Emergency Involuntary Psychiatric Examinations in Florida

Florida's mental health statute is known as the Baker Act (1). Like such laws in most states, Florida's statute requires evidence of a mental illness and harm to self or to others, or of neglect in order to initiate a short-term involuntary "Baker Act examination." Baker Act examinations can be initiated by mental health professionals, law enforcement officials, or judges. Examinations take place at the more than 115 designated Baker Act receiving facilities in Florida and can last up to 72 hours. Designated Baker Act receiving facilities may be stand-alone units or may be located in general hospitals with psychiatric units, in psychiatric hospitals, or at community mental health centers with residential units.

Scrutiny of the civil commitment process increased in the mid-1990s because of abuses, notably of the elderly (2). The Florida legislature substantially revised the Baker Act in 1996. Reforms included greater protections for persons on voluntary and involuntary status, stronger informed consent and guardian advocacy provisions, expanded notice requirements, and rules for the suspension and withdrawal of receiving and treatment facility designations.

One revision in the law requires all receiving facilities to send a copy of every form initiating an involuntary examination to the Florida Agency for Health Care Administration. The Baker Act Reporting Center at the Louis de la Parte Florida Mental Health Institute has served as the repository of these forms since 1997. Florida is the only state that collects this type of involuntary examination or "emergency commitment" data. The data set provides a unique opportunity to describe emergency commitment and the individuals subject to it for an entire state.

Although a national survey conducted by the National Institute of Mental Health in the early 1980s indicated that 26 percent of psychiatric admissions were for persons in an involuntary noncriminal status (3), little information has been generated since then on the numbers of individuals subject to longer-term civil commitment. Even less is known about the frequency of short-term involuntary examination or emergency commitment. The purpose of this article is to provide descriptive information about emergency involuntary examination in Florida and about the individuals subject to these examinations.

Methods

The Baker Act Reporting Center at the Florida Mental Health Institute receives Baker Act initiation forms and cover sheets containing information about the individual and the facility by mail each business day from Baker Act receiving facilities state-wide. The data are entered and quality checked with a series of queries structured to identify missing or discrepant information. The number of initiation forms received has increased each year; 69,235 forms were received in 1997, 73,900 in 1998, 78,064 in 1999, and 83,989 in 2000.

We generated frequency data for the information on initiation forms received in calendar year 2000 to characterize who initiates the examinations, who fills out the form, what sort of evidence is cited to justify the examination, the age and sex of the persons subject to Baker Act examinations, and how some of these data may be related. Forms for the same individual with identical dates of initiation or dates within three days of each other were identified as duplicates and excluded from the analyses. These represented just over 4 percent of the forms received in 2000. We analyzed data from the 80,869 nonduplicated forms received in 2000.

Results

Just over half of the examinations were initiated by mental health professionals (41,503 or 51 percent), followed by law enforcement officials (35,862, or 44 percent) and judges (3,504, or 4 percent). Eighty-four percent (34,656) of the forms completed by mental health professionals indicated the "professional type" on the form. The majority of these forms (29,612 or 85 percent) were completed by physicians. Social workers (3,213, or 9 percent), clinical psychologists (978, or 3 percent), and nurses (853, or 3 percent) also completed forms.

The most common type of evidence—referred to as "evidence type"—used to substantiate initiations was harm to self or others only (55,948, or 69 percent), followed by neglect only (15,131, or 19 percent), and both harm and neglect (5,754, or 6 percent). Evidence type was not indicated on 6 percent of the forms. Overall, 75 percent of the initiation forms indicated harm to self or others, either alone or in combination with neglect, and 25 percent of the forms indicated neglect, either alone or in combination with harm.

Of the 60,702 forms indicating harm (with or without neglect), 49,920 (82 percent) indicated the type of harm. Harm to self only was the most frequently indicated type (35,134, or 70 percent), followed by both harm to self and others (10,296, or 21 percent) and harm to others only (4,490, or 9 percent). Combining percentages of forms indicating harm to self only and harm to both self and others indicates that harm to self was listed on the vast majority (91 percent) of forms for which harm was an evidence type. Mental health professionals (77 percent) and law enforcement officials (65 percent) indicated harm to self most frequently, and judges indicated both harm to self and others (44 percent) and harm to self (38 percent) with similar regularity.

The mean±SD age was 39±19.7 years, and the median age was 37 years. Just under 19 percent of initiations (13,749 of 73,293 forms with a complete date of birth) were for persons under 18 years of age, and just over 7 percent of initiations were for persons 65 years old and older. Over a quarter of initiations were for persons aged 18 to 44 (19,742 or 27 percent). Social Security numbers, which served to uniquely identify individuals, were indicated on 70,315 forms from 56,141 individuals.

The majority of individuals (47,282, or 84 percent) had only one initiation, 15 percent (8,562) had two to five initiations, and less than 1 percent (297) had more than five initiations. The maximum number of initiations for an individual in this one-year period was 18. While those with two or more initiations represent 16 percent of the individuals who had an examination, they account for 33 percent of the examinations.

Examinations of individuals in older age groups were more commonly initiated by mental health professionals, whereas examinations of younger age groups were more likely to be initiated by law enforcement officials. Evidence of neglect was more commonly cited for individuals in the older age groups, whereas evidence of harm was more likely to be cited for those in younger age groups.

Gender was indicated on 72,088 forms, with 51 percent for males and 49 percent for females. The most commonly indicated race on the 65,908 forms with information on race or ethnicity was white (47,915, or 72 percent), followed by black (11,788, or 18 percent), Hispanic (4,976, or 8 percent), Asian (178, or less than 1 percent), and other (1,051, or 2 percent).

Discussion and conclusions

These data are valuable because they not only allow us to describe involuntary examinations for an entire state and the characteristics of persons who are subject to them for an entire state but also to investigate the involvement of these individuals with certain services, such as mental health services, and systems, such as the criminal justice system.

The most striking aspect of the data set is its size. The completion of initiation forms containing 56,141 unique Social Security numbers in calendar year 2000 for a state population estimated by the 2000 census at 15,982,378 indicates that about three of every 1,000 people in Florida was subject to a Baker Act initiation in that single 12-month period.

Nearly 19 percent of the initiations were for persons under 18 years of age. This is striking, particularly given the continuing controversy over the use of psychiatric hospitalization for children and adolescents (4,5).

One limitation of these data is that they may represent an undercount of initiations. The Baker Act Reporting Center at the Florida Mental Health Institute may not receive forms for all initiations. We know from our experience with facility staff that some facilities initially were not sending in data or were not sending in a form for every Baker Act initiation. Thus the annual increase of 5 to 7 percent in number of forms received may be attributable to more consistent reporting by Baker Act receiving facilities or to an increasing rate of emergency commitment in Florida. Studies are under way to explore how the numbers of forms received at the reporting center compare with the records kept at the various receiving facilities. The results will help shed light on this question.

This description of involuntary psychiatric examinations suggests the need for investigations of the numbers of individuals subject to such examinations in other states, of the service planning issues relevant to the volume of examinations and the characteristics of individuals subject to them, and of the disposition of individuals after this initial involuntary examination.

The authors are affiliated with the Department of Mental Health Law and Policy, Louis de la Parte Florida Mental Health Institute, University of South Florida, 1330 Bruce B. Downs Boulevard, MHC 2620, Tampa, Florida 33612 (e-mail, [email protected]).