{"id":43108,"date":"2025-07-28T17:20:22","date_gmt":"2025-07-28T17:20:22","guid":{"rendered":"https:\/\/www.newsbeep.com\/us\/43108\/"},"modified":"2025-07-28T17:20:22","modified_gmt":"2025-07-28T17:20:22","slug":"when-mental-health-commitments-lead-to-more-harm","status":"publish","type":"post","link":"https:\/\/www.newsbeep.com\/us\/43108\/","title":{"rendered":"When mental health commitments lead to more harm"},"content":{"rendered":"

\"Large<\/a><\/p>\n

Involuntary psychiatric hospitalization can put some people in Allegheny County on a path that leads to violence or death \u2014 outcomes that fly in the face of what civil commitment laws intended, new research has found.<\/p>\n

The people at risk are those whose behavior may not be a clear-cut case for hospitalization, but are hospitalized anyway due to a doctor\u2019s judgment call, often driven by risk-aversion and fear of liability. But instead of keeping these patients from harming themselves or others, hospitalization nearly doubles their risk of being charged with a violent crime in the months following their evaluation. It also nearly doubles their risk of dying by suicide or overdose.\u00a0\u00a0<\/p>\n

The findings are detailed in a paper<\/a> published by the Federal Reserve Bank of New York and co-authored by one of its economists, a researcher based at Allegheny County\u2019s Department of Human Services [ACDHS] and a fellow at Stanford University\u2019s Hoover Institution<\/a>. The research is likely the first to establish a causal link between hospitalization and harm a person experiences after they\u2019re discharged, said Pim Welle, a co-author and the county department\u2019s chief data scientist, during an interview.\u00a0<\/p>\n

\u201cIt was a surprising result for us to see because the goal of this statute is really to prevent harm,\u201d Welle said, referring to Section 302<\/a> of Pennsylvania\u2019s Mental Health Procedures Act<\/a>, which empowers anyone to file a petition to involuntarily hospitalize a person whom they believe needs emergency psychiatric treatment. \u201cThat\u2019s the justification for this thing, and we\u2019re seeing these marginal cases break the other way.\u201d\u00a0<\/p>\n

\"\"From left, Alex Jutca, director of the Office of Analytics, Technology and Planning and Pim Welle, chief data scientist, discuss AOT during an interview at the Allegheny County Department of Human Services, May 6, in Downtown. (Photo by Stephanie Strasburg\/Pittsburgh\u2019s Public Source)<\/p>\n

The research focuses on about 40% of the people involuntarily hospitalized in the county: those who would be committed by some doctors \u2014 who may be more likely to uphold petitions \u2014 but would not be committed by others. The sample is made up of involuntary hospitalization evaluations of people aged 18 to 64 that took place here from June 2014 through the end of 2023. Welle emphasized the results can\u2019t be generalized to the total population of those involuntarily hospitalized in the county.\u00a0<\/p>\n

\u201cThe last thing that we want people to take away from this study is that we should get rid of this 302 system \u2014 that would be a tragic conclusion if people understood that from our work,\u201d he said. But the data suggests \u201cwe should dial back\u201d the amount of cases that fall into a gray area.\u00a0<\/p>\n

The paper was published this month during a time of increasing political support for involuntary commitment. President Donald Trump signed an executive order<\/a> Thursday that aims to institutionalize unhoused people who have mental illnesses, substance use disorders or both. The impact is unclear because states make laws that regulate involuntary commitment and programs are administered by county and local governments. The order also directs federal agencies to shift funding away from housing-first<\/a> and harm-reduction<\/a> programs, which are supported by evidence. \u201cShifting homeless individuals into long-term institutional settings for humane treatment through the appropriate use of civil commitment will restore public order,\u201d the order said.\u00a0<\/p>\n

Many states, including Pennsylvania, have expanded involuntary commitment laws over the past decade, though implementation has been limited<\/a>. Allegheny County\u2019s top human services official, Erin Dalton, informed the state in December that the county will implement Pennsylvania\u2019s statute<\/a> for assisted outpatient treatment [AOT] by this fall, though she told Public Source in May<\/a> that a final decision hasn\u2019t been made. AOT is a controversial legal mechanism for forced treatment in the community, which human services officials are considering as part of a plan<\/a> to mitigate the poor outcomes of involuntary inpatient commitment described in the working paper. The evidence for AOT is mixed and no Pennsylvania county has successfully implemented it since it became state law in 2018.\u00a0\u00a0<\/p>\n

