to provide a mechanism to help untreated patients with intractable psychiatric conditions and to lend government support to this effort. A great deal of thought, discussion, and research went into the legislation, and the hope is that it captures the individuals who are homeless, who risk incarceration, and who suffer needlessly and die prematurely. If done well, it might ultimately give individuals more autonomy.</p><p class="pb-2">For the moment, there are too many questions about who will be targeted for AOT, how the logistics of getting individuals into courtrooms will work, how it will be implemented, and exactly what types of treatment can be mandated.</p><p class="pb-2"><strong>Dr Miller</strong> <em>is a clinical psychiatrist and writer in Baltimore, Maryland. She is on the faculty at the Johns Hopkins School of Medicine.</em></p><p class="pb-2"><strong>References</strong></p><p class="pb-2">1. Assisted outpatient treatment. Treatment Advocacy Center. Accessed June 10, 2024. <a rel="nofollow noreferrer noopener" target="_blank" href="https://www.treatmentadvocacycenter.org/aot/">https://www.treatmentadvocacycenter.org/aot/</a></p><p class="pb-2">2. Sample S. After 23 years, stakeholders celebrate court-ordered treatment in Maryland. Maryland Association of Counties. May 22, 2024. Accessed June 10, 2024. <a rel="nofollow noreferrer noopener" target="_blank" href="https://conduitstreet.mdcounties.org/2024/05/22/after-23-years-stakeholders-celebrate-court-ordered-treatment-in-maryland/">https://conduitstreet.mdcounties.org/2024/05/22/after-23-years-stakeholders-celebrate-court-ordered-treatment-in-maryland/</a></p><p class="pb-2">3. Mental Health-Assisted Outpatient Treatment Programs, S 453, 446th Leg (Md 2024). May 22, 2024. Accessed June 10, 2024. <a rel="nofollow noreferrer noopener" target="_blank" href="https://mgaleg.maryland.gov/2024RS/fnotes/bil_0003/sb0453.pdf">https://mgaleg.maryland.gov/2024RS/fnotes/bil_0003/sb0453.pdf</a></p><p class="pb-2">4. Harris AJ, Ransom J. Audit finds fatal lapses in mental health program meant to curb violence. <em>New York Times</em>. Updated February 9, 2024. Accessed June 10, 2024. <a rel="nofollow noreferrer noopener" target="_blank" href="https://www.nytimes.com/2024/02/08/nyregion/ny-kendras-law-audit.html">https://www.nytimes.com/2024/02/08/nyregion/ny-kendras-law-audit.html</a></p><p class="pb-2">5. Hot topics. Maryland Association of County Health Officers. Accessed June 10, 2024. <a rel="nofollow noreferrer noopener" target="_blank" href="https://mdhealthofficers.org/">https://mdhealthofficers.org/</a></p><p class="pb-2">6. Sample S. Court-ordered treatment passed in MD—what’s next for counties establishing their own programs. Maryland Association of Counties. April 23, 2024. Accessed June 10, 2024. <a rel="nofollow noreferrer noopener" target="_blank" href="https://conduitstreet.mdcounties.org/2024/04/23/court-ordered-treatment-passed-in-md-whats-next-for-counties-establishing-their-own-programs/">https://conduitstreet.mdcounties.org/2024/04/23/court-ordered-treatment-passed-in-md-whats-next-for-counties-establishing-their-own-programs/</a></p><p class="pb-2">7. Testimony in opposition of Senate Bill 453. Social Work Advocates for Social Change. February 20, 2024. Accessed June 10, 2024. <a rel="nofollow noreferrer noopener" target="_blank" href="https://mgaleg.maryland.gov/cmte_testimony/2024/fin/1Vo1T8gWhH5I92DA7QGjNuzmEcMi6UGfZ.pdf">https://mgaleg.maryland.gov/cmte_testimony/2024/fin/1Vo1T8gWhH5I92DA7QGjNuzmEcMi6UGfZ.pdf</a></p><p class="pb-2">8. Spears B. <em>The Woman in Me.</em> Gallery Books; 2023.</p><p class="pb-2"><br/></p></div></div><div class="flex items-center lg:w-3/4 mb-4 pb-12"><div class="flex sm:inline"><a target="_blank" class="mr-[5px] md:mr-2 p-[.56rem] border rounded-md bg-primary text-white" href="https://cdn.sanity.io/files/0vv8moc6/psychtimes/e73b24eb6b6a8533850b423308f680229086cdea.pdf/PSY0824_eZine.pdf">Download Issue PDF</a></div></div><div class="mb-6"><div class="jsx-19ede9f0a5a45918 py-4 relative bg-primary md:px-8 pl-2 -ml-6 xs:ml-0 w-screen xs:w-full mb-4 "><div class="jsx-19ede9f0a5a45918 px-4 sm:px-0"><div class="jsx-19ede9f0a5a45918 text-white text-2xl md:text-3xl pb-2 md:pb-1">Articles in this issue</div><hr class="jsx-19ede9f0a5a45918 -mr-2"/></div><div style="scroll-snap-type:none" class="jsx-19ede9f0a5a45918 flex items-start overflow-x-auto space-x-4 py-4 relative mx-auto w-full pl-4'"><div class="jsx-19ede9f0a5a45918 mr-12 pl-4"><img 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Advocates are often the parents of adult children with untreated mental illness, while patient and civil rights groups argue for the right to medical autonomy.\n\nOutpatient commitment is often touted as something that can protect both the patient and society from the ravages of untreated psychiatric disorders. It is seen as a means to prevent violence by individuals with psychiatric disorders as well as homelessness, incarceration, inpatient hospitalization, family estrangement, and the inadvertent overuse of the health care system.\n\nAs the coauthor of a book on involuntary psychiatric care, I have not found a reason to be supportive of outpatient commitment for any but the very sickest of patients, and I do not feel it should be used in place of providing comprehensive, easy-to-access, voluntary treatment. When we mandate care, we remove the patient’s agency in their own treatment, risk setting up an adversarial relationship with those we treat, divert funds away from an underfunded mental health system for others, and frighten people away from seeking voluntary services for fear that they too might be court ordered to treatment.\n\nMaryland is 1 of only 3 states that had not had civil outpatient commitment, also called assisted outpatient treatment (AOT). Legislation has been repeatedly proposed over the last 23 years, often spearheaded by the Treatment Advocacy Center (TAC),1 a Virginia-based advocacy group. Until this year, the legislation has always been defeated. \n\nThis year was different: In the final days of the 2024 Maryland General Assembly session, an outpatient commitment legislation bill passed.2 Senate Bill 453/House Bill 5763 requires that all 23 counties in Maryland have outpatient commitment, and if a county does not implement it, the Maryland Department of Health is required to do so. The bill had bipartisan sponsorship and the strong support of Maryland Gov. Wes Moore.\n\nThe implementation of outpatient commitment is difficult, and in many places with legislation, it is not used at all. New York devoted funding to the program, and its AOT program was held as a standard. Recently, however, a New York Times article4 discussed difficulties the program is having.\n\nMaryland may be the first state to require a statewide rollout, with the specific requirement for a care coordination team—specified as a psychiatrist, a case manager, and a certified peer specialist—and a $3 million fiscal note.2 The Maryland Association of County Health Officers has estimated that each county will spend from $250,000 to up to $5 million annually on associated costs.5,6 The hope is that this will be a mechanism for offering services more than forcing care and that the state will bear the burden if the counties cannot.\n\n“I have been directing the emergency department for 10 years now, and the tools that are currently in place are failing our patients miserably. There is no mechanism to help those who suffer from symptoms that prevent them from appreciating the need to help themselves,” said Cynthia Major Lewis, MD, director of psychiatric emergency services at Johns Hopkins Hospital, in Baltimore, Maryland, who is an avid supporter of legislation for outpatient commitment. “At the end of the day, many of my patients remain homeless, estranged from their families, are being dragged into the emergency department on emergency petitions that further impact their rights, and many are dying early deaths. If there was more appreciation for which population of patients AOT is trying to target, I believe there would be less misinformation and more support for this program.”\n\nThe group Social Work Advocates for Social Change opposed the legislation,7 noting, “Each county would be compelled to establish AOT programs, with the Maryland Office of the Public Defender (MOPD) tasked with providing representation in related proceedings. Some of these provisions will cause considerable harm by causing increased involuntary treatment, overburdening the already strained mental health system, and negatively impact the relationships between mental health care providers and clients.” The group further noted that two-thirds of Maryland counties have shortages of mental health professionals.4\n\nOutpatient civil commitment in Maryland will go into effect in July 2025. Although AOT is aimed at the sickest of patients who have repeated relapses because of nonadherence to psychiatric treatment, this legislation has a low bar for inclusion. Any interested party—a family member, a treating clinician, a roommate, an employer—can petition the court to place someone on outpatient commitment. The patient must have had 2 psychiatric admissions in a 36-month period, including very brief voluntary admissions. There is not a requirement that the patient have ever been committed to a hospital. The patient must have a severe and persistent mental illness and be nonadherent to treatment, and any relapses must include a level of dangerousness to the patient or others, which may include credible threats of violence or suicide.3 There are no set definitions of “severe and persistent,” and there are many individuals who could be captured with these criteria.\n\nAlthough the inclusion criteria for AOT are wide, the logistics are neither easy nor clear. The hearings will be held in a public courthouse as a judicial matter, not in a hospital conference room by an administrative law judge. The treating psychiatrist must testify at the court hearing to present the treatment plan, and it is not clear how this will transpire if the patient refuses the evaluation and does not attend the court hearing. If the patient agrees to the stipulations of the treatment plan, the hearing will be canceled and the patient will not be placed on outpatient commitment.\n\nThere is also no obvious recourse if the patient then does not comply. For those who have AOT orders, failure to abide by them will not result in a contempt order or in hospitalization. So, there is a low bar that enables many individuals to be eligible for petition and a logistically complicated hearing process, and it is easily skirted by patients who want to avoid treatment.\n\nThe issue came up in the Maryland General Assembly as to what types of treatment the legislation specifically permits. The attorney general’s comments reportedly left it wide open: Outpatient commitment could include any type of medical care. Sen. Clarence Lam, MD, a physician, filed an amendment to limit the extent of what could be ordered, and that amendment was not passed.