North Carolina lawmakers are now taking a closer look at how people with mental health issues can be involuntarily committed for treatment in the wake of a new law they passed — in September.
Lawmakers created Iryna’s Law in response to the fatal stabbing in August of Ukrainian immigrant Iryna Zarutska on a light rail train in Charlotte. The man charged in the crime has a history of mental illness and previous encounters with law enforcement.
The intent behind the bill was to tighten restrictions on pretrial release and mandate that more people who are arrested undergo mental health evaluations to see if they should be hospitalized involuntarily. However, the legislation didn’t provide more resources for mental health nor address root problems that often lead people to cycle through jails and psychiatric hospitals.
State representatives met last week for the first meeting of a new House Select Committee on Involuntary Commitment and Public Safety which aims to study the current involuntary commitment process and make administrative and policy recommendations to improve it. Committee Co-Chair Rep. Tim Reeder (R-Ayden), an emergency department physician, told NC Health News that he and other lawmakers have had multiple concerns about the involuntary commitment system for a while.
“I think Iryna’s Law was an impetus to get this group together,” he said.
More patients funneled to treatment
NC Health News reporting has found that an increasing number of people are being held and evaluated for psychiatric hospitalization through North Carolina’s involuntary commitment process; petitions for involuntary commitment rose by at least 97 percent from 2011 to 2021. NC Health News and other nonprofits have compiled petition data through the years, but other data points about involuntary commitments in the state are unknown because no one tracks them — a fact mentioned in the committee meeting several times when lawmakers asked presenters for more information.
When a person is having a mental health crisis — whether they’re thinking about suicide, acting erratically or experiencing hallucinations — they often end up in a hospital emergency department. They’re commonly brought in by concerned family members or by police who have responded to a 911 call.
If a medical provider determines that the patient is a danger to themselves or to those around them, they will file a petition with the courts for an involuntary commitment custody order. These committed patients temporarily lose the right to make their own decisions while being treated for psychiatric problems or substance use.
On Thursday, lawmakers listened to a detailed overview of North Carolina’s involuntary commitment process and heard from experts representing hospitals and emergency physicians in the state who have concerns about Iryna’s Law. The legislation moved quickly through the General Assembly and was signed into law by Gov. Josh Stein with little input from medical or criminal justice experts.
Hospital leaders told the committee that bringing people charged with a crime into hospital emergency departments — already overcrowded with mental health patients — could be dangerous and affect the care of everyone there.
Rep. Donny Lambeth (R-Winston-Salem), a former hospital president, said he heard from several hospital leaders who were unhappy with Iryna’s Law, which he admitted had an all-too-quick passage through the legislative process. Throughout Thursday’s committee meeting, Lambeth said he also heard presenters talking about problems within the mental health system that he’s heard about for years.
“This is a way of looking at it after the fact and then adjusting, as we may need to adjust as we learn more facts from some of the professionals,” he told NC Health News. “Unfortunately in our society, we wait until we have a crisis, then start asking a lot of questions. And this is a whole systematic problem that’s been around for a long time.
“The good news is we’re now talking about it and trying to figure it out, and there are some things that we can do to fix it,” Lambeth said.
Hospitals already overburdened
Every day, across North Carolina, there are patients who are essentially living in hospital emergency departments who shouldn’t be there. Hospital leaders have sounded the alarm for years about this problem, which has only worsened since the coronavirus pandemic.
Sometimes the wait for an inpatient psychiatric bed can be lengthy if the patient has more complex needs. A patient can be held under an involuntary custody order for seven days, and if a bed is not found by then, the petition can be renewed. State law allows these holds to be renewed indefinitely — and patients don’t receive legal representation until after they arrive at a psychiatric inpatient facility.
Several lawmakers on the committee expressed concern about the potential for endless “seven-day” holds.
Some patients end up in the emergency department for evaluation for an involuntary commitment, but then they do not meet the criteria for inpatient hospitalization: danger to self or others. Nonetheless, these patients can end up spending weeks in the emergency department simply because they don’t have anywhere else to go.
“For patients who received care in a nursing home, mental health group home or individuals in the custody of local DSS offices … the [involuntary commitment] evaluation is accompanied by the individual losing their placement under special rules that allow for an emergency discharge,” Johana Troccoli, vice president of behavioral health in the Duke University Health System, explained to lawmakers during the committee meeting. “Oftentimes, these patients will hold in the [emergency department] for not just days, but weeks and months, while the emergency department team bears the full responsibility of coordinating a new placement.”
A shortage of specialty psychiatric beds and providers exacerbates the situation, she said, and creates a bottleneck that limits access to care in psychiatric facilities for everyone.
“I have also seen patients and their families, especially children, be failed by our [involuntary commitment] system,” Troccoli said. “It is hard as an administrator to witness … nurses and doctors buy holiday gifts or celebrate birthdays for children who are in the [emergency department] for weeks and months.”