What\u2019s it like to be involuntarily hospitalized?\u00a0<\/p>\n

Cassandra, a 34-year-old native of Long Island, New York, was first involuntarily hospitalized as a teen. At her request, Public Source is withholding her last name to keep her diagnoses of depression and schizoaffective disorder private. She said she \u201cstruggles with paranoia\u201d and \u201cgets overwhelmed very easily,\u201d among her other symptoms.\u00a0<\/p>\n

<\/p>\n

She witnessed and experienced constant domestic violence in her household while growing up. That triggered an outburst when she was 19 that led her parents to call the ambulance that took her to a local hospital. She described an overwhelmingly negative experience during the three months she spent in its psychiatric unit: Hospital staff wouldn\u2019t take her off the antipsychotic risperodone, despite her complaints about its side effects. \u201cI had to pull my pants down and get injected in the behind\u201d by male hospital workers, she said, which traumatized her so much that she punched a window.\u00a0<\/p>\n

\u201cThe hospital that was treating me mistreated me,\u201d she said. \u201cThe staff members were just very disrespectful.\u201d\u00a0<\/p>\n

The paper\u2019s findings are unique to conditions in Allegheny County and can\u2019t be tied to Cassandra\u2019s experiences in another jurisdiction. But an expert who wasn\u2019t involved in the study said too many patients like her lose trust in the mental health care system after such bad experiences.\u00a0<\/p>\n

What happens to people while they\u2019re hospitalized \u201cis just this black box that goes unexamined,\u201d said Morgan Shields, an assistant professor in the School of Public Health at Washington University in St. Louis. Her research focuses on that quality of inpatient psychiatric care<\/a>, including how institutional betrayal can affect trust<\/a> and engagement with systems.\u00a0<\/p>\n

\"\"A heart hangs in one of the windows of UPMC Western Psychiatric Hospital, July 24, in Oakland. (Photo by Stephanie Strasburg\/Pittsburgh\u2019s Public Source)<\/p>\n

\u201cWe really need to be thinking about what\u2019s happening inside of that black box, and how much of this effect is due to\u201d force, disruption and what\u2019s happening overall to people in hospitals, said Shields. \u201cThose are outstanding empirical questions that, while this paper is a huge contribution, it can\u2019t answer.\u201d She noted the experiences of those who are committed \u201caren\u2019t a monolith\u201d and \u201csome people have what they feel are really good experiences.\u201d\u00a0<\/p>\n

\u201cThe therapeutic care that happens in inpatient [settings] has to outweigh\u201d the cost of negative experiences in hospitals, Welle said, \u201cbut that\u2019s not happening\u201d for those who fall into the gray area where they would be hospitalized by some doctors, but not others.\u00a0<\/p>\n

Evidence that hospitalization can cause harm\u00a0\u00a0<\/p>\n

The county\u2019s uniquely robust data collection system<\/a> allowed the research team to investigate the effects of involuntary hospitalization, Welle said. It integrates Medicaid records, court records, death notices, state unemployment insurance claims and data from other sources to create the dataset. (The team explained their research design in answers to these frequently asked questions<\/a>.)\u00a0<\/p>\n

Physician tendency to hospitalize in the sample ranged from 11% to 100%, indicating some doctors were more likely to hospitalize those facing 302 petitions while others were less likely to do so.\u00a0 An increase in a doctor\u2019s tendency to hospitalize was associated with an increase in a patient\u2019s likelihood of being charged with a violent crime in the following three months.\u00a0<\/p>\n

\"\"The likelihood of a violent criminal charge was much higher for people who were involuntarily committed in borderline cases than for a control group. (Source: report co-authored by the Allegheny County Department of Human Services.)<\/p>\n

An increase in a doctor\u2019s tendency to hospitalize was also associated with an increase in the probability of suicide or overdose death.\u00a0<\/p>\n

\"LineSimilarly, the risk of death by suicide or overdose was substantially higher during the months after an involuntary commitment that was a judgment call than for a control group. (Source: reporter co-authored by the Allegheny County Department of Human Services)<\/p>\n

