1. New York State MHL §9.41 allows a police officer to “take into custody any person who appears to be mentally ill and is conducting himself or herself in a manner which is likely to result in serious harm to the person or others. Such officer may … remove him or her to any hospital specified in subdivision (a) of section 9.39 or any comprehensive psychiatric emergency program specified in subdivision (a) of section 9.40 of this article, or pending his or her examination or admission to any such hospital or program, temporarily detain any such person in another safe and comfortable place….” This subsection of the mental health law is what authorizes a police officer to take an individual into custody and an ED to involuntarily detain that patient during a mental health evaluation until it can be determined the patient is not a danger to themselves or others.

2. From an emergency physician’s perspective, the mandatory (i.e., standard of care) evaluation of a patient who presents under a MHL §9.41 hold includes obtaining an accurate history, performing a thorough physical examination, performing testing to identify organic causes for the patient’s abnormal behavior, and ensuring a safe disposition for the patient at the conclusion of the encounter.

3. In obtaining a history, the emergency physician utilizes several resources. Frequently, a patient’s history in this type of presentation is unreliable, whether due to impairment from substances, impairment from underlying psychiatric illness, or because the patient is not forthcoming. Consequently, the history must come from, or be supplemented by, the police, paramedics, family members, friends, and other sources, including such things as agency records and records of prior medical and psychiatric evaluations. Often, the emergency physician relies on a clinical specialist, typically a social worker or behavioral therapist, to perform a more detailed psychiatric evaluation of the patient. These practitioners typically contact others who can provide collateral information to help determine the patient’s risk to themselves or others.

4. In the absence of immediately life-threatening situations, a thorough physical examination is performed to identify constellations of signs that suggest physical conditions (e.g., stroke, brain tumor, or infection) that may cause the patient’s abnormal behavior. Patients are also assessed for signs of toxic ingestions, whether intentional or unintentional, that may cause abnormal behavior. Intoxication with certain substances will create certain identifiable patterns of signs during the physical examination.

5. Testing may include blood and urine, imaging (e.g., head computed tomography), and electrocardiogram. Clinical testing serves a two-fold purpose. First, it may identify an organic cause of the patient’s abnormal behavior. Most of the time, however, it rules out an organic cause for the patient’s behavior.

6. Finally, based on the overall evaluation, a safe disposition plan is developed, usually in conjunction with the social worker or behavioral therapist who co-evaluated the patient. Patients who are at a low risk for harming themselves or others may be discharged and linked with community resources. Patients who are not at low risk are admitted for psychiatric treatment. When the source of the patient’s abnormal behavior is not clear, especially if there has been a suspected significant substance ingestion, prolonged observation in the ED or in a hospital medical ward may be warranted.

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