\n\nIn a live streamed meeting, the finance committee specifically discussed involuntary outpatient electroconvulsive therapy (ECT), implanted contraception, the off-label use of medications, and the discontinuation of medications used to treat substance use disorder. Written documentation of these meetings is difficult to find. The Maryland General Assembly’s office noted that legal interpretations are not available to the public or the media, and the live streamed meeting of the finance committee hearing is no longer available.\n\nPsychiatrists in Maryland do not perform involuntary ECT on hospitalized patients, with the possible exception of catatonic patients who are under guardianship, so there is no reason to believe it will be used on outpatients. Involuntary implanted contraception is not in psychiatry’s purview, and it is hard to imagine a treatment plan that orders a patient to stop methadone or suboxone.\n\nI listened to the finance committee’s hearing, and I felt like our legislators have very little understanding of what it is we do. I also had the sense that they were talking about individuals they saw as “other,” not about humans who have conditions to which they, or people they know, could be susceptible.\n\nOne concern is that such laws will cause individuals to shy away from voluntary treatment, and especially hospitalizations during crises, for fear of being court ordered to care, whether that fear is well founded or not. Another concern is that it might divert resources away from those who want care.\n\nLegislation that limits civil rights for psychiatric patients has gone very wrong in the past, and while one hopes that only the most disabled of patients are captured and helped by this legislation, there are risks. For example, performer Britney Spears wrote of the abuses of her psychiatric guardianship in her memoir, The Woman in Me.8 In the book, she notes that she was well enough to perform a grueling schedule of concerts for years, yet she was required to pay a court-appointed attorney, and her guardian made decisions for her on many basic aspects of her life. Her guardianship lasted for 13 years, and there was a “Free Britney” movement of protestors.\n\nThe intent of Maryland legislation for AOT is to provide a mechanism to help untreated patients with intractable psychiatric conditions and to lend government support to this effort. A great deal of thought, discussion, and research went into the legislation, and the hope is that it captures the individuals who are homeless, who risk incarceration, and who suffer needlessly and die prematurely. If done well, it might ultimately give individuals more autonomy.\n\nFor the moment, there are too many questions about who will be targeted for AOT, how the logistics of getting individuals into courtrooms will work, how it will be implemented, and exactly what types of treatment can be mandated.\n\nDr Miller is a clinical psychiatrist and writer in Baltimore, Maryland. She is on the faculty at the Johns Hopkins School of Medicine.\n\nReferences\n\n1. Assisted outpatient treatment. Treatment Advocacy Center. Accessed June 10, 2024. https://www.treatmentadvocacycenter.org/aot/\n\n2. Sample S. After 23 years, stakeholders celebrate court-ordered treatment in Maryland. Maryland Association of Counties. May 22, 2024. Accessed June 10, 2024. https://conduitstreet.mdcounties.org/2024/05/22/after-23-years-stakeholders-celebrate-court-ordered-treatment-in-maryland/\n\n3. Mental Health-Assisted Outpatient Treatment Programs, S 453, 446th Leg (Md 2024). May 22, 2024. Accessed June 10, 2024. https://mgaleg.maryland.gov/2024RS/fnotes/bil_0003/sb0453.pdf\n\n4. Harris AJ, Ransom J. Audit finds fatal lapses in mental health program meant to curb violence. New York Times. Updated February 9, 2024. Accessed June 10, 2024. https://www.nytimes.com/2024/02/08/nyregion/ny-kendras-law-audit.html\n\n5. Hot topics. Maryland Association of County Health Officers. Accessed June 10, 2024. https://mdhealthofficers.org/\n\n6. Sample S. Court-ordered treatment passed in MD—what’s next for counties establishing their own programs. Maryland Association of Counties. April 23, 2024. Accessed June 10, 2024. https://conduitstreet.mdcounties.org/2024/04/23/court-ordered-treatment-passed-in-md-whats-next-for-counties-establishing-their-own-programs/\n\n7. Testimony in opposition of Senate Bill 453. Social Work Advocates for Social Change. February 20, 2024. Accessed June 10, 2024. https://mgaleg.maryland.gov/cmte_testimony/2024/fin/1Vo1T8gWhH5I92DA7QGjNuzmEcMi6UGfZ.pdf\n\n8. Spears B. The Woman in Me. Gallery Books; 2023.\n\n\n","description":"Outpatient civil commitment in Maryland will go into effect in July 2025. 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It is seen as a means to prevent violence by individuals with psychiatric disorders as well as ","_key":"da71527a4c7f0","_type":"span","marks":[]},{"_type":"span","marks":["606c7b1bda01"],"text":"homelessness","_key":"548fa6e2c2e7"},{"_type":"span","marks":[],"text":", incarceration, inpatient hospitalization, family estrangement, and the inadvertent overuse of the health care system.","_key":"73b13e6f3486"}],"_type":"block","style":"normal","_key":"cde31020752c","upload_doc":null,"uploadAudio":null,"medias":null},{"style":"normal","_key":"9151393977c6","markDefs":[],"children":[{"_type":"span","marks":[],"text":"As the coauthor of a book on involuntary psychiatric care, I have not found a reason to be supportive of outpatient commitment for any but the very sickest of patients, and I do not feel it should be used in place of providing comprehensive, easy-to-access, voluntary treatment. When we mandate care, we remove the patient’s agency in their own treatment, risk setting up an adversarial relationship with those we treat, divert funds away from an underfunded mental health system for others, and frighten people away from seeking voluntary services for fear that they too might be court ordered to treatment.","_key":"67fbe71258ef0"}],"upload_doc":null,"uploadAudio":null,"medias":null,"_type":"block"},{"_type":"block","style":"normal","_key":"37d8a6227c29","markDefs":[],"upload_doc":null,"uploadAudio":null,"medias":null,"children":[{"_type":"span","marks":[],"text":"Maryland is 1 of only 3 states that had not had civil outpatient commitment, also called assisted outpatient treatment (AOT). Legislation has been repeatedly proposed over the last 23 years, often spearheaded by the Treatment Advocacy Center (TAC),","_key":"d2fe9de241e50"},{"_type":"span","marks":["superscript"],"text":"1","_key":"e627e67455dc"},{"marks":[],"text":" a Virginia-based advocacy group. Until this year, the legislation has always been defeated. ","_key":"b8847784c114","_type":"span"}]},{"_key":"6b6a9791670c","markDefs":[],"upload_doc":null,"uploadAudio":null,"medias":null,"children":[{"marks":[],"text":"This year was different: In the final days of the 2024 Maryland General Assembly session, an outpatient commitment legislation bill passed.","_key":"0c08e70710e30","_type":"span"},{"_type":"span","marks":["superscript"],"text":"2","_key":"e9e87c7c380d"},{"_type":"span","marks":[],"text":" Senate Bill 453/House Bill 576","_key":"165664c4aa46"},{"_type":"span","marks":["superscript"],"text":"3","_key":"7bdc2a81be84"},{"_type":"span","marks":[],"text":" requires that all 23 counties in Maryland have outpatient commitment, and if a county does not implement it, the Maryland Department of Health is required to do so. The bill had bipartisan sponsorship and the strong support of Maryland Gov. Wes Moore.","_key":"c7725e0fe835"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_key":"a1f3d989bae90","_type":"span","marks":[],"text":"The implementation of outpatient commitment is difficult, and in many places with legislation, it is not used at all. New York devoted funding to the program, and its AOT program was held as a standard. Recently, however, a "},{"marks":["em"],"text":"New York Times","_key":"f50738769ae5","_type":"span"},{"_type":"span","marks":[],"text":" article","_key":"0b50841ddcb8"},{"_key":"d6f1339df5d2","_type":"span","marks":["superscript"],"text":"4"},{"_type":"span","marks":[],"text":" discussed difficulties the program is having.","_key":"7a6c830ba475"}],"upload_doc":null,"uploadAudio":null,"medias":null,"_type":"block","style":"normal","_key":"d47276f69db4"},{"_type":"block","style":"normal","_key":"2b44e8dedff9","upload_doc":null,"uploadAudio":null,"medias":null,"markDefs":[],"children":[{"marks":[],"text":"Maryland may be the first state to require a statewide rollout, with the specific requirement for a care coordination team—specified as a psychiatrist, a case manager, and a certified peer specialist—and a $3 million fiscal note.","_key":"baed79a2f3f50","_type":"span"},{"text":"2","_key":"447e444bb9e1","_type":"span","marks":["superscript"]},{"_type":"span","marks":[],"text":" The Maryland Association of County Health Officers has estimated that each county will spend from $250,000 to up to $5 million annually on associated costs.","_key":"76589dafa673"},{"_key":"0ba6c2ba6929","_type":"span","marks":["superscript"],"text":"5,6 "},{"_type":"span","marks":[],"text":"The hope is that this will be a mechanism for offering services more than forcing care and that the state will bear the burden if the counties cannot.","_key":"b0892410ce24"}]},{"medias":null,"_type":"block","style":"normal","_key":"14e747e96c39","markDefs":[{"nofollow":true,"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/view/critical-care-psychiatry-the-value-of-psychiatrists-in-the-icu","_key":"4de2625ba607"}],"children":[{"_type":"span","marks":[],"text":"“I have been directing the emergency department for 10 years now, and the tools that are currently in place are failing our patients miserably. There is no mechanism to help those who suffer from symptoms that prevent them from appreciating the need to help themselves,” said Cynthia Major Lewis, MD, director of ","_key":"39d16af600cb0"},{"_key":"4a749f6cd32e","_type":"span","marks":["4de2625ba607"],"text":"psychiatric emergency services"},{"_type":"span","marks":[],"text":" at Johns Hopkins Hospital, in Baltimore, Maryland, who is an avid supporter of legislation for outpatient commitment. “At the end of the day, many of my patients remain homeless, estranged from their families, are being dragged into the emergency department on emergency petitions that further impact their rights, and many are dying early deaths. If there was more appreciation for which population of patients AOT is trying to target, I believe there would be less misinformation and more support for this program.”","_key":"b374b994c6dd"}],"upload_doc":null,"uploadAudio":null},{"_type":"block","style":"normal","_key":"95a976e87e44","markDefs":[],"upload_doc":null,"uploadAudio":null,"medias":null,"children":[{"_type":"span","marks":[],"text":"The group Social Work Advocates for Social Change opposed the legislation,","_key":"2ebf4565f8e30"},{"_type":"span","marks":["superscript"],"text":"7","_key":"061fc50095ad"},{"_type":"span","marks":[],"text":" noting, “Each