In the course of researching our book, “Committed: The Battle Over Involuntary Psychiatric Care,” I came to a few very important conclusions. Involuntary commitment can be traumatizing to patients, and it should be done as a last resort when patients are dangerous (generally to themselves, but sometimes toward others) or tormented, and when they can’t be persuaded to get voluntary care. That may sound obvious, but in practice, it doesn’t always work that way. Furthermore, if there is no choice but to hold people against their will, there should be no use of physical force unless it is absolutely necessary to maintain safety, and patients should be treated with kindness and respect. It’s what we’d all want if we were the patient, and it’s not what all patients get.

Knowing that, you can imagine my shock when I saw reporter Mike Anderson’s article “Jail cells await mentally ill in Rapid City” in the Feb. 8, 2017, edition of the Rapid City Journal. Mr. Anderson noted that the Rapid City Regional Hospital was changing its policy on psychiatric admissions. The South Dakota city of 60,000 has a 44-bed psychiatric hospital located 1.5 miles from the main hospital. It is the only inpatient facility for at least 250 miles and serves a total population of approximately 250,000 people. If the unit is full – either because all beds are full or because staffing and acuity issues limit capacity – its policy always has been to admit overflow psychiatric patients to medical beds.

That policy changed recently. The interim director of Rapid City Regional Hospital, Dennis Millirons, reportedly wrote a letter on Jan. 23, 2017, to the Pennington County Board of Mental Health defining a new policy. The letter stated:

Effective Feb. 1, 2017, we will no longer admit behavioral health patients who do not have acute medical needs to the main hospital when the Behavioral Health facility is at capacity. In these instances, we will expect the County to take custody of patients who are subject to the involuntary mental commitment process, pending an opening at the Behavioral Health unit. It is simply no longer feasible for us to care for behavioral health patients who do not have acute medical needs outside of the Behavioral Health facility. Unless we hear differently, we will contact the Sheriff’s Office to take custody of involuntarily detained persons when the Behavioral Health facility is at capacity.

Also, by way of information, we will no longer admit patients to the Behavioral Health facility who have neurodevelopmental/cognitive disorders such as dementia, Alzheimer’s disease, or Autism Spectrum Disorders. We believe it is in the best interest of all patients to limit the conditions which are appropriate for treatment in our facility.

In other words, if there are no open beds in a psychiatric facility, patients would be transported from the emergency deparment to the Pennington County Jail. The fate of patients with psychiatric issues and dementia or autism was not at all clear.

I spoke with Stephen Manlove, MD, DFAPA. Dr. Manlove has a psychiatric outpatient practice but worked for the Rapid City Regional Hospital for 26 years. He left this past September because he felt the facility had lost sight of its mission to give psychiatric patients excellent care. He also works two mornings a week providing psychiatric treatment at the local jail, a 600-bed facility where 1 in 6 inmates is on psychotropic medications, and an average of 25 inmates at any given time suffer from severe and persistent mental disorders.

“This is obviously a complicated story,” Dr. Manlove noted. “The hospital gave the jail only a few days’ notice. The hospital doesn’t seem to want to invest in this population. They are investing millions of dollars in other projects but can’t find the money to fund psychiatry. Surprisingly, the medical community seems to have accepted this.”

Dr. Manlove noted that the jail is not equipped to offer comprehensive psychiatric treatment, and that inmates are held in cinder block cells with very limited medical supervision.

Kevin Thom, the Pennington County sheriff, was quick to say, “We shouldn’t be criminalizing mental health problems.” While he noted that local statute allows for patients to be held in a jail cell for up to 24 hours if a hospital bed is not available, he commented on the inappropriateness of this and on the brief notice his office was given: “There was no time to figure out a process or alternatives. It’s frustrating.”

Dr. Manlove said he believes that a few patients may have been taken to the jail since the new policy was instituted, but the jail has turned some away. Sheriff Thom said his office had been called to transport a patient and had refused.

I asked what happens when a voluntary patient needs a bed and there is no room. Dr. Manlove replied: “If they are not considered acutely dangerous, I assume they will be told to go to another hospital. If they are acutely dangerous to themselves or others, then a mental health hold would be placed, and they would be sent to jail.”

Of note, the closest hospital with a psychiatric unit is 253 miles away, in Casper, Wyo.

One reason for limiting the type of patients the psychiatric facility will admit may have to do with an effort by the hospital to lower its use of seclusion and restraint. In an article in the Rapid City Journal on Feb. 19, 2017, reporter Chris Huber noted that between July 2015 and July 2016, Rapid City Behavioral Health had seclusion rates 300 times higher than the national average, a fact the hospital attributes to the high acuity needs of autistic patients. Rather than improving its ability to treat these patients, the facility has decided not to accept them.

In June 2016, the Boston Globe Spotlight team began a series called “The Desperate and the Dead” as a way to highlight deficiencies in the Massachusetts public mental health system. The first article was a sensationalized piece about psychiatric patients who kill their family members. The backlash to the stigmatization of psychiatric patients as murderers was huge; a Facebook page set up to accept comments soon had more than 1,300 members, and the entrance to the Globe was blocked by 150 protesters. The response to the Rapid City hospital’s decision to jail people with psychiatric disorders who have committed no crime has been surprisingly quiet; there have been no stories of protests or advocacy outrage. In this egregious stigmatization of those with psychiatric disorders, I had to wonder what they do when the medical beds overflow: Do they send those patients to jail? Of course not. And why would anyone think this is okay?

We know that involuntary care can be traumatizing and that psychiatric care can feel demeaning. On the one hand, there is a call to pass laws to make it easier to treat patients involuntarily. In our polarized world with rising suicide rates, should we be doing everything possible to engage patients in voluntary care? How do we reconcile the fact that a hospital administration can decide that if distressed people seek care, having broken no law, they can be sent to jail? And finally, since suicide rates among physicians remain so high, I’d like to ask this: Would you go to a hospital for treatment if you knew you might end up desperate and alone, receiving no treatment, in a jail cell?

My thanks to Mr. Anderson of the Rapid City Journal, Dr. Manlove, and Sheriff Thom for their help with this article.

Dr. Miller wrote “Committed: The Battle Over Involuntary Psychiatric Care” with Annette Hanson, MD (Baltimore: Johns Hopkins University Press, 2016).

Mentally ill? Go directly to jail