72 Hours

The Baker Act

72 Hours. That’s the standard “holding time” for a patient hospitalized under a Baker Act status. Which means they either came to the hospital by ambulance, by law enforcement or brought in by someone concerned enough about their well-being to decide that the person needs a psychiatric evaluation. Most people don’t know this, but even if a patient comes to the hospital voluntarily, they can still be converted to a “Baker Act” in the great state of Florida. Another piece of information most people are missing is the fact that if they present to the emergency department, their Baker Act clock doesn’t start until they are medically cleared to come to the fourth floor. The behavioral health floor. Once moved to the fourth floor, a technician will perform a “skin check” and write down piercings, tattoos, and any marks/lesions/bruises that are apparent or not so apparent on your body Then the technician goes through every piece of property that you have on your person and documents your belongings The next step is to sign consent forms You’re asked to consent to treatment, but what are you even consenting to?

You’re required to sign a consent form for every medication prescribed. You’re required to sign a general consent for treatment. However, most patients have zero understanding of what a Baker Act is, the process, the difference between voluntary versus involuntary status, and the requirements to be considered competent or incompetent And most patients (and some residents) use the phrase “Voluntary Baker Act” which is a complete contradiction.

After 72 Hours

If you are admitted to a behavioral health unit, be advised that this is an acute setting 72 hours is usually the amount of time you’re expected to be on the floor. However, if your 72 hour “holding period” (which is exactly what it is) is up and your psychiatrist believes that you are still a danger to yourself or others or that discharging you will have extreme negative consequences for your health, then they have the ability to convert you to a “32 status.” If you’re converted to this status, this means that two psychiatrists have agreed that if you are discharged, there will be negative consequences severe enough to warrant going to mental health court to ask a judge to rule over whether or not you will be legally required to stay in the hospital Mental health court involves you, a public defender, a guardian advocate (if requested,) an attorney for the hospital, a psychiatrist, and perhaps a social worker and/or a Baker Act Coordinator The judge usually hears from all parties that have been sworn in to testify and makes a ruling of whether or not it is the court’s opinion that you have whatever diagnosis the psychiatrist proclaims you do and decides whether you need to stay in the hospital for longer. In my experience, psychiatrists request an additional 4-6 weeks for treatment.

In Reality

So it is an entirely plausible scenario that you bring yourself voluntarily to the hospital, stay for 72 hours, request to be discharged and instead of being discharged, you can have your legal status changed to involuntary, be forced to go to court to plead your case, and if the judge rules in favor of the psychiatrist, you can be forced to stay in the hospital for weeks. It’s also possible that if you have refused medications up until this point (which is your right,) a guardian advocate can be appointed to make medical and mental health decisions on your behalf including you taking prescribed medications. And if you refuse oral medications, they can consent to intramuscular injections on your behalf.

THAT is the best we have come up with for acute mental health care? Seriously? We went from treatments such as bloodletting, lobotomies, trephination, isolation, insulin comas, metrazol therapy, and ECT (which is still widely used today) to seeing patients for 72 hours and prescribing psychiatric medications that have such severe side effects that we have to prescribe them additional medications to offset the side effects of their antidepressants and antipsychotics?

Diagnosis

The behavioral health unit I work on has 25 beds. At any given point, I can-with confidence-assume that if 25 patients are on the floor, a good estimate is that at least 9 have a Bipolar diagnosis, 8 have a Schizoaffective diagnosis, 2 have a Schizophrenia diagnosis, 3 have Brief Reactive Psychosis (mostly induced by substances,) and 3 have Major Depressive Disorder. Based on the feedback provided to me by patients in my group therapy sessions and individual meetings, most of them are unaware of their diagnosis, unaware of what medications they are on and why, and have a poor understanding of the risks of taking psychotropic medications long-term. And you might think that this is biased and that they aren’t being active participants in their treatment. Surely their psychiatrist has discussed all of the above with these patients and they are educated about their treatment right?

Every morning myself, medical students, a resident, and the attending meet with all patients assigned to the attending. I have worked with this doctor for 6 months and the number of times I have heard the doctor discuss side effects with patients can be counted on one hand and each time it has been discussed only after the patient specifically asked about side effects. Most of them don’t ask. It is also disappointing to me the number of patients who don’t ask what their diagnosis is-their diagnosis is what justifies to insurance companies them being in the hospital and dictates what medications they are prescribed. Few ask. The majority trust the white lab coat as the expert and don’t question the doctor’s judgment.

The History of Pharmaceutical Advertising

Because this is an acute setting I don’t have the time to educate every patient on the history of direct-to-consumer advertising (which is only allowed in the U.S and New Zealand) and how pharmaceutical companies influence clinical trials which influence what medications are prescribed by doctors which influence how patients are treated and diagnosed I don’t get the time with patients to explain that the DSM was created by a bunch of psychiatrists-mostly white and male psychiatristswho argued over what diagnosis should be included and which ones should be omitted and finally arrived at a consensus. I can’t go over with patients the fact that when pharmaceutical ads were initially created they were targeting “depressed” stayat-home housewives who needed to resume household duties and “agitated” African Americans whose behavior needed to be “controlled.” This has no doubt contributed to a disproportionate amount of African Americans being diagnosed with Schizophrenia and an excessive amount of women being prescribed antidepressants. Our present day understanding of diagnosis and how we understand mental illness has been significantly influenced by racism, sexism, and let’s not forget that homosexuality was in the DSM up until 1973 That’s only 50 years ago.

Side Effects of Psychotropic Medications

According to the Depression and Bipolar Support Alliance (and most other sources) Bipolar Disorder affects about 2 6% of the U.S population. Yet, about 36% of our patients carry this Bipolar diagnosis-what’s going on here? Is the Orlando area just a special place full of unique Bipolar patients? Or is it possible that the mental health field has medicalized mental illness to the point of overdiagnosis, overmedication, and lack of serious consideration for the patients and families affected by our current psychiatric standards and view of “wellness?”

The question needs to be asked because not only do I see an unlikely number of truly Bipolar patients and those being forced to stay in our hospital, I also see the harmful effects psychotropic medications have on patients on a daily basis. The amount of patients with extrapyramidal symptoms I see is disturbing. I see patients who have tremors that are uncontrollable, patients whose tongue protrudes involuntarily every minute, patients who appear to be nodding their head who aren’t doing so intentionally, and patients with eye twitches and leg spasms. I see patients who tell me they feel like they are crawling out of their skin and have to constantly pace to try to alleviate this feeling. I’ve seen patients over 60 years old who have been prescribed 2-4 milligrams daily of a benzodiazepine for years who were never told of the potential consequences of this course of “treatment” for their anxiety I’ve seen chronic pain patients prescribed high doses of opioids in conjunction with high doses of benzodiazepines despite the dangerous risk of respiratory distress I’ve also heard this concern over and over again which haunts me, “I just don’t feel like myself since I started taking this SSRI-I feel numb and detached.”

Again, I’d like to ask, is this the best we’ve come up with since severing people’s frontal lobes?

We’re not educating patients on medication risks, diagnosis, metabolic syndrome, extrapyramidal symptoms, the importance that diet and exercise have on mental health, and alternatives to psychiatric medications. We have medicalized every aspect of mental health and it has gotten us where? We’re not patient-focused, we ' re medication-focused.

We take 72 hours to create a lifelong patient And we are failing

Written By: Lexi Clyne, MA

Lexi is currently a social worker at a behavioral health unit in Orlando, Florida and specializes in substance abuse She has five years of experience in outpatient, intensive outpatient, an in-patient settings