county would be compelled to establish AOT programs, with the Maryland Office of the Public Defender (MOPD) tasked with providing representation in related proceedings. Some of these provisions will cause considerable harm by causing increased involuntary treatment, overburdening the already strained mental health system, and negatively impact the relationships between mental health care providers and clients.” The group further noted that two-thirds of Maryland counties have shortages of mental health professionals.","_key":"7216f360d7fc"},{"text":"4","_key":"52ad4318e05e","_type":"span","marks":["superscript"]}]},{"style":"normal","_key":"2c352817d71e","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Outpatient civil commitment in Maryland will go into effect in July 2025. Although AOT is aimed at the sickest of patients who have repeated relapses because of nonadherence to psychiatric treatment, this legislation has a low bar for inclusion. Any interested party—a family member, a treating clinician, a roommate, an employer—can petition the court to place someone on outpatient commitment. The patient must have had 2 psychiatric admissions in a 36-month period, including very brief voluntary admissions. There is not a requirement that the patient have ever been committed to a hospital. The patient must have a severe and persistent mental illness and be nonadherent to treatment, and any relapses must include a level of dangerousness to the patient or others, which may include credible threats of violence or suicide.","_key":"38a8b68de7bf0"},{"_type":"span","marks":["superscript"],"text":"3","_key":"346c51660a3e"},{"text":" There are no set definitions of “severe and persistent,” and there are many individuals who could be captured with these criteria.","_key":"3beaad9dd074","_type":"span","marks":[]}],"upload_doc":null,"uploadAudio":null,"medias":null,"_type":"block"},{"medias":null,"_key":"2b1f9626af8d","markDefs":[],"children":[{"text":"Although the inclusion criteria for AOT are wide, the logistics are neither easy nor clear. The hearings will be held in a public courthouse as a judicial matter, not in a hospital conference room by an administrative law judge. The treating psychiatrist must testify at the court hearing to present the treatment plan, and it is not clear how this will transpire if the patient refuses the evaluation and does not attend the court hearing. If the patient agrees to the stipulations of the treatment plan, the hearing will be canceled and the patient will not be placed on outpatient commitment.","_key":"19fbb0ba3ba30","_type":"span","marks":[]}],"_type":"block","style":"normal","upload_doc":null,"uploadAudio":null},{"uploadAudio":null,"medias":null,"style":"normal","_key":"173da3d0a83b","markDefs":[],"children":[{"_type":"span","marks":[],"text":"There is also no obvious recourse if the patient then does not comply. For those who have AOT orders, failure to abide by them will not result in a contempt order or in hospitalization. So, there is a low bar that enables many individuals to be eligible for petition and a logistically complicated hearing process, and it is easily skirted by patients who want to avoid treatment.","_key":"611b934ee6160"}],"_type":"block","upload_doc":null},{"medias":null,"_key":"cd926e2dee01","markDefs":[],"children":[{"marks":[],"text":"The issue came up in the Maryland General Assembly as to what types of treatment the legislation specifically permits. The attorney general’s comments reportedly left it wide open: Outpatient commitment could include any type of medical care. Sen. Clarence Lam, MD, a physician, filed an amendment to limit the extent of what could be ordered, and that amendment was not passed.","_key":"c1d090b4c57a0","_type":"span"}],"_type":"block","style":"normal","upload_doc":null,"uploadAudio":null},{"uploadAudio":null,"medias":null,"style":"normal","_key":"28fc27336f14","markDefs":[{"href":"https://www.psychiatrictimes.com/view/electroconvulsive-therapy-in-individuals-with-behavioral-and-psychological-symptoms-of-dementia","_key":"e511f3bf9839","nofollow":true,"blank":true,"_type":"link"}],"children":[{"text":"In a live streamed meeting, the finance committee specifically discussed involuntary outpatient ","_key":"3e31c6ed78960","_type":"span","marks":[]},{"_type":"span","marks":["e511f3bf9839"],"text":"electroconvulsive therapy (ECT)","_key":"4ec1ff5f34cd"},{"_type":"span","marks":[],"text":", implanted contraception, the off-label use of medications, and the discontinuation of medications used to treat substance use disorder. Written documentation of these meetings is difficult to find. The Maryland General Assembly’s office noted that legal interpretations are not available to the public or the media, and the live streamed meeting of the finance committee hearing is no longer available.","_key":"6c79409e6778"}],"_type":"block","upload_doc":null},{"markDefs":[],"children":[{"text":"Psychiatrists in Maryland do not perform involuntary ECT on hospitalized patients, with the possible exception of catatonic patients who are under guardianship, so there is no reason to believe it will be used on outpatients. Involuntary implanted contraception is not in psychiatry’s purview, and it is hard to imagine a treatment plan that orders a patient to stop methadone or suboxone.","_key":"5839687a399d0","_type":"span","marks":[]}],"_type":"block","style":"normal","upload_doc":null,"uploadAudio":null,"medias":null,"_key":"2006052489a8"},{"_key":"92433058291c","upload_doc":null,"uploadAudio":null,"medias":null,"markDefs":[],"children":[{"text":"I listened to the finance committee’s hearing, and I felt like our legislators have very little understanding of what it is we do. I also had the sense that they were talking about individuals they saw as “other,” not about humans who have conditions to which they, or people they know, could be susceptible.","_key":"3e46c62b58720","_type":"span","marks":[]}],"_type":"block","style":"normal"},{"medias":null,"_key":"21e893de6db9","markDefs":[],"children":[{"marks":[],"text":"One concern is that such laws will cause individuals to shy away from voluntary treatment, and especially hospitalizations during crises, for fear of being court ordered to care, whether that fear is well founded or not. Another concern is that it might divert resources away from those who want care.","_key":"fd4e6f9c91c20","_type":"span"}],"_type":"block","style":"normal","upload_doc":null,"uploadAudio":null},{"style":"normal","upload_doc":null,"uploadAudio":null,"medias":null,"_key":"8eabf017a9c4","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Legislation that limits civil rights for psychiatric patients has gone very wrong in the past, and while one hopes that only the most disabled of patients are captured and helped by this legislation, there are risks. For example, performer Britney Spears wrote of the abuses of her psychiatric guardianship in her memoir, ","_key":"3c0f75320a0b0"},{"_type":"span","marks":["em"],"text":"The Woman in Me","_key":"f2c966727bde"},{"_type":"span","marks":[],"text":".","_key":"d3694b9c41dd"},{"_type":"span","marks":["superscript"],"text":"8","_key":"f3124731f134"},{"marks":[],"text":" In the book, she notes that she was well enough to perform a grueling schedule of concerts for years, yet she was required to pay a court-appointed attorney, and her guardian made decisions for her on many basic aspects of her life. Her guardianship lasted for 13 years, and there was a “Free Britney” movement of protestors.","_key":"6cff8f0e5bdc","_type":"span"}],"_type":"block"},{"uploadAudio":null,"medias":null,"_key":"ea382f811629","markDefs":[],"children":[{"_type":"span","marks":[],"text":"The intent of Maryland legislation for AOT is to provide a mechanism to help untreated patients with intractable psychiatric conditions and to lend government support to this effort. A great deal of thought, discussion, and research went into the legislation, and the hope is that it captures the individuals who are homeless, who risk incarceration, and who suffer needlessly and die prematurely. If done well, it might ultimately give individuals more autonomy.","_key":"be4330a8b55c0"}],"_type":"block","style":"normal","upload_doc":null},{"style":"normal","upload_doc":null,"uploadAudio":null,"medias":null,"_key":"a70aa3998eb2","markDefs":[],"children":[{"text":"For the moment, there are too many questions about who will be targeted for AOT, how the logistics of getting individuals into courtrooms will work, how it will be implemented, and exactly what types of treatment can be mandated.","_key":"fdd8e78655060","_type":"span","marks":[]}],"_type":"block"},{"style":"normal","_key":"b535b78f32f6","markDefs":[],"children":[{"marks":["strong"],"text":"Dr Miller","_key":"eae2434bb51a","_type":"span"},{"text":" ","_key":"b73e8f1391e6","_type":"span","marks":[]},{"_type":"span","marks":["em"],"text":"is a clinical psychiatrist and writer in Baltimore, Maryland. 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If you do not already have an account with Physicians’ Education Resource, LLC, you will be prompted to create one. You must have an account to evaluate and request credit for this activity.","_key":"038de917ff11","_type":"span","marks":[]}],"_type":"block","style":"normal"},{"_key":"4ef192764e6a","_type":"brtag"},{"markDefs":[{"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/topics/eating-disorders","_key":"e45352746d85","nofollow":true}],"children":[{"text":"With the onset of the COVID-19 pandemic, rates of medical hospitalization for severe malnutrition in the context of ","_key":"511d50fbcc5d0","_type":"span","marks":[]},{"_type":"span","marks":["e45352746d85"],"text":"eating disorders","_key":"30036e586128"},{"marks":[],"text":" increased dramatically among children and adolescents.","_key":"c989d409afc5","_type":"span"},{"_type":"span","marks":["superscript"],"text":"1","_key":"b6dec395dc7c"},{"_type":"span","marks":[],"text":" First-time presentations rose, average age at admission fell, and overall acuity heightened, as evidenced by higher rates of in-hospital psychotropic use, longer lengths of stay, and greater need for intensive services like inpatient psychiatric or residential care upon discharge.","_key":"34e696b573b2"},{"_type":"span","marks":["superscript"],"text":"2","_key":"1bdbddc04b54"},{"_type":"span","marks":[],"text":" Hospitalization rates have shown a downward trend over the last year, but total and first-time admissions to pediatric medical units for eating disorder care remain significantly higher than prepandemic levels.","_key":"a397781e7668"},{"_type":"span","marks":["superscript"],"text":"3","_key":"e45a9935255e"}],"_type":"block","style":"normal","_key":"abba94df99a6"},{"_key":"a6722b12c287","markDefs":[],"children":[{"_type":"span","marks":[],"text":"For pediatric hospitalists and consultation-liaison (CL) psychiatry teams, caring for severely malnourished children and adolescents in the acute medical setting poses unique challenges, both for in-hospital management and