Telehealth evaluations suggested
Iryna’s Law mandates that law enforcement officers take someone to an emergency department for a psychiatric evaluation if the arresting officer has reason to believe the defendant is mentally ill and a danger, whether their crime was violent or not. Also, if someone is charged with a violent offense and has been subject to an involuntary commitment order at any time in the past three years, officers are required to take that person for a psychiatric evaluation.
Emergency departments are not designed to be long-term holding facilities, Troccoli said, and they are not set up to serve defendants charged with violent crimes.
“The prolonged boarding of [involuntary commitment] patients, especially those with forensic involvement, pose a significant safety risk,” she said.
She said that hospital security staff are already preparing for Iryna’s Law to go into effect in December 2026. This may include sectioning off portions of the hospital for forensic exams, which will likely affect total emergency department capacity.
Smaller community hospitals will struggle the most, she said.
“Requiring defendants to be assessed at the [emergency department], which is currently provisioned in Iryna’s Law — potentially alongside those children, alongside those employees who have been subjected to workplace violence — will make a strained process impossible to manage,” Troccoli said.
Speaking on behalf of North Carolina College of Emergency Physicians, Jeremiah Gaddy echoed many of Troccoli’s safety concerns. He said that the committee should look into tele-psychiatry evaluations for defendants in need of mental health evaluation. Most hospital emergency departments do not have a separate behavioral health unit, which means mental health patients languish alongside the general emergency room population. Many hospitals do not have round-the-clock psychiatrists, and many patients are already evaluated through a virtual tele-psychiatry program called NC-STeP.
The North Carolina Health Care Association, which represents hospitals in the state, also recommended that the committee expand non-emergency department sites as the preferred location for first examination and make local emergency departments the last resort. The association recommended that the first commitment examinations under Iryna’s Law be completed by telehealth in the local detention centers.
Lambeth told NC Health News that he’s been in favor of increased telehealth access, particularly since the pandemic. This is one area where Iryna’s Law could be adjusted, he said.
A broken system
Several committee members with law enforcement experience brought up the strain the involuntary commitment process has put on local law enforcement departments. Officers are required to transport and often stay with patients awaiting evaluations, which leaves their coworkers shorthanded.
Rep. Reece Pyrtle (R-Stoneville), retired police chief of the City of Eden, said his department tracked the increasing number of hours officers spent transporting patients to involuntary commitment examinations and to psychiatric hospitals. He said they would transport some of the same people over and over because after they left the hospital, they received only a small amount of medication and were told to contact outpatient providers for follow up appointments, which often did not happen.
“There was no soft handoff at the end of that time,” Pyrtle said. “And I asked one time why we couldn’t coordinate like the mobile crisis unit response out there to leave that soft handoff … I was told they didn’t meet the service definition. So we continue to do what we do, and continue to have the issues that we have. It’s sad that law enforcement and hospitals are the ones that can’t say ‘no.’”
“The real tragedy here is there’s consumers out there that are not getting services they justly deserve, and it’s a lot of bureaucratic intake they have to go through,” Pyrtle said.
Many in the mental health and substance use treatment community argue that forced psychiatric hospitalization does not address severe and complex mental illness, and it doesn’t often yield desired results. These commitments are temporary, and people are often discharged without the community support they need. Coerced treatment can also lead patients to distrust the system and make them reluctant to seek help the next time.
Rep. Carson Smith (R-Hampstead) said, from his perspective as a former Pender County sheriff, he believed the state “took a bad system and made it worse” when it started closing psychiatric hospital beds such as Dorothea Dix Hospital in 2012.
“The money is going to follow the folks, we’re going to put them out in the community,” he recalled health officials saying at the time.
“I don’t think that worked. These folks that go in, they get their medication. Everything’s cool. They go back to the community. There’s nobody to check on them. They go downhill. They start hurting people. We pick them up again, and it’s over and over and over again,” Smith told his fellow committee members. “Instead of letting these people sleep under cardboard boxes on the streets, why can’t we put them in long-term commitment if they need it?”
Lately, lawmakers from New York to California have proposed to involuntarily hospitalize people who are homeless, to force them into mental health treatment. However, the Supreme Court has previously ruled that people cannot be held indefinitely due to their mental illness.
People with severe mental health disorders often cycle in and out of hospital rooms and jail cells, with little to no mental health treatment in between. Many also struggle with basic needs — housing, employment, access to care — that, if met, would help them be productive and stable in the community.
In the wake of Iryna Zarutska’s death, mental health and criminal justice experts told NC Health News that it will take significant resources and willpower to overhaul parts of the mental health system that aren’t working and to establish an array of services in the community that actually support people.
This article first appeared on North Carolina Health News and is republished here under a Creative Commons Attribution-NoDerivatives 4.0 International License.