Psychiatric System Crunch Worsens

Lois Fisher, chief attorney for the mental health division of the state public defender's office, which represents most involuntarily committed patients, said cases of patients who waited in emergency rooms for more than 30 hours were rare a few years ago.

"We're seeing it more frequently," she said. "We're seeing it several times a week. We've all expressed concern about it."

Petralia, the Potomac Ridge official, said involuntarily detained patients who have spent more than 30 hours in emergency rooms are a near certainty on the weekly court docket.

Under state law, people in Maryland who are involuntarily committed by law enforcement officials or at the request of their relatives are taken to emergency departments for an initial evaluation. They must be evaluated by two physicians within six hours of their commitment. If the doctors think the patients, if released, would pose a threat to themselves or others, hospital officials have 24 hours to get them to a psychiatric facility.

Once there, involuntarily committed patients go before a judge for an administrative hearing in which they can contest their hospitalization. A judge can release the patient if he has spent more than 30 hours in what some refer to as the "gray zone."

Public defenders often fight to get those patients released. Supreme Court cases and statutory law establish that people ought to be free if their commitment is unlawful, regardless of their mental state, they argue.

"We're talking about 48, 72 hours," Fisher said. "We're talking about major league delays in the ER."

Brian Drayton didn't have to wait quite that long. On Jan. 4 relatives obtained a court order to involuntarily hospitalize the 22-year-old Baltimore man.

"He imagines he's still in jail, very hostile and agitated," his mother wrote in an evaluation for an emergency petition. "He verbally threatens to defend his self. (ex. he says I'm gonna kill them before they get me.)"

He was evaluated at Greater Baltimore Medical Center, where officials signed off on the commitment order and tried to find him placement at a psychiatric hospital. He spent about two days at the center, far longer than the 30-hour legal maximum.

It can be trickier to place uninsured patients such as Drayton in psychiatric facilities because some private hospitals don't accept them, even if the state agrees to pay for their care, health care officials said.

Drayton was admitted to Potomac Ridge on Jan. 7. He authorized Potomac Ridge officials to allow a reporter to examine his medical record.

On Jan. 10, when a state judge made a weekly visit to Potomac Ridge to decide which involuntarily committed patients could leave, Drayton's condition had improved, but doctors said they felt that he was not ready to return home.

Shortly before his hearing was to start, Drayton signed a form agreeing to be hospitalized. Potomac Ridge officials said it was a huge relief, as they would have faced long odds had his case gone before the judge -- solely because it took more than 30 hours to get him to Potomac Ridge.

The crunch became a crisis at Shady Grove Adventist Hospital in Rockville about two years ago.

"It was not unusual to have patients in the [emergency department] for four days, even a week," said David G. Srour, the hospital's chief of emergency medicine. "It was like warehousing patients."

State and county officials last summer developed a pilot program at Shady Grove to streamline the referral of uninsured psychiatric patients. County crisis center mental health experts are now on call 24 hours a day to respond to Shady Grove to conduct evaluations and help find placement at a psychiatric facility when necessary.

Shady Grove officials say the pilot program has dramatically cut waiting times for referrals and allowed them to route patients to the right services.

Hepburn, the state official, said other jurisdictions across the state are taking similar steps.

But patient advocates say the long-term solution to the problem is simple: Make more beds available.

Fisher, the public defender, said she fears that the lack of prompt screening, referrals and comprehensive care will increase the likelihood that patients will wind up getting in trouble with the law.

"There is no more expensive way to access the mental health system than through the court system," she said.

Staff writer Steve Vogel contributed to this report.