longer-term care planning. We present a multidisciplinary approach and clinical practice guideline (CPG) for providing evidence-based standardized treatment to this special population. The CPG was developed by an interdisciplinary workgroup at the University of Michigan, C.S. Mott Children’s Hospital, based on our own clinical experience and modeled on standard practices within the field of adolescent medicine, as outlined in a similar protocol by Sylvester and Forman at Boston Children’s Hospital.","_key":"9839bab2e0bc0"},{"_type":"span","marks":["superscript"],"text":"4","_key":"b6bbfd6a30aa"},{"text":" Additionally, we share access to internally developed psychoeducation materials for patients and families in hopes that these resources might aid in practice efforts at other institutions. Even with a formalized protocol, we highlight ongoing treatment challenges relating to acute behavior management, capacity concerns, ethics around compelling care, and common barriers to discharge planning.","_key":"87d34d64329c","_type":"span","marks":[]}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"A Multidisciplinary Approach","_key":"7b0ac63cd5690"}],"_type":"block","style":"normal","_key":"9b53583ed214"},{"markDefs":[],"children":[{"text":"At our hospital, patients who are admitted for medically monitored nutrition restoration are cared for by a primary general pediatrics team, made up of an attending pediatric hospitalist, pediatric residents, and medical students. Our protocol requires consultation to adolescent medicine (AM), pediatric CL psychiatry, and a registered dietitian nutritionist (RDN). Additional team members have varied levels of involvement based on each patient’s needs, and might include psychiatry social workers, a behavioral support nurse, child life specialists, art and music therapists, spiritual care, learning specialists, and any other relevant medical subspecialty consultants (eg, pediatric endocrinology, pediatric cardiology). Bedside nurses play a crucial role in each patient’s care and are vital members of the multidisciplinary team. A patient care attendant (a 1:1 bedside observer) is assigned to each patient upon admission and is continued for at least the first 24 hours, at which point the team and family discuss the benefit of maintaining that resource for the duration of the stay. Indication for the patient care attendant include increased supervision and monitoring of eating disorder behaviors in the hospital setting to ensure integration of these concerns into the treatment plan.","_key":"71012045b6e40","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"b18f8ef07e4a"},{"_key":"49d48242bdac","markDefs":[],"children":[{"_type":"span","marks":[],"text":"In many cases, complexities in the clinical presentation or psychosocial situation are so impactful for treatment planning that it is beneficial for the primary and consultant teams to round jointly each day. We also regularly convene multidisciplinary care team meetings, generally once toward the beginning of the admission and again closer to discharge. These meetings typically include the family (and sometimes the patient) and, if needed, step-down treatment centers, to optimize treatment progress and to plan for next steps in care.","_key":"aafc703267200"}],"_type":"block","style":"normal"},{"_key":"5fe64c3b474d","markDefs":[],"children":[{"text":"Approaching the medical admission with this multidisciplinary team model from start to finish helps signal to patients and families that eating disorders are complex illnesses requiring not only medical stabilization and treatment but also comprehensive mental health, family, and social support interventions. Furthermore, we find that the multidisciplinary approach is vital for the well-being of our care teams, providing reinforcement and reassurance to individual team members as they navigate complex family dynamics and high expressed-emotion interactions.","_key":"7c7e51a172f80","_type":"span","marks":[]}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_key":"801ff04e13980","_type":"span","marks":["strong"],"text":"Patient Characteristics"}],"_type":"block","style":"normal","_key":"d266949fddb2"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"C.S. Mott Children’s Hospital admits patients through aged 24 years though most are younger than 21 years. Most patients who are admitted for malnutrition related to disordered eating are in their mid- to late teens, but we have seen increasingly younger patients over the last few years, especially in the 10- to 12-year-old range. Patients 25 years and older are admitted to our University Hospital, where they are treated under a similar protocol, modified for that age population.","_key":"7082161184120"}],"_type":"block","style":"normal","_key":"4cd7089aed59"},{"children":[{"_type":"span","marks":[],"text":"Some patients self-present to the ","_key":"58bf5dd9ca830"},{"_type":"span","marks":["588605806bf8"],"text":"emergency department","_key":"f127921226f4"},{"_type":"span","marks":[],"text":" (ED) due to significant weight loss or concerning symptoms, such as fainting or fatigue. Many patients are referred to the ED by primary care physicians or our own outpatient AM clinic upon detecting abnormal vitals, labs, physical exam signs, or failure to respond to outpatient management in the context of weight loss or reported food restriction. Often, patients carry an existing diagnosis of an eating disorder and are being followed longitudinally for that condition by AM or outside eating disorder specialists. Some patients, however, are presenting for first-time evaluation in the acute care setting and have never discussed the notion of an eating disorder diagnosis with a medical or mental health clinician. Unfortunately, there is a cohort of patients who have had multiple medical admissions to our hospital for malnutrition and are well known to the inpatient pediatric and consultation teams; this can be both helpful and challenging in treatment planning.","_key":"c5c0edccb54d"}],"_type":"block","style":"normal","_key":"03170a85ee66","markDefs":[{"nofollow":true,"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/topics/emergency-psychiatry","_key":"588605806bf8"}]},{"children":[{"_type":"span","marks":[],"text":"The overwhelming majority of patients fit the picture of anorexia nervosa (AN) but we do occasionally admit patients with bulimia nervosa or other disordered eating behaviors. When patients are admitted for malnutrition in the context of avoidant/restrictive food intake disorder (ARFID), we alter the protocol to better align with the unique needs of those patients. We currently have a multidisciplinary work group collaborating to formalize a separate protocol for ARFID admissions. When the diagnosis remains unclear or points toward a non–eating-disordered psychiatric reason for malnutrition, such as severe depression, ","_key":"ae4905dc5b1e0"},{"_type":"span","marks":["cf67a9076898"],"text":"psychosis","_key":"f958acc1c77d"},{"text":", obsessive-compulsive disorder, or catatonia, the CL team collaborates with the medical providers to devise a treatment plan that is best suited for the presentation.","_key":"412ef9100869","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"3f5fb6fccdf4","markDefs":[{"_type":"link","href":"https://www.psychiatrictimes.com/topics/schizophrenia","_key":"cf67a9076898","nofollow":true,"blank":true}]},{"_key":"6307078c9431","markDefs":[],"children":[{"text":"The Protocol","_key":"ac0c5523d9050","_type":"span","marks":["strong"]}],"_type":"block","style":"normal"},{"_key":"17af79dd6893","markDefs":[],"children":[{"_type":"span","marks":[],"text":"The CPG outlines specific admission criteria to aid the ED clinicians who first assess these patients. Any questions or uncertainty regarding the appropriateness of admission can be discussed in real time with the on-call AM consultant. Admission criteria include any of the following: acute food refusal for 24 hours with failure to demonstrate 100% completion of a standard meal in the ED; concerning physical signs or symptoms of malnutrition; body mass index (BMI) less than or equal to 75% of the median for age and sex; bradycardia (\u003c 50 beats per minute while awake), hypotension (\u003c 90/45 mm Hg), or hypothermia (\u003c 96 °F, \u003c 36 °C); intractable vomiting or uncontrolled bingeing/purging; or failure of outpatient treatment.","_key":"e10398a067090"},{"marks":["superscript"],"text":"5","_key":"1ad9c1b24a06","_type":"span"}],"_type":"block","style":"normal"},{"style":"normal","_key":"9d181c7e57a9","markDefs":[],"children":[{"text":"Once the decision is made to admit the patient, the primary team places a standardized order set, which triggers a specific meal plan, sets up regular laboratory monitoring, and prompts consultation to AM, CL, and the RDN. Efforts are made to transition the patient out of the ED space as soon as possible, as that environment is not ideally suited for following a strict meal plan and supervision protocol. Ultimately, hospital census and acuity guide bed placement. For situations in which prolonged ED boarding is unavoidable, the CPG contains a section outlining adaptations of the protocol for the ED setting.","_key":"c13462ddf97a0","_type":"span","marks":[]}],"_type":"block"},{"alignment":"right","blank":true,"_key":"04a9096a3066","disableLightBox":true,"disableTextWrap":false,"_type":"figure","alt":"TABLE. Medical Monitoring and Diagnostic Testing","imgcaption":[{"_key":"3b5e25e5fce7","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Table. ","_key":"04057562ae040"},{"_key":"95546b63afc3","_type":"span","marks":[],"text":"Medical Monitoring and Diagnostic Testing"}],"_type":"block","style":"normal"}],"asset":{"_ref":"image-452fd7b2757bc5bc6b877fe55fc0cc2831188c4f-1676x590-png","_type":"reference"},"widthP":70},{"children":[{"_type":"span","marks":[],"text":"Because of the potential development of refeeding syndrome in severely malnourished patients undergoing nutrition repletion, close medical monitoring is paramount. A standard panel of labs and diagnostic testing is collected upon admission and throughout the hospital stay, as outlined in the ","_key":"dfb5e06d5a170"},{"_type":"span","marks":["strong","a5b8fa72cbcf"],"text":"Table","_key":"c6152116fec8"},{"_type":"span","marks":[],"text":". Fluid balance is closely monitored and a daily fluid goal and free water limit are set. Intravenous (IV) fluids are avoided in favor of enteral nutrition and hydration, but dextrose-containing IV fluids are occasionally necessary to maintain appropriate blood glucose levels or address clinical dehydration or ketonuria. Phosphorus and thiamine supplementation are initiated reflexively for patients with BMI less than 70% of the median for age and sex at the time of admission. Other electrolyte replacement and supplementation is instituted as needed throughout the hospitalization, based on lab