The team explored \u201cmechanisms\u201d that could be driving these outcomes, including the disruption of employment and access to housing, and loss of trust between the patient and the petitioner \u2014 who may be a loved one or a professional such as a social worker \u2014 and in the entire mental health care system.\u00a0<\/p>\n

The study also found that people subject to involuntary commitments included just 1.5% of the county\u2019s Medicaid enrollees, but accounted for nearly 25% of Medicaid-paid behavioral health spending.<\/p>\n

Some doctors fear liability<\/p>\n

A psychiatrist told Public Source he initially didn\u2019t want to believe the research findings.\u00a0<\/p>\n

\u201cI was somewhat incredulous, and I felt that there had to be some other explanation for this increase in suicide, overdose and criminal charges we\u2019re seeing,\u201d said Awais Aftab, a clinical assistant professor of psychiatry at Case Western Reserve University, who spent several years working at a state hospital in Northfield, Ohio. \u201cBut the more I looked at the data, the more I cannot find some methodological limitation or some kind of confounding variable,\u201d he said. \u201cThe data held up pretty well.\u201d<\/p>\n

Aftab \u2014 who once sat on a symposium panel with Welle \u2014 wrote a Substack essay<\/a> about the findings, where he quoted from the book Skin in the Game<\/a> by the statistician Nassim Nicholas Taleb: \u201cA doctor is pushed by the system to transfer risk from himself to you, and from the present into the future, or from the immediate future into a more distant future.\u201d\u00a0<\/p>\n

\u201cThe real thing to do is that, if you\u2019re in doubt, then discharge the person. Only admit them if you\u2019re very sure that this is what they need right now.\u201d\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n

Awais Aftab<\/p>\n

Aftab described a culture of \u201cdefensive decision-making\u201d around involuntary commitments, motivated by a doctor\u2019s fear of liability if a patient whose petition they didn\u2019t uphold harms themselves or others in the community. When those doctors admit patients, he said, \u201cthey\u2019re not thinking of what will happen three months down the road,\u201d such as the adverse outcomes in the research. There could be tradeoffs between ensuring a person\u2019s safety in the moment and ensuring their safety in the long-term, and physicians should be trained to navigate that, he added.<\/p>\n

\u201cThe real thing to do is that, if you\u2019re in doubt, then discharge the person,\u201d he said. \u201cOnly admit them if you\u2019re very sure that this is what they need right now.\u201d\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n

Aftab also attributed the study\u2019s findings to a nationwide shortage in psychiatrists. They tend to hospitalize people at lower rates than emergency physicians less experienced in mental health, the researchers wrote in the report.\u00a0<\/p>\n

And physician bias against Black patients \u2014 who are disproportionately committed in the sample the researchers studied and nationally \u2014 could be playing a role, too. \u201cClinicians tend to perceive Black [patients] as being more dangerous and being more at risk,\u201d he said.\u00a0<\/p>\n

What the county is doing to help those at risk\u00a0<\/p>\n

The study \u201cshould not have been possible,\u201d said Alex Jutca, director of the Office of Analytics, Technology and Planning within ACDHS. He pointed out the health system failures that contributed to the harms experienced by those in the research sample. \u201cThere should not be sufficient variation in the [physicians\u2019 decision-making] to allow us to estimate this.\u201d\u00a0<\/p>\n

After the paper was published on July 15, the county\u2019s Department of Human Services put out a statement that said it\u2019s \u201ccommitted to improving outcomes and reducing adverse events\u201d for people with serious mental illness, and listed 11 policies and programs<\/a> it\u2019s implementing or considering. The plan includes:\u00a0\u00a0<\/p>\n

Working with providers to \u201creexamine physician training,\u201d facilitate \u201cknowledge-sharing across disciplines\u201d and promote more circumspection around the choice to hospitalize\u00a0\u00a0\u00a0<\/p>\n

Launching a new \u201cpeer-led, short-term respite overnight program\u201d in a \u201chome-like environment,\u201d staffed by those with personal recovery experience who are trained to provide non-clinical crisis services\u00a0<\/p>\n

Launching an \u201cAlternative Response program,\u201d which routes 911 calls to behavioral health first responders in lieu of police across 11 municipalities and two police departments\u00a0<\/p>\n

Deploying multidisciplinary crisis response teams to key areas, including downtown Pittsburgh, to \u201cmeet people where they are,\u201d offer to connect them to low-barrier care and reengage them frequently<\/p>\n

