Under the Involuntary Treatment Act (ITA), a person may be committed by a court for involuntary behavioral health treatment if the person, due to a mental health or substance use disorder, poses a likelihood of serious harm, is gravely disabled, or is in need of assisted outpatient treatment. Commitment under the ITA begins with an evaluation and treatment period of up to 120 hours initiated by a designated crisis responder. After the initial detention, the facility providing treatment may petition the court to have the person committed for further behavioral health treatment for up to 14 days. Upon subsequent petitions and hearings, a court may order up to an additional 90 days of commitment at a state hospital, followed by successive terms of up to 180 days of commitment.
Commitment Petitions.
A petition for a 14-day commitment must state facts supporting a finding that the person, as a result of a behavioral health disorder, presents a likelihood of serious harm or is gravely disabled, and that there are no less restrictive alternatives to detention in the best interest of the person or others. The petition must be signed by two medical professionals who have examined the person, as follows:
A petition for substance use disorder treatment may be signed by a substance use disorder professional instead of a mental health professional and by an advanced registered nurse practitioner instead of a psychiatric advanced registered nurse practitioner.
Less Restrictive Alternative Treatment.
When entering an order for involuntary treatment at any stage, the court must order an appropriate less restrictive alternative (LRA) course of treatment rather than inpatient treatment if the court finds that LRA treatment is in the best interest of the person. Less restrictive alternative treatment is for up to 90 days if ordered, instead of a 14- or 90-day inpatient order, and up to 180 days if ordered, instead of a 180-day inpatient order. Certain services are required under the LRA order and are outlined in statute. Upon request by a party, an LRA order may be modified or revoked if the person is failing to adhere to the terms and conditions of the court-ordered treatment, is substantially deteriorating or decompensating, or poses a likelihood of serious harm.
Assisted Outpatient Treatment.
Assisted outpatient treatment (AOT) allows a court to order a person who has a behavioral health disorder to undergo involuntary outpatient treatment. A court may grant a petition for AOT and order up to 18 months of LRA treatment if the court finds by clear, cogent, and convincing evidence that the person has a behavioral health disorder, will benefit from AOT, and a number of additional criteria are met.
A petition for AOT must include specified information, including a declaration from a medical professional who has examined the person no more than 10 days prior to the submission of the petition and who is willing to testify in support of the petition, or who has attempted to examine the person without success and is willing to testify to the reasons for believing the person meets criteria for AOT.
Medical professionals who are authorized to submit a declaration in support of an AOT petition are physicians, physician assistants, advanced registered nurse practitioners, or the person's treating mental health professional or substance use disorder professional.
Involuntary Medication.
A facility may provide involuntary medication during a period of detention for involuntary treatment only in an emergency situation or by following certain procedures. For short-term treatment up to 30 days, the facility must have attempted and failed to obtain the informed consent of the person and there must be a concurring medical opinion by a professional with prescribing authority. For patients in long-term detention, a petition must be filed to obtain a court order based on a lack of medically acceptable alternatives that are likely to be successful.
An LRA treatment provider is authorized to administer outpatient involuntary medication to a person on an LRA order, provided that:
psychiatrist, physician assistant working with a psychiatrist who is acting as a participating physician, psychiatric advanced registered nurse practitioner, or physician or physician assistant in consultation with an independent mental health professional with prescribing authority.
Licensed Pharmacists.
Pharmacists are licensed by the Pharmacy Quality Assurance Commission upon meeting certain educational and experience requirements and passage of required examinations. The practice of pharmacy includes: interpreting prescriptions; compounding, dispensing, labeling, administering, distributing, and storing drugs and devices; monitoring drug therapy; initiating or modifying drug therapy in accordance with written guidelines; participating in drug utilization reviews and product selection; and providing information on legend drugs.
The practice of pharmacy includes the initiation or modification of drug therapy according to written guidelines or protocols established and approved for the pharmacist's practice by a practitioner authorized to prescribe drugs. The written guideline or protocol, called a Collaborative Drug Therapy Agreement (CDTA), is an agreement in which a practitioner authorized to prescribe legend drugs delegates to a pharmacist or group of pharmacists the authority to conduct specified prescribing functions. A CDTA includes: the parties subject to the agreement; the type of prescriptive authority decisions the pharmacist is authorized to make; the activities the pharmacist is to follow in the course of exercising prescriptive authority; and the time period during which the agreement will be in effect.
Board-certified psychiatric pharmacists are added to the list of medical professionals who are authorized to:
Board-certified psychiatric pharmacist means a pharmacist licensed by the Pharmacy Quality Assurance Commission who holds a psychiatric pharmacy specialty certification.
(In support) This legislation is about workforce capacity and continuity of care for patients. There is a significant shortage of providers across the behavioral health system. Allowing psychiatric pharmacists to participate in court proceedings will increase capacity, improve efficiency, and provide patients with another trusted, highly trained professional who understands their treatment.
Pharmacists in behavioral health facilities work with patients who have conditions that are primarily managed through medications. They work under a collaborative drug therapy agreement signed with an independent prescriber which allows for a hands-on patient-prescriber relationship. They are able to take a history, evaluate symptoms, and assess for appropriateness of medications and ongoing response to treatment. Providing medical testimony in an LRA hearing requires a description of a person's behavioral health symptoms and how those symptoms make the person unsafe to themselves or others. This is within the current scope of psychiatric pharmacists.
Psychiatric pharmacists undergo extensive postgraduate training focused specifically on mental health. They manage complex psychotropic regimens, monitor safety and side effects, and collaborate with providers, prescribers, and care teams. They provide direct care to patients who already have an established diagnosis, yet they are not allowed to testify about their patients' progress in commitment hearings. As a result, pharmacists have to pull in other individuals to provide secondhand information to the court, creating delays, inefficiencies and burnout. Psychiatric pharmacists should be able to participate to support their patients and the court. They have significantly more training than other professionals who are allowed to participate in these proceedings.
(Opposed) Medical doctors serve as petitioners and expert witnesses for involuntary commitment proceedings. This includes a medical doctor's ability to diagnose and treat, and to assess for risk of violence and grave disability. Psychiatric pharmacists play a crucial role in the operations of the team and treatment of the patient. However, they do not have the education and training for diagnosis and treatment, and a collaborative drug therapy agreement does not provide authority for diagnosis and treatment. Without this authority, it would be difficult for a psychiatric pharmacist to do a full assessment of a patient for involuntary commitment.
This bill expands the pool of individuals who can sign off on commitment orders, weakening civil liberty protections for Washington citizens. Civil commitment can have substantially detrimental and disruptive effects, not only on the life of the person who is committed, but also the lives of their families, friends, and community members. The bill would make Washington one of the only states to give psychiatric pharmacists this power. This is going in the wrong direction for the state.
(In support) Representative Darya Farivar, prime sponsor; Aubrie Duke; Laura Powers, Comprehensive Healthcare; Mark Bradshaw, Comprehensive Healthcare; Courtney Hesla, Comprehensive Healthcare; Alan Kearns, Comprehensive Healthcare; Jenny Arnold, Washington State Pharmacy Association; and Aya Samman, Fourfront Contributor.