monitoring.","_key":"897df64eda8d"},{"_type":"span","marks":["superscript"],"text":"5","_key":"dc291d90e0b4"}],"_type":"block","style":"normal","_key":"86e858a42a56","markDefs":[{"nofollow":true,"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F452fd7b2757bc5bc6b877fe55fc0cc2831188c4f-1676x590.png%3Ffit%3Dcrop%26auto%3Dformat\u0026w=3840\u0026q=75","_key":"a5b8fa72cbcf"}]},{"children":[{"_type":"span","marks":[],"text":"Nutrition is initiated at a level of 1500 kcal per day unless otherwise directed by AM. Calorie level is advanced by 300 kcal/day to until the patient is reliably gaining at least 0.3 kg to 0.4 kg every 2 days. The patient is not told calorie content or goals, and all information labels are removed from food items. The RDN meets with the patient and family upon admission to obtain the dietary history and to allow the patient to select 3 “no” foods for the duration of the hospitalization (these are limited to specific food items and cannot represent an entire food group). Subsequently, the RDN manages the patient’s meal plan entirely, selecting the menu and ordering the trays in accordance with the given kcal level, rate of advancement, known allergies or intolerances, and specified “no” foods.","_key":"e141966bf1920"}],"_type":"block","style":"normal","_key":"b563863d5359","markDefs":[]},{"style":"normal","_key":"efb8cef8eeb9","markDefs":[],"children":[{"_type":"span","marks":[],"text":"In the case of vegetarianism or veganism, the context of this preference is critical. If the family has been vegetarian/vegan for years and/or adheres to religious or culturally specified dietary restrictions, efforts are made to accommodate as able. If vegetarianism/veganism arose in the context of disordered eating behaviors, animal sources of food are gradually reintroduced alongside explanatory and supportive discussions with the patient and family. No outside food is permitted throughout the hospitalization to ensure accurate evaluation and monitoring of nutritional and fluid intake and to limit opportunities for negotiation or counterproductive behaviors.","_key":"6f951682c49f0"}],"_type":"block"},{"markDefs":[],"children":[{"marks":[],"text":"Calorie needs are provided as 3 meals and 3 snacks daily, following a set schedule and adhering to firm time limits to allow for proper digestion and prevent behavioral tactics to prolong meals or avoid food. Meals and snacks are to be completed in 30 min and 15 min, respectively. Food or beverages that are not completed within the time frame are replaced with a commercially available nutritional supplement drink at a concentration of 1.5 kcal/mL. Nursing follows an algorithm in which the proportion of food remaining on the tray at the end of the time limit is estimated, either 1% to 50% or 51% to 99% of total calories, and then cross-referenced to the calorie level for the day to determine the milliliter amount. The patient is allotted 10 to 15 minutes to complete the supplement, depending on the volume. If the patient is unable to take in the necessary dose of nutrition via food and oral supplement within the given time frame, a nasogastric (NG) tube is placed to ensure nutrition delivery. We help patients and families to understand that in the context of an eating disorder, “food is medicine.” The tube is not meant to be a threat or a punishment but rather a tool to provide the medical intervention the patient needs when oral intake has been too difficult to achieve on their own. When an NG tube is needed, it is left in place until the patient has been able to take in 100% of their nutrition orally (food or supplement) for at least 24 hours.","_key":"dd993212d48c0","_type":"span"}],"_type":"block","style":"normal","_key":"907e173108dc"},{"markDefs":[],"children":[{"marks":[],"text":"To ensure that energy intake is directed toward organ recovery and weight restoration, energy expenditure is limited as much as possible via activity restriction. For the first 24 hours, the patient is placed on bed rest with assistance to the bathroom. This measure also helps to prevent falls related to syncope or cardiovascular compromise, which are more commonly encountered near the start of admission. Activity is gradually reintroduced with time spent in a bedside chair, seated showers, 30-minute wheelchair rides, and attendance at child life or music therapy events, all based on the clinical assessment of stability for each activity. Exercise of any kind is prohibited and patients are monitored for subtle exercise attempts such as pacing, squatting, or leg lifts in bed. Bathroom use is supervised with the door cracked open, with direct visualization expected for hygiene activities like teeth brushing and hair care but listening only for toileting and showering. These measures allow staff to monitor for purging, exercise, or fluid loading and to observe for signs of distress or syncope. Patients are encouraged to use the bathroom before meals or snacks, and bathroom use is discouraged for 1 hour after.","_key":"3fc0375df0d60","_type":"span"}],"_type":"block","style":"normal","_key":"9fd7e518dcee"},{"style":"normal","_key":"e0b38d39b8f1","markDefs":[],"children":[{"marks":[],"text":"Throughout hospitalization, the CL team provides psychoeducation and psychotherapeutic support to the patient and family as they navigate the protocol. Because of the high comorbidity of eating disorders with other psychiatric conditions, a thorough diagnostic evaluation is conducted upon admission, with a special focus on safety assessment.","_key":"f73109a698fa0","_type":"span"},{"marks":["superscript"],"text":"6,7","_key":"bc134f7c67a8","_type":"span"},{"marks":[],"text":" In cases where active suicidal ideation raises imminent safety concerns, we institute our hospital’s suicide precautions protocol and reassess daily the need for maintaining that level of care. Suicide risk management also becomes a specific part of the treatment plan, including potential need for a higher level of care after medical stabilization or formal safety planning and lethal means restriction in the discharge planning process.","_key":"6ef9889b29d2","_type":"span"}],"_type":"block"},{"style":"normal","_key":"c90e4f8a1134","markDefs":[{"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/topics/psychopharmacology","_key":"c1e7cacbb995","nofollow":true}],"children":[{"_type":"span","marks":[],"text":"Many patients experience high levels of anxiety around mealtimes, especially as food volume increases or as patients detect changes in how their body looks or feels upon gaining weight. When anxiety and distress become so overwhelming as to affect the patient’s ability to eat or otherwise engage in necessary cares, or when distress manifests in severe behavioral dysregulation or aggression, psychotropic medication support can be helpful, either on an as-needed basis or scheduled. When medications are initiated, it is understood that this intervention is likely time limited during this high-acuity period. Medication targets symptom management and psychiatric comorbidities rather than serving as a primary intervention for the eating disorder itself, recognizing the lack of support in the literature for the efficacy of ","_key":"dea5677b3bd60"},{"_type":"span","marks":["c1e7cacbb995"],"text":"psychopharmacology","_key":"f7ef40e48615"},{"_type":"span","marks":[],"text":" in longer-term eating disorder treatment.","_key":"a6032cb972d2"},{"_type":"span","marks":["superscript"],"text":"8","_key":"eeb49ac767cc"},{"text":" The goal is to enable the patient to restore nutrition enough to engage in evidence-based therapies post discharge. Hydroxyzine and olanzapine are the most frequently utilized medications, with aripiprazole used occasionally and selective serotonin reuptake inhibitors sometimes initiated to address comorbid depression or anxiety.","_key":"915a9aad932e","_type":"span","marks":[]}],"_type":"block"},{"children":[{"_type":"span","marks":[],"text":"The CL team typically provides patients with psychotherapeutic worksheets relating to insight, self-reflection, and coping, and uses those worksheets as platforms for deeper discussion. For many patients, however, malnutrition is so profound that their ability to engage with executive function–related tasks and higher-order thinking around emotion regulation are significantly impaired, with limited insight into the need for treatment. We advise patients and families that the primary goal during medical hospitalization is to restore nutrition and that mental health interventions at this acute point are purposely focused on psychoeducation and broad emotional support; these are the aims that malnourished brains are best able to target. Therapeutic interventions integrate aspects of family-based treatment (FBT) related to externalizing the eating disorder and promoting parental management of meals and nutrition. When patients do demonstrate insight and interest in processing the emotional and cognitive side of their illness, we do our best to engage in brief and focused psychotherapy as often as possible within the constraints of a busy consultation service. Ultimately, helping to coordinate longer-term mental health supports at the appropriate level of care upon discharge is the most impactful mental health intervention.","_key":"f74242d3d3640"}],"_type":"block","style":"normal","_key":"2ba445d1d1d3","markDefs":[]},{"_type":"block","style":"normal","_key":"6acef4e13a62","markDefs":[],"children":[{"text":"Readiness for discharge is determined on a case-by-case basis, but generally is considered when vital signs have improved; short-term labs have normalized; the patient is eating adequately at goal calories (taking oral supplement is occasionally acceptable, depending on percentage of intake coming from supplement alone and the anticipated next level of care); a clear weight-gain trend is noted (if needed); and a follow-up plan is in place. Families meet with the RDN prior to discharge to ensure they understand the caloric needs of the patient and how best to meet these needs with an at-home meal plan. The treatment team coordinates with schools and universities, with permission of the patient and family, to provide guidance on safely acclimating back to typical routines or to request accommodations or temporary academic deferrals.","_key":"9d07f76dde550","_type":"span","marks":[]}]},{"_type":"block","style":"normal","_key":"c25a6113db56","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Most patients discharge to outpatient care, a partial hospitalization program (PHP), or an intensive outpatient program (IOP), sometimes in person and sometimes virtually. We are fortunate to have access to an excellent multidisciplinary care center at our own institution, the Comprehensive Eating Disorders Program, which offers an FBT approach at the PHP, IOP, and outpatient levels. For more acute needs, patients might transfer to an inpatient psychiatric unit or discharge to a residential treatment center.","_key":"60ccf03cb5ce0"}]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Psychoeducation and Family