2007 Summer, Pg. 68. New Hampshire's Commitment Law: Treatment Implications.

• Author: By Alexander de Nesnera, M.D., DFAPA and Robert M. Vidaver, M.D., DFAPA

New Hampshire Bar Journal

2007.

2007 Summer, Pg. 68.

New Hampshire's Commitment Law: Treatment Implications

New Hampshire Bar JournalSummer 2007, Volume 48, No. 2Annual Survey of New Hampshire LawNew Hampshire's Commitment Law: Treatment ImplicationsBy Alexander de Nesnera, M.D., DFAPA and Robert M. Vidaver, M.D., DFAPAIntroduction

States have developed a variety of legal strategies to address the treatment of individuals suffering from mental illness who are a danger to themselves or others. The great majority of state laws have focused on outpatient commitment, and arguments have been put forth (pro and con) regarding the appropriateness of this approach (See references 1-7).

New Hampshire has two commitment options: outpatient or inpatient. The outpatient commitment statute is poorly designed and ineffective. The inpatient commitment law is well-structured and is accepted as the most effective way to get individuals needing mental heath treatment the care they deserve. This has led to the development of programs for individuals suffering from mental illness that are more coordinated and focused on community-based treatment and recovery in the real world.

This article will describe the New Hampshire commitment law from a clinician's perspective, and how this law has improved the care of our most mentally ill individuals.

Description of the Inpatient Commitment Process

New Hampshire Hospital (NHH) is the only state hospital in New Hampshire. It is a 222-bed facility. Approximately 2,000 children, adolescents, and adults are admitted each year 95 percent involuntarily. Initial evaluation of an individual for potential involuntary hospitalization typically occurs in a local emergency room. If the person is felt to meet the criteria for commitment (danger to themselves or others as a result of mental illness), they are sent to New Hampshire Hospital for admission on an Involuntary Emergency Admission (IEA) [see Table 1]. Within three business days of admission, a probable cause hearing is held at NHH where a district court judge hears the evidence regarding the IEA and makes a determination whether there was probable cause for the individual's involuntary admission.

A finding of probable cause needs to meet the lowest legal threshold (preponderance of the evidence), and if found, allows the treatment team caring for the individual to keep the person involuntarily at NHH for up to ten days. During that time multiple assessments are completed, many aspects of treatment are initiated (medications, rehabilitation treatment groups, individual and group therapy), and many individuals end up being discharged. If at the end of the ten-day period the treating psychiatrist believes the individual is still a danger to themselves or others as a result of mental illness, a petition for involuntary commitment to NHH is initiated. This petition is brought to the county probate court, where the burden of proof is on the State of New Hampshire to show by clear and convincing evidence (a higher legal threshold) that the individual needs involuntary hospitalization and treatment.

At every step of the way the individual is provided legal counsel. During the IEA process, individuals who cannot pay for legal representation are provided attorneys who are contracted by Client and Legal Services of the Office of Operation Support of the Department of Health and Human Services. During the probate process, the county probate court assigns a lawyer to the individual who cannot afford legal representation. In both situations the State of New Hampshire pays for legal representation for indigent individuals. Individuals always have the option of hiring their own lawyer if they have the means to pay for one.

The length of commitment to NHH requested by the state varies from three months to five years. Prior to the court hearing, an independent court-appointed psychiatrist meets with the individual and prepares a report for the probate court judge, rendering an opinion as to whether the patient meets the criteria for involuntary commitment to NHH. If, after the court hearing, the petition for commitment is granted, the individual is allowed to be involuntarily hospitalized at NHH for the...