Original Article

Patients Threatening Harm to Others Evaluated in the Emergency Department under the Florida Involuntary Hold Act (Baker Act)

Authors: Michael J. Maniaci, MD, M. Caroline Burton, MD, Christian Lachner, MD, Tyler F. Vadeboncoeur, MD, Nancy L. Dawson, MD, Archana Roy, MD, Adrian G. Dumitrascu, MD, Patricia C. Lewis, ARNP, Teresa A. Rummans, MD

Abstract

Objectives: This study describes the specific threats of harm to others that led to the use of the Baker Act, the Florida involuntary hold act for emergency department (ED) evaluations. The study also summarizes patient demographics, concomitant psychiatric diagnoses, and emergent medical problems.

Methods: This is a retrospective review of 251 patients evaluated while on involuntary hold from January 1, 2014 through November 30, 2015 at a suburban acute care hospital ED. The data that were collected included demographic information, length of stay, reason for the involuntary hold, psychiatric disorder, substance use, medical illness, and violence in the ED. The context of the homicidal threat also was collected.

Results: We found that 13 patients (5.2%) were homicidal. Three patients had homicidal ideations alone, whereas 10 made homicidal threats toward others. Of the 10 making homicidal threats, 7 named a specific person to harm. Ten of the 13 homicidal patients (76.9%) also were suicidal. Eleven patients (84.6%) had a psychiatric disorder: 9 patients (69.2%) had a depressive disorder and 8 patients (61.5%) had a substance use disorder. Eight patients had active medical problems that required intervention in the ED.

Conclusions: We found that three-fourths of patients expressing homicidal threats also were suicidal. The majority of patients making threats of harm had a specific plan of action to carry out the threat. It is important to screen any patient making homicidal threats for suicidal ideation. If present, there is a need to implement immediate management appropriate to the level of the suicidal threat, for the safety of the patient. Eighty-five percent of patients making a homicidal threat had a previously documented psychiatric disorder, the most common being a depressive disorder. This finding differs from previous studies in which psychosis predominated. More than 60% of homicidal patients had an unrelated medical disorder requiring intervention. It is important not to overlook these medical disorders while focusing on the psychiatric needs of the patient; most of our homicidal patients proved to be cooperative in the ED setting.

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References

1. Thienhaus OJ, Piasecki M. Assessment of psychiatric patients’ risk of violence toward others. Psychiatr Serv 1998;49:1129-1147.
2. Stern TA, Schwartz JH, Cremens MC, et al. The evaluation of homicidal patients by psychiatric residents in the emergency room: a pilot study. Psychiatr Q 1991;62:333-344.
3. Pétursson H, Gudjónsson GH. Psychiatric aspects of homicide. Acta Psychiatr Scand 1981;64:363-372.
4. Dawson NL, Lachner C, Vadeboncoeur TF, et al. Violent behavior by emergency department patients with an involuntary hold status. Am J Emerg Med 2018;36:392-395.
5. Mental Health Program Office & Department of Mental Health Law & Policy. 2014 Baker Act user reference guide: the Florida mental health act. 2014; http://www.dcf.state.fl.us/programs/samh/mentalhealth/laws/BakerActManual.pdf. Published 2014. Accessed July 1, 2015.
6. Tarasoff v. Regents of the University of California , 17 Cal. 3d 425, 551 P.2d 334, 131 (Cal. 1976).
7. Communications Confidential , 2012; Fl Stat ch 456.059.
8. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
9. Harris PA, Taylor R, Thielke R, et al. Research Electronic Data Capture (REDCap)-a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42:377-381.
10. Gupta D, Bzeih R, Osta W. Minimal/underreported but definite risk of death/bodily harm threats (DBHTs) to pain practitioners: results of nationwide survey from United States. Middle East J Anaesthesiol 2013;22:317-326.
11. Bridges FS, Lester D. Homicide-suicide in the United States, 1968-1975. Forensic Sci Int 2011;206:185-189.
12. Barraclough B, Harris EC. Suicide preceded by murder: the epidemiology of homicide-suicide in England and Wales 1988-92. Psychol Med 2002;32:577-584.
13. New York City Police Department. Active shooter: recommendations and analysis for risk management. http://www.nyc.gov/html/nypd/downloads/pdf/counterterrorism/ActiveShooter.pdf. Accessed November 1, 2017.
14. Fox JA, Fridel EE. Gender differences in patterns and trends in U.S. homicide, 1976-2015. Violence Gend 2017;4:37-43.
15. Oliver CL, Jaffe PG. Comorbid depression and substance abuse in domestic homicide: missed opportunities in the assessment and management of mental illness in perpetrators. J Intepers Violence. doi: 10.1177/0886260518815140.