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Betz ME, Bowen DM, Rowhani-Rahbar A, McCourt AD, Rivara FP. State Reporting Requirements for Involuntary Holds, Court-Ordered Guardianship, and the US National Firearm Background Check System. JAMA HEALTH FORUM 2023; 4:e233945. [PMID: 37976049 PMCID: PMC10656649 DOI: 10.1001/jamahealthforum.2023.3945] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 09/19/2023] [Indexed: 11/19/2023] Open
Abstract
Importance Firearm violence is a leading cause of death in the US. There is broad public agreement that individuals at high risk of perpetrating violence should not be allowed to purchase or possess firearms. The National Instant Criminal Background Check System (NICS) is a national system intended to stop firearm purchases or possession by prohibited persons, but there is heterogeneity in how states interact with and report data to NICS. Objective To examine variability in state requirements for NICS reporting for mental health prohibitions. Design and Setting This cross-sectional study in the US reviewed current statutes for all 50 states and the District of Columbia (enacted through the 2021 legislative session) regarding reporting mental health prohibitions to NICS or state systems. Data were analyzed from October 2022 to April 2023. Main Outcomes and Measures For each state, the following were recorded: reliance on Federal Bureau of Investigation vs state point of contact for NICS checks; regulation requiring or allowing reporting to NICS for 3 hypothetical cases; and details on reporting responsibility and time frame. The number of NICS listings for adjudicated mental health reasons was obtained, and state rates per 1000 population were calculated. To compare states, we developed 3 hypothetical cases of individuals with risk of firearm violence, whether possibly temporary (involuntary commitment for decompensated psychosis, or involuntary short-term psychiatric hold for suicidal ideation) or chronic and progressive (court-appointed guardianship for dementia). Results A total of 39 states required and 5 allowed reporting to NICS for court-ordered, involuntary psychiatric hospitalization. Thirteen states required and 5 allowed reporting to NICS when a court determines an individual is mentally incompetent to manage their affairs (with or without guardianship). Two states required NICS reporting for short-term emergency psychiatric holds. Five states and the District of Columbia had no legislation explicitly requiring or allowing NICS reporting in the 3 scenarios. Conclusions and Relevance In this cross-sectional study of state laws, there was substantial heterogeneity in NICS reporting requirements and lack of clarity around processes. This raises questions about the ability of NICS to be used to block firearm purchases or possession by individuals with court-identified high risk of perpetrating violence toward themselves or others.
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Affiliation(s)
- Marian E. Betz
- Department of Emergency Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora
- VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver
| | - Deirdre M. Bowen
- Seattle University School of Law, Seattle, Washington
- Firearm Injury and Policy Research Program, University of Washington, Seattle
| | - Ali Rowhani-Rahbar
- Firearm Injury and Policy Research Program, University of Washington, Seattle
- Department of Pediatrics, School of Medicine, University of Washington, Seattle
- Department of Epidemiology, School of Public Health, University of Washington, Seattle
| | - Alexander D. McCourt
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Frederick P. Rivara
- Firearm Injury and Policy Research Program, University of Washington, Seattle
- Department of Pediatrics, School of Medicine, University of Washington, Seattle
- Department of Epidemiology, School of Public Health, University of Washington, Seattle
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Choi KR, Castillo EG, Seamans MJ, Grotts JH, Rab S, Kalofonos I, Mead M, Walker IJ, Starks SL. Mental Health Conservatorship Among Homeless People With Serious Mental Illness. Psychiatr Serv 2022; 73:613-619. [PMID: 34704772 PMCID: PMC9132544 DOI: 10.1176/appi.ps.202100254] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The purpose of this study was to examine associations between homelessness and length of psychiatric hospitalization and to explore the role of mental health conservatorship in determining discharge location for patients who are homeless and have a grave disability from serious mental illness. METHODS This observational study used administrative data from a safety-net psychiatric hospital in Los Angeles. The sample included 795 adults (≥18 years) who were hospitalized on an involuntary psychiatric hold between 2016 and 2018. The outcome variables were length of stay (days) and discharge location (home, locked psychiatric facility, unlocked psychiatric facility, unhoused). The predictor variables were homelessness status and whether a mental health conservatorship was initiated during hospitalization. Multiple regression models were used to estimate associations between variables. RESULTS Homelessness status was associated with 27.5 additional days (SE=3.5 days) of hospitalization in adjusted models. Homeless patients for whom conservatorship was initiated comprised 6% of the sample but 41% of total inpatient days. Among people who were homeless, initiation of a conservatorship was associated with significantly longer length of inpatient stay (mean=154.8 days versus 25.6 days for the whole sample) but also with lower odds of being unhoused at the time of discharge (risk ratio=0.19, 95% confidence interval=0.09-0.34). CONCLUSIONS A mental health conservatorship can be a mechanism for helping homeless people with a grave disability from mental illness to transition from the streets to residential psychiatric treatment, but it requires substantial resources from facilities that initiate such conservatorships and does not guarantee resolution of long-term supportive housing needs.