Expanding the supply of supportive housing for people with serious mental illness and co-occurring substance use disorders, with the goal of adding 300 beds this year.<\/p>\n

The plan also includes two controversial proposals: AOT and a pilot program to test the efficacy of financially incentivizing people to adhere to psychiatric medication in the form of long-acting injectables.\u00a0<\/p>\n

\"\"UPMC Western Psychiatric Hospital, July 24, in Oakland. (Photo by Stephanie Strasburg\/Pittsburgh\u2019s Public Source)<\/p>\n

\u201cReexamining physician training\u201d will require buy-in from the region\u2019s large health systems. The research sample contained 424 physicians at 14 different hospitals, which likely includes UPMC and Allegheny Health Network facilities.\u00a0<\/p>\n

UPMC Western Psychiatric Hospital<\/a> in Oakland is a major provider of inpatient behavioral health services in the region. A spokesperson wrote that hospital officials discussed the paper\u2019s findings with county human services officials.\u00a0<\/p>\n

\u201cThese nuanced situations underscore the importance of clinical judgment and specialized training in making informed decisions about each individual\u2019s unique clinical status, and care needs,\u201d they wrote, referring to people whose 302 petitions may be upheld by some doctors, but not others. They didn\u2019t address a question specifically about new training initiatives, but said \u201cUPMC is committed to working collaboratively with the county \u2026 and continuously evolving our practices to best serve the mental health needs of our individuals in our communities.\u201d<\/p>\n

An Allegheny Health Network spokesperson couldn\u2019t immediately confirm its officials have seen the study and are in discussions with the county.\u00a0\u00a0<\/p>\n

Independent experts weigh in on research and policy<\/p>\n

Public Source asked researchers who were not involved in the study to evaluate its methodology and findings, and the county\u2019s policy solutions. One praised the study\u2019s findings, but criticized the county\u2019s lack of investment in qualitative research that directly engages those who\u2019ve been through involuntary commitment.\u00a0<\/p>\n

\u201cI sent it to a bunch of people who were very excited to have such a paper,\u201d said Nev Jones, an associate professor in the School of Social Work at the University of Pittsburgh. Jones is an expert on psychosis interventions and was awarded a contract<\/a> by New York state to study the impacts of AOT there. Cassandra, who is under an AOT order, is a participant in the evaluation.\u00a0<\/p>\n

\"ANev Jones, an associate professor in the School of Social Work at the University of Pittsburgh, stands for a portrait on May 7, in Uptown. Jones is leading a large-scale study of the effects of AOT in New York State. She has lived experience of serious mental illness and opposes the implementation of AOT in Allegheny County. (Photo by Stephanie Strasburg\/Pittsburgh\u2019s Public Source)<\/p>\n

The paper is a valuable contribution to the scientific literature on involuntary treatment, she said, but \u201cthe next step here is simply not more administrative data analysis. \u2026 It requires a deeper understanding of where the gaps are from the perspective of the people in question, and what is going wrong from the perspective of the people in question.\u201d Methods could include interviews, focus groups or ethnography, such as ridealongs with mobile crisis teams.<\/p>\n

Welle agreed that \u201cdata only gets us so far,\u201d but the county needs to be \u201cvery careful\u201d in its engagement with \u201cindividuals pretty soon after a traumatic event.\u201d It\u2019s why \u201creally serious qualitative work here is a large challenge,\u201d he said, noting the possibility of surveying people with lived experience, among other qualitative pursuits.\u00a0<\/p>\n

Jones and Shields also criticized the county\u2019s inclusion of AOT and financial incentives for medication adherence in its policy plan, and described serious concerns around the ethics of and evidence behind these interventions.\u00a0<\/p>\n

\u201cI think that [AOT is] quite an inappropriate conclusion\u201d to draw from the research findings, said Shields, of Washington University. \u201cI think, if anything, there should be increased skepticism about forced treatment.\u201d\u00a0<\/p>\n

Venuri Siriwardane is the health and mental health reporter at Pittsburgh\u2019s Public Source. She can be reached at venuri@publicsource.org<\/a> or on Bluesky @venuri.bsky.social<\/a>.<\/p>\n

The Jewish Healthcare Foundation has contributed funding to Public Source\u2019s health care reporting.<\/p>\n

This story was fact-checked by Rich Lord.<\/p>\n

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