Communication","_key":"4c45c83f8dd50"}],"_type":"block","style":"normal","_key":"b0bc8c32c84f"},{"_key":"72d8385dc8ce","markDefs":[{"nofollow":true,"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F6acf7d5ddd45d1336d7986854fc7e45a0fcf5263-276x658.png%3Ffit%3Dcrop%26auto%3Dformat\u0026w=640\u0026q=75","_key":"1105bf236c8d"}],"children":[{"marks":[],"text":"Immediately upon admission, the primary team provides the family with our internally developed guidebook, Inpatient Nutrition Recovery for Children. This 40-page booklet relays information about the multidisciplinary care team, what is happening medically and psychologically relating to the eating disorder, what nutrition recovery entails and why it is important to monitor closely throughout, how the protocol works and why limitations are set, helpful things for parents to say and do, pitfalls to avoid, general information about planning for discharge, and a list of external resources for families to access. The book was written and edited by a multidisciplinary work group and was processed through our institution’s Plain Language Review Board to ensure broad accessibility. With a small internal grant for patient education, we funded professional graphic design and binding for the book and obtained 300 hard copies to distribute. Future goals include translation of the guidebook into additional languages. Families have provided positive feedback about the value of the book in addressing their questions and alleviating their distress about hospitalization. We welcome others to freely access and distribute the digital booklet (see ","_key":"505bb11433010","_type":"span"},{"_type":"span","marks":["strong","1105bf236c8d"],"text":"Figure 1","_key":"4aab48ff9061"},{"_type":"span","marks":["strong"],"text":" ","_key":"700e3769e196"},{"text":"for QR code).","_key":"28b3313dd1c5","_type":"span","marks":[]}],"_type":"block","style":"normal"},{"disableTextWrap":false,"disableLightBox":true,"imgcaption":[{"style":"normal","_key":"8abb8889ad5e","markDefs":[],"children":[{"marks":["strong"],"text":"Figure 1. ","_key":"8854d1b525f10","_type":"span"},{"_key":"4d65f2f7ebac","_type":"span","marks":[],"text":"QR Code for Inpatient Nutrition Recovery for Children Guidebook"}],"_type":"block"}],"asset":{"_type":"reference","_ref":"image-6acf7d5ddd45d1336d7986854fc7e45a0fcf5263-276x658-png"},"blank":true,"_type":"figure","widthP":40,"alt":"FIGURE 1. QR Code for Inpatient Nutrition Recovery for Children Guidebook","_key":"b4ff643a20d0","alignment":"right"},{"children":[{"_type":"span","marks":[],"text":"Alongside the guidebook, the grant funded the creation of a professionally produced a 12-minute video, Managing Eating Disorder Behaviors, that addresses helpful ways for families to manage common eating disorder behaviors. The video features actors portraying a mother and daughter sitting through a meal and outlines strategies for handling negotiation attempts, food diversion, and emotional outbursts. For hospitalized patients, the video is preloaded onto an internal network that offers informational videos pertinent to each patient’s presenting concerns on the television in their hospital room. Caregivers are also provided with a QR code linking directly to the video so they can watch it on a personal device away from their child (see ","_key":"0e09dd9dc5f90"},{"_type":"span","marks":["strong","985a6fe02ef5"],"text":"Figure 2","_key":"cf051c897361"},{"marks":[],"text":" for QR code).","_key":"18707cb6d5d5","_type":"span"}],"_type":"block","style":"normal","_key":"4da1d2bc51a9","markDefs":[{"nofollow":true,"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F43ac29c2955c9bc8eddececcb805d51633558b3c-318x528.png%3Ffit%3Dcrop%26auto%3Dformat\u0026w=640\u0026q=75","_key":"985a6fe02ef5"}]},{"widthP":40,"alt":"FIGURE 2. QR Code for Managing Eating Disorder Behaviors Video","imgcaption":[{"style":"normal","_key":"5ef466099ce3","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Figure 2. ","_key":"941772eec0370"},{"_key":"621f1512d709","_type":"span","marks":[],"text":"QR Code for Managing Eating Disorder Behaviors Video"}],"_type":"block"}],"_key":"7d5d01d7e5a1","disableLightBox":true,"_type":"figure","alignment":"right","asset":{"_ref":"image-43ac29c2955c9bc8eddececcb805d51633558b3c-318x528-png","_type":"reference"},"blank":true,"disableTextWrap":false},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Acute Behavior Dysregulation","_key":"9596bdb9b0ac0"}],"_type":"block","style":"normal","_key":"9a1a2d811a15"},{"_type":"block","style":"normal","_key":"99f821294841","markDefs":[],"children":[{"text":"It is not uncommon for patients to demonstrate significant behavioral dysregulation during the refeeding process, manifesting as emotional or verbal outbursts, throwing food or other objects, physical aggression toward others, self-harm attempts, or tampering with or removing the NG tube, and this remains an important challenge for care. When verbal de-escalation measures and environmental interventions alone are insufficient, our care team works together with the patient and family to devise a structured behavioral plan (eg, access to electronics or other preferred activities contingent on maintaining safe behaviors and engaging in cares). We are fortunate to have a skilled behavioral support nurse on the CL team who can sit with patients and families during meals and help with coaching and distress tolerance. Oral medications can be helpful for addressing anxiety and agitation. Intramuscular medication is occasionally necessary to ensure the safety of the patient and others around them.","_key":"1a988888f9e90","_type":"span","marks":[]}]},{"markDefs":[],"children":[{"marks":[],"text":"On rare occasions, patients refuse NG tube placement or go to great lengths to disrupt or remove the tube once it is placed. We have seen patients try to cut or chew through the tubing or pull it out completely, even when bridled. If these behaviors are not manageable with the previously mentioned interventions, and they prevent us from delivering necessary nutrition in the context of severe medical compromise, we sometimes employ physical restraint to ensure that the patient receives the imperative medical care. In these instances, we first consult the Pediatric Ethics Committee and convene with the multidisciplinary team and family to discuss the safest and most appropriate approach to the intervention. Even for minors, whose parents ultimately make medical decisions, we are thoughtful about valuing patient autonomy and the importance of assenting to care. Acknowledging the effects of malnutrition and the eating disorder itself on the patient’s ability to recognize the need for treatment, we work to balance self-determination against the imminent risk of serious medical complications or death. Furthermore, we consider the psychological effects of physical restraint, especially in the context of the patient’s past mental health history and any previous experiences with restraint or forced care. We aim to make the most compassionate and medically safe decision possible in each context.","_key":"74919c4d69790","_type":"span"}],"_type":"block","style":"normal","_key":"8910d773e06b"},{"markDefs":[],"children":[{"marks":[],"text":"Modifications to the protocol or changes to the level of staffing are often instituted before proceeding to forced use of an NG tube, and we have had several cases in which these alterations have successfully allowed us to restore nutrition safely without using physical restraint. When implemented, restraint is used only for the duration of the time needed to place the tube and safely administer nutrition; a patient would not be left in restraints between meals for the sake of maintaining the integrity of the tube. If needed, formula administration is consolidated and clustered as is safely possible given the volume to reduce the number of tube administrations or time needed in restraints.","_key":"db7b021442fb0","_type":"span"}],"_type":"block","style":"normal","_key":"867bb0081832"},{"_type":"block","style":"normal","_key":"315c76df6201","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Typically, this level of behavioral dysregulation occurs in the context of the most severe cases of malnutrition, and we see significant and rapid improvement as the brain is refed. After extreme behavioral exacerbations requiring intensive interventions, we prioritize debriefing and processing with staff across disciplines, acknowledging the moral distress that can come with providing care in these difficult situations.","_key":"4ff1bee323e80"}]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Decisional Capacity","_key":"e693b250a6f10"}],"_type":"block","style":"normal","_key":"7aa5e47e5e7e"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Implementing the protocol and eliciting patient engagement can be especially challenging for 18- to 24-year-olds, as these patients typically have legal decision-making rights over their care (unless under guardianship/conservatorship). Questions regularly arise regarding the decisional capacity to decline an NG tube or dispositional capacity to leave the hospital before it is medically safe to do so. We can divide these patient types conceptually into 2 groups: those who live at home with their parents (and may still be in high school) or are otherwise dependent on their caregivers, and those who live independently as working adults or college/university students who do not rely on family support for daily living.","_key":"36ca830acf8c0"}],"_type":"block","style":"normal","_key":"dde19e5dbf19"},{"markDefs":[],"children":[{"_key":"0085d53c6c770","_type":"span","marks":[],"text":"For the first group, parents who align with the treatment team in recognizing the need for care can support their child’s recovery by declining to take them home if the child wants to leave the hospital or enacting firm limits and other forms of “tough love” to encourage their child’s participation in care. In the context of an eating disorder, this may include not paying for cellular telephone service, removing access to preferred activities, or withdrawing tuition support for college/university. We try to help parents and patients understand that these measures are not meant to be punitive but to guide the patient toward sound decision-making when the eating disorder and malnutrition are clouding their judgment. In fact, when parents take these steps to help their child’s recovery, they are actively working toward enabling the young adult to regain autonomy, not just with respect to food but also in other aspects of their life that may have been commandeered by the eating disorder."