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Affiliation(s)
- Kristen R Choi
- School of Nursing, University of California, Los Angeles (UCLA) (Choi, Grotts); Department of Health Policy and Management (Choi) and Department of Epidemiology (Seamans), Fielding School of Public Health, UCLA; Center for Social Medicine and Humanities, Jane and Terry Semel Institute for Neuroscience and Human Behavior, UCLA (Castillo, Kalofonos, Starks); Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA (Rab); Department of Psychiatry, West Los Angeles Veterans Affairs (VA) Medical Center (Kalofonos); Gateways Hospital and Mental Health Center (Mead, Walker); all in Los Angeles
| | - Enrico G Castillo
- School of Nursing, University of California, Los Angeles (UCLA) (Choi, Grotts); Department of Health Policy and Management (Choi) and Department of Epidemiology (Seamans), Fielding School of Public Health, UCLA; Center for Social Medicine and Humanities, Jane and Terry Semel Institute for Neuroscience and Human Behavior, UCLA (Castillo, Kalofonos, Starks); Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA (Rab); Department of Psychiatry, West Los Angeles Veterans Affairs (VA) Medical Center (Kalofonos); Gateways Hospital and Mental Health Center (Mead, Walker); all in Los Angeles
| | - Marissa J Seamans
- School of Nursing, University of California, Los Angeles (UCLA) (Choi, Grotts); Department of Health Policy and Management (Choi) and Department of Epidemiology (Seamans), Fielding School of Public Health, UCLA; Center for Social Medicine and Humanities, Jane and Terry Semel Institute for Neuroscience and Human Behavior, UCLA (Castillo, Kalofonos, Starks); Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA (Rab); Department of Psychiatry, West Los Angeles Veterans Affairs (VA) Medical Center (Kalofonos); Gateways Hospital and Mental Health Center (Mead, Walker); all in Los Angeles
| | - Joseph H Grotts
- School of Nursing, University of California, Los Angeles (UCLA) (Choi, Grotts); Department of Health Policy and Management (Choi) and Department of Epidemiology (Seamans), Fielding School of Public Health, UCLA; Center for Social Medicine and Humanities, Jane and Terry Semel Institute for Neuroscience and Human Behavior, UCLA (Castillo, Kalofonos, Starks); Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA (Rab); Department of Psychiatry, West Los Angeles Veterans Affairs (VA) Medical Center (Kalofonos); Gateways Hospital and Mental Health Center (Mead, Walker); all in Los Angeles
| | - Shayan Rab
- School of Nursing, University of California, Los Angeles (UCLA) (Choi, Grotts); Department of Health Policy and Management (Choi) and Department of Epidemiology (Seamans), Fielding School of Public Health, UCLA; Center for Social Medicine and Humanities, Jane and Terry Semel Institute for Neuroscience and Human Behavior, UCLA (Castillo, Kalofonos, Starks); Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA (Rab); Department of Psychiatry, West Los Angeles Veterans Affairs (VA) Medical Center (Kalofonos); Gateways Hospital and Mental Health Center (Mead, Walker); all in Los Angeles
| | - Ippolytos Kalofonos
- School of Nursing, University of California, Los Angeles (UCLA) (Choi, Grotts); Department of Health Policy and Management (Choi) and Department of Epidemiology (Seamans), Fielding School of Public Health, UCLA; Center for Social Medicine and Humanities, Jane and Terry Semel Institute for Neuroscience and Human Behavior, UCLA (Castillo, Kalofonos, Starks); Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA (Rab); Department of Psychiatry, West Los Angeles Veterans Affairs (VA) Medical Center (Kalofonos); Gateways Hospital and Mental Health Center (Mead, Walker); all in Los Angeles
| | - Meredith Mead
- School of Nursing, University of California, Los Angeles (UCLA) (Choi, Grotts); Department of Health Policy and Management (Choi) and Department of Epidemiology (Seamans), Fielding School of Public Health, UCLA; Center for Social Medicine and Humanities, Jane and Terry Semel Institute for Neuroscience and Human Behavior, UCLA (Castillo, Kalofonos, Starks); Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA (Rab); Department of Psychiatry, West Los Angeles Veterans Affairs (VA) Medical Center (Kalofonos); Gateways Hospital and Mental Health Center (Mead, Walker); all in Los Angeles
| | - Imani J Walker
- School of Nursing, University of California, Los Angeles (UCLA) (Choi, Grotts); Department of Health Policy and Management (Choi) and Department of Epidemiology (Seamans), Fielding School of Public Health, UCLA; Center for Social Medicine and Humanities, Jane and Terry Semel Institute for Neuroscience and Human Behavior, UCLA (Castillo, Kalofonos, Starks); Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA (Rab); Department of Psychiatry, West Los Angeles Veterans Affairs (VA) Medical Center (Kalofonos); Gateways Hospital and Mental Health Center (Mead, Walker); all in Los Angeles
| | - Sarah L Starks
- School of Nursing, University of California, Los Angeles (UCLA) (Choi, Grotts); Department of Health Policy and Management (Choi) and Department of Epidemiology (Seamans), Fielding School of Public Health, UCLA; Center for Social Medicine and Humanities, Jane and Terry Semel Institute for Neuroscience and Human Behavior, UCLA (Castillo, Kalofonos, Starks); Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA (Rab); Department of Psychiatry, West Los Angeles Veterans Affairs (VA) Medical Center (Kalofonos); Gateways Hospital and Mental Health Center (Mead, Walker); all in Los Angeles
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Abstract
Psychiatry has a contentious history of coercion in the care of patients with mental illness, and legal frameworks often govern use of coercive interventions, such as involuntary hospitalization, physical restraints, and medication over objection. Research also suggests that informal coercion, including subtle inducements, leverage, or threats, is prevalent and influential in psychiatric settings. Digital technologies bring promise for expanding access to psychiatric care and improving delivery of these services; however, use and misuse of digital technologies, such as electronic medical record flags, surveillance cameras, videoconferencing, and risk assessment tools, could lead to unexpected coercion of patients with mental illness. Using several composite case examples, the author proposes that the integration of digital technologies into psychiatric care can influence patients' experiences of coercion and provides recommendations for studying and addressing these effects.
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Affiliation(s)
- Nathaniel P Morris
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco
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