}],"_type":"block","style":"normal","_key":"e1de0f9e4b09"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"For young adults who live independently, or for situations in which the parental intervention approach is not possible or is ineffective, questions related to compelling care are more difficult. Comprehensive psychiatric assessment of capacity is required in each case and for each decision point as it cannot be generalized that the presence of a severe eating disorder (or severe malnutrition) necessarily compromises decision-making capacity. Additionally, the risk level for each decision is crucial, especially as it pertains to leaving the hospital before reaching medical stability. Discharging to an apartment with roommates, a sedentary job, established provider connections, and a grocery delivery service is very different from transitioning to a solo apartment with out-of-state parents, a limited friend base, no established care providers, and an on-your-feet job or full academic course load. For students, support through their college/university may also be activated to enhance their support network, including academic accommodations, school-based health programs, and residential advisers. To the extent that patients are willing to engage, we partner with them to mitigate the risks as best as possible before we consider discharging against medical advice.","_key":"3ea5263da6560"}],"_type":"block","style":"normal","_key":"7175dcb04cee"},{"_key":"55b2b1391b8f","markDefs":[],"children":[{"text":"Sometimes, we send patients out with the expectation that we will see them again in the ED very soon, hoping that we can be more effectual with our help the next time. For cases in which patients truly do not demonstrate capacity or willingness to collaborate to mitigate risk, and medical compromise is so severe that the only medically safe decision is to continue treatment in the hospital, we again consult with our Ethics Committee, Clinical Risk and Patient Relations, and our Office of the General Counsel as pursuit of emergency medical guardianship (either by family or a third party) may be necessary.","_key":"4cc3b0b000fe0","_type":"span","marks":[]}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"marks":[],"text":"Notably, significant debate continues around the concept of involuntary or compulsory treatment for AN, with varied opinions from medical, ethical, legal, philosophical, psychological, and societal perspectives.","_key":"3e0ce70367720","_type":"span"},{"_type":"span","marks":["superscript"],"text":"9","_key":"f40d07817d8d"},{"text":" As providers, our goal is to care for the patient before us. We do our best to act responsibly, compassionately, transparently, and within the bounds of our professional ethics. We learn from every case and we always strive to improve.","_key":"2c307b89b33f","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"882177001103"},{"children":[{"marks":["strong"],"text":"Barriers to Discharge Planning","_key":"f8be0bf2f9cf0","_type":"span"}],"_type":"block","style":"normal","_key":"11c339287e5f","markDefs":[]},{"_key":"ee80ce35c438","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Unfortunately, resources for eating disorder care are limited and wait lists are long. When transitioning to outpatient-level care, we typically can arrange for weekly weigh-ins and vitals checks at the primary care office, but mental health supports are more challenging to align quickly. Sometimes, the inability to arrange for appropriate outpatient therapy within a reasonable time frame pushes us toward PHP or IOP as the best discharge plan.","_key":"e9ad235b5d8c0"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"e6c30f7490e1","markDefs":[],"children":[{"_type":"span","marks":[],"text":"In Southeast Michigan, we are fortunate to have several options for PHPs focused on eating disorder care, though only 1 of them (our own) operates under an in-person, family-based treatment model. There are a number of common barriers to accessing any of these programs, including insurance coverage, patient age, and geographic limitations; driving more than an hour each way—twice daily—is often not feasible for working families. Additionally, BMI/weight at discharge can be a limiting factor, as many programs will not accept patients below a BMI of 15 or weight less than 80% of estimated goal. Our own program can be more flexible around this metric as we have ready access to AM, specialized nursing, and the hospital itself. When weight or BMI affect placement options, we must consider prolonging hospitalization to achieve the necessary weight gain vs discharging home for weight restoration, which can be onerous on families and often results in readmission.","_key":"72f5836e62370"}]},{"_type":"block","style":"normal","_key":"878dbd1ce009","markDefs":[],"children":[{"_type":"span","marks":[],"text":"When psychiatric hospitalization is needed, either due to comorbid safety concerns, comorbid psychiatric illnesses, or psychological factors impeding the patient from progressing past tube dependence, our options are significantly limited. Only 2 psychiatric units in our state (ours included) can accommodate NG tubes or will consider admitting patients with an active eating disorder diagnosis. Payer coverage is also challenging, especially if there is not a clear suicide risk. Payers will often authorize only 1 or 2 days of treatment in the context of an eating disorder, which offers little value in helping the patient to progress. If the psychiatric inpatient team cannot successfully advocate for additional covered days, then the options amount to hastening the discharge, billing the family, or (more commonly) positioning the hospital to absorb the cost. Ultimately, clinical need guides decision-making around inpatient psychiatric admission, but the coverage constraints can certainly burden families in an already stressful situation, and they highlight a clear inequity in the provision of care for this population.","_key":"8259ecb54f6f0"}]},{"children":[{"_type":"span","marks":[],"text":"For patients who need residential care, there are no eating disorder–specific facilities that accept children in our state. Medicaid will not cover out-of-state residential care, leaving publicly insured patients without any options. For those with private insurance coverage or who can self-pay, we look regionally or nationally, which involves significant care coordination and supplemental cost to the family for transportation and local lodging. Once again, equitable access to care is a clear problem. Another significant barrier is that the patient must agree to enter the residential program voluntarily, even in cases when the parents are the legal guardians and decision- makers. We have seen many patients 18 years and older refuse residential treatment entirely or check themselves out prematurely, leaving their families with little recourse and often prompting repeat medical admission.","_key":"3540d0600a6b0"}],"_type":"block","style":"normal","_key":"cba38e065558","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Concluding Thoughts","_key":"e34ec70ec1920"}],"_type":"block","style":"normal","_key":"a52aa0ae62cf"},{"children":[{"_type":"span","marks":[],"text":"Caring for patients with malnutrition due to eating disorders presents significant challenges related to patient insight and buy-in, behavior management, and longer-term care planning. Despite these challenges, inpatient medical admission often serves as the first step in recovery and may be perceived as a wake-up call by both patients and families.","_key":"5ab27b6211f30"},{"marks":["superscript"],"text":"10","_key":"022991598829","_type":"span"},{"_type":"span","marks":[],"text":" Implementing a formalized CPG and disseminating standardized psychoeducation materials to patients and families has unquestionably improved the process at our institution. Still, we continue to face challenges in this space. We are hopeful that the resources needed to support patients with this illness can grow and develop at a rate commensurate with the clear increase in disease burden we are all experiencing across the country. We welcome questions, discussion, and open distribution of our materials.","_key":"aac115a2102b"}],"_type":"block","style":"normal","_key":"2de5f439f0b7","markDefs":[]},{"_type":"block","style":"normal","_key":"959fde07bec3","markDefs":[],"children":[{"marks":["strong"],"text":"Dr Pierce","_key":"762f53b0c0090","_type":"span"},{"_type":"span","marks":[],"text":" ","_key":"6837ddd46529"},{"_type":"span","marks":["em"],"text":"is the medical director of the Pediatric Consultation-Liaison Psychiatry Service and the child and adolescent psychiatry hospital education lead at the C.S. Mott Children’s Hospital, University of Michigan Hospital Systems. She is also a clinical assistant professor in the Department of Psychiatry, Division of Child and Adolescent Psychiatry. ","_key":"2c3873f0cc66"},{"_type":"span","marks":["strong"],"text":"Dr Stoody","_key":"2c1e0db87dd3"},{"_type":"span","marks":["strong","em"],"text":" ","_key":"05736f0dfb8d"},{"_type":"span","marks":["em"],"text":"is an assistant professor at the C.S. Mott Children’s Hospital, University of Michigan Hospital Systems.","_key":"55980a6dfb4e"},{"_key":"83cb6e4185e7","_type":"span","marks":[],"text":" "},{"_type":"span","marks":["strong"],"text":"Dr Cwynar","_key":"08903a069197"},{"marks":["em"],"text":" is a dual-certified pediatric and psychiatric mental health nurse practitioner. She has worked on the Child and Adolescent Consult and Liaison Service at C.S. Mott Children’s Hospital, University of Michigan Hospital Systems, since 2016.","_key":"e6d2cda9461b","_type":"span"},{"_type":"span","marks":[],"text":" ","_key":"8e85bc664366"},{"text":"Ms Khan ","_key":"360fef3070d1","_type":"span","marks":["strong"]},{"_type":"span","marks":["em"],"text":"is the lead social worker for the child psychiatry hospital section and a clinical social worker on the Pediatric Consultation-Liaison Psychiatry Service in the University of Michigan Hospital Systems. ","_key":"4161c0b52386"},{"_type":"span","marks":["strong"],"text":"Dr Bravender","_key":"10be47035966"},{"_type":"span","marks":[],"text":" ","_key":"67a6e2bf13a7"},{"_type":"span","marks":["em"],"text":"is the David S. Rosen Collegiate Professor of Adolescent Medicine and clinical professor of pediatrics and psychiatry at the University of Michigan. He also serves as associate chair for faculty affairs in the Department of Pediatrics, Division of Adolescent Medicine director, executive director of the Mott Comprehensive Eating Disorders Program, and comedical director of the University of Michigan Adolescent Health Initiative.","_key":"ada4ed79e064"}]},{"children":[{"_key":"5355f9277e9d0","_type":"span","marks":["strong"],"text":"References"}],"_type":"block","style":"normal","_key":"273de78cbef0","markDefs":[]},{"children":[{"_type":"span","marks":[],"text":"1. Otto AK, Jary JM, Sturza J, et al. ","_key":"fbb09b2a8c860"},{"_type":"span","marks":["4efdbe5ae105"],"text":"Medical admissions among adolescents with eating disorders during the COVID-19 pandemic.","_key":"fbb09b2a8c861"},{"_key":"ae6f8f96635e","_type":"span","marks":[],"text":" "},{"_key":"fbb09b2a8c862","_type":"span","marks":["em"],"text":"Pediatrics"},{"_type":"span","marks":[],"text":". 2021;148(4):e2021052201.","_key":"fbb09b2a8c863"}],"_type":"block","style":"normal","_key":"f683db49ae87","markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/34244452/","_key":"4efdbe5ae105"}]},{"markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/35815415/","_key":"ed9d9f285517"}],"children":[{"_type":"span","marks":[],"text":"2. Shum M, Moreno C, Kamody R, et al. 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Previously, he received the Administrative Award in 2016 from the American Psychiatric Association, the one-time designation of being a Hero of Public Psychiatry from the Speaker of the Assembly of the APA in 2002, and the Exemplary Psychiatrist Award from the National Alliance for the Mentally Ill in 1991. He is an advocate and activist for mental health issues related to climate instability, physician burnout, and xenophobia. He is now editing the final book in a 4-volume series on religions and psychiatry for Springer: Islamophobia, anti-Semitism, Christianity, and now","_key":"ee5d823cfb522"},{"text":" The Eastern Religions, and Spirituality","_key":"ee5d823cfb523","_type":"span","marks":[]},{"marks":["em"],"text":". 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He encourages expressing appreciation to those who have positively impacted our careers, highlighting the psychological benefits of gratitude. Dr. Moffic, a prolific writer and speaker, has received numerous accolades, including the 2024 Abraham Halpern Humanitarian Award. He is an advocate for mental health issues related to climate change, physician burnout, and xenophobia, and is finalizing a book series on religions and psychiatry.","_updatedAt":"2024-11-20T20:33:48Z","is_visible":true,"ExcludeFromPubMedXML":false,"factCheckAuthorMapping":null,"summary":"What can we collectively be grateful for? 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","authors":[{"displayName":"Mena Mirhom, MD, FAPA","url":"mena-mirhom-md-fapa"}],"factCheckAuthors":null,"authorMapping":[{"displayName":"Mena Mirhom, MD, FAPA","_createdAt":"2024-05-10T16:15:35Z","_rev":"QwMm59Oay7ZYj8Ct6b9dyv","_type":"author","_id":"f5403268-b617-49d0-9493-3ee35be8a425","biography":[{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Dr Mirhom","_key":"49e3e3c534eb"},{"text":" ","_key":"5e2999d95886","_type":"span","marks":[]},{"_type":"span","marks":["em"],"text":"is the immediate past president of the New York County Psychiatric Society, an assistant professor of Psychiatry at Columbia University, codirector of the PPF Express Program, and the Chief Wellbeing Officer at Athletes for Hope.","_key":"e93721daad6c"}],"_type":"block","style":"normal","_key":"2b0f1d88ec12"}],"_updatedAt":"2024-09-26T19:03:05Z","url":{"current":"mena-mirhom-md-fapa","_type":"slug"}}],"drugMentions":"{\"drug_mentions\": []}","taxonomyMapping":[{"pixelTrackingCode":null,"identifier":"commentary","_createdAt":"2020-03-26T06:11:21Z","_rev":"CT8kz40NBv9JvHKzAk1arA","_updatedAt":"2021-10-07T14:44:33Z","parent":null,"_type":"taxonomy","name":"Commentary","_id":"pst_taxonomy_54_commentary"},{"name":"Gender Issues","_updatedAt":"2020-06-10T19:45:36Z","identifier":"topics/gender","parent":{"cmeType":"per","perKeywordMapping":["Psychiatry","Neurology"],"_rev":"uvXJooXtzvjNOyx50HVRwO","_createdAt":"2020-03-26T06:11:21Z","_type":"taxonomy","name":"Special Populations","_id":"pst_taxonomy_53201_specialpopulations","_updatedAt":"2023-03-31T19:34:04Z","parent":{"identifier":"topics","isMainTopic":true,"_createdAt":"2020-03-26T06:11:21Z","_rev":"uvXJooXtzvjNOyx50HTt8m","_type":"taxonomy","name":"Topics","_id":"pst_taxonomy_53202_clinical","_updatedAt":"2023-03-31T19:15:59Z"},"identifier":"topics/special-populations"},"_createdAt":"2020-03-26T06:11:21Z","_id":"pst_taxonomy_180_genderissues","_rev":"snQqhhB4O8T5bi1viUSkda","_type":"taxonomy","pixelTrackingCode":null}],"published":"2024-11-20T14:00:48.197Z","body":[{"imgcaption":[{"children":[{"_key":"8c31cf5d0b700","_type":"span","marks":[],"text":"Konstantin Yuganov/AdobeStock"}],"_type":"block","style":"normal","_key":"8313a46b6b30","markDefs":[]}],"alignment":"left","asset":{"_ref":"image-7c39102898e611ce3507c55a3fa8e14543b73169-4436x3000-jpg","_type":"reference"},"widthP":50,"disableTextWrap":false,"disableLightBox":true,"_type":"figure","alt":"superhero","_key":"7b2f28841e37"},{"markDefs":[],"children":[{"_key":"ea96fc79b5130","_type":"span","marks":["strong"],"text":"COMMENTARY"}],"_type":"block","style":"normal","_key":"68f3a792a14e"},{"_type":"block","style":"normal","_key":"1adc246f78b5","markDefs":[],"children":[{"marks":[],"text":"“You’re not going to make me cry…so stop trying.” Peter told me in response to what I thought was a seemingly surface level question about a difficult experience he had. “I’ve looked into the eyes of a man before he died by suicide…and I saw that regret. I never want to feel that. So when those thoughts come, I remember him.”","_key":"baa545031cd50","_type":"span"}]},{"children":[{"text":"","_key":"4455b337bd850","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"1ef8b131c26a","markDefs":[]},{"_key":"09e5a43f5769","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Peter spent a long career in law enforcement and became accustomed to war. After a while, when every day is filled with pain that is beyond the capacity of the human heart to bear, we have no choice but to become numb. He only realized his anesthetized state after retiring from law enforcement. “I remember one day that I responded to a shooting. As I walked by 2 bodies on the street, I realized I hadn’t eaten in 12 hours and had a tuna sandwich in my hand. Here I was with a sub, as I walked through death. That was not normal. 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This November, we can help sound the alarm to change that.","_key":"a970105586e30"}],"_type":"block","style":"normal"},{"children":[{"text":"","_key":"5234a983f21f0","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"b9381f7be868","markDefs":[]},{"_key":"219dfc99ed57","markDefs":[],"children":[{"marks":[],"text":"I got a glimpse of this the first time I saw a patient die in the hospital. As the psychiatry intern rotating on the medicine team, we arrived in the morning to discover “Mr Jones” had passed away overnight. He was there for 2 weeks and the team got to know him, his wife, and his family. And now he was gone. What do we do next? Round. There are other patient to treat, codes to attend to, admissions, discharges, and no room to mourn. That also was not normal. All of us in health care felt the magnified version of this when we experienced the collective trauma during COVID-19 of losing multiple patients every single day. I have since treated several clinicians who were surprised to hear that they experienced a war-like trauma that must be processed and treated.","_key":"4244555d8c8f0","_type":"span"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_key":"1347c82b5b440","_type":"span","marks":[],"text":""}],"_type":"block","style":"normal","_key":"e3eac63a9f0b"},{"_type":"block","style":"normal","_key":"be21034ed6ff","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Men are often taught to not be distracted by processing what they witness or experience. It is often challenging to allow a man the space to express the reality of horror he encountered in a way that is comfortable for him. For Peter, he wanted no “fluff” and would often tell me: “Listen, I’m not here for hugs. I’m here because my wife made me. She said I’ve just been way more angry than usual.”","_key":"e04442db24190"}]},{"style":"normal","_key":"42301086f25c","markDefs":[],"children":[{"text":"","_key":"89514f08ed7f0","_type":"span","marks":[]}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"That anger that masks our sadness is often expressed with family members, loved ones, and even coworkers. Peter slowly came to recognize the source of that anger. There was fear beneath it. He feared the helplessness of not being able to protect his loved ones one day. He could not talk about his experiences because most people simply “would not understand” and those who would, are struggling with their own experiences just the same.","_key":"fd3ef768dc3b0"}],"_type":"block","style":"normal","_key":"a2bba655b684"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"9cbb5ad5e83b0"}],"_type":"block","style":"normal","_key":"03a346fd7fe8"},{"_key":"739729530a7a","markDefs":[],"children":[{"_type":"span","marks":[],"text":"We came to Peter on his own terms. Things were not sugar coded, no pleasantries. John Mulaney, a well-known comedian who struggled with substance use and chronicled his experiences in comedy specials, once spoke about a conversation with a doctor he had at rehab. He was intent on leaving and ready to argue his way out. The doctor simply looked at him and said, “John, we both know how this movie ends.” No arguments. No poetic therapeutic lingo; just direct truth that he needed to hear. John describes this ending: “I heard that…and I went right back to my room and finished my rehab.”","_key":"34ed317724020"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"855f52341dea0"}],"_type":"block","style":"normal","_key":"3e716bcbd278"},{"_key":"e8815e40aaac","markDefs":[],"children":[{"_key":"78f24bd9f71d0","_type":"span","marks":[],"text":"Men speak a language that is reachable if we take the time to learn it. Just as we use an interpreter when speaking with a patient whose native tongue is foreign to us, could we allow ourselves to take a moment to translate our knowledge to a language that can penetrate the very fragile armor that men walk into our offices with?"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"5630116e2e82","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"0a9b564b96870"}]},{"_key":"90d1393c704e","markDefs":[],"children":[{"_type":"span","marks":[],"text":"In so doing, perhaps we can help save their own lives… in truly heroic human fashion.","_key":"36f20c20fea50"}],"_type":"block","style":"normal"},{"children":[{"_type":"span","marks":[],"text":"","_key":"deccba8143f90"}],"_type":"block","style":"normal","_key":"d96203e789f0","markDefs":[]},{"_key":"551d290fda6c","alignment":"left","asset":{"_type":"reference","_ref":"image-a0d37e90f9a97fe854dce129836bf3d4978f7f49-1080x1080-jpg"},"widthP":40,"disableTextWrap":false,"disableLightBox":true,"_type":"figure","alt":"Mena Mirhom, MD"},{"style":"normal","_key":"4fcb2e0e34e3","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Dr Mirhom","_key":"144f1cbda9ae0"},{"_type":"span","marks":[],"text":" ","_key":"144f1cbda9ae1"},{"_key":"144f1cbda9ae2","_type":"span","marks":["em"],"text":"is the immediate past president of the New York County Psychiatric Society, an assistant professor of Psychiatry at Columbia University, codirector of the PPF Express Program, and the Chief Wellbeing Officer at Athletes for Hope."}],"_type":"block"},{"_key":"e808de1bf488","markDefs":[],"children":[{"_key":"dceea30d0a620","_type":"span","marks":[],"text":""}],"_type":"block","style":"normal"}],"url":"our-capes-are-killing-us-how-do-we-support-mens-mental-health-month","_id":"77a361d0-f01a-4e50-b123-dea11309cfb7","_type":"article","documentGroupMapping":null,"summary":"November is Men's Health Awareness Month. 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