Mental-Health Hospitalization During Cancer Treatment

Call or text 988 for the 988 Suicide and Crisis Lifeline. It is free and open 24 hours a day. Call 911 if there is immediate danger.

Most calls to a crisis line do not end in a hospital stay. They end with a plan and a follow-up.

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Fear of the unknown keeps people quiet. Someone in cancer treatment stops saying how bad things have got. They are afraid of what saying it might set off.

So here is a plain account of how inpatient mental health care usually works in the United States. One warning first. The details differ a great deal by state and by hospital. No page written for the whole country can tell you what would happen to you.

Most stays are voluntary. SAMHSA describes voluntary admission as resting on your own willingness to seek and take part in treatment in hospital. You are assessed first. In most states the admitting psychiatrist must also attest that you are suitable for admission, or that you are competent to agree to it.

One detail surprises people. Voluntary does not always mean you can walk out the moment you choose. SAMHSA cites a study finding that most jurisdictions apply a waiting and observation period after a voluntary patient asks to be discharged, often 72 hours. At the end of it, the hospital must either release the person or seek involuntary commitment, if a clinician judges that they meet the state's standard.

That is worth knowing before you sign, not after.

Involuntary care usually starts with a short hold, not a court order.

SAMHSA describes an emergency pickup or a temporary hold at the start. Short-term hospital care follows, and it typically lasts about 2 to 5 days. A judge does not usually review those first few days beforehand. How long you can be held before any review varies widely: from 23 hours in North Dakota to 10 days in New Hampshire and Rhode Island, and 60 days in New York. In at least 17 states it is 72 hours, and in three — Kansas, Nebraska, and West Virginia — SAMHSA says no time period is specified at all.

Three things can happen at the end of a hold. The person is released. Or the stay becomes voluntary. Or the hospital applies for civil commitment, which is the legal process, and that involves a hearing.

The legal bar is meant to be high. The Supreme Court set the minimum standard of proof for civil commitment as "clear and convincing evidence" in Addington v. Texas in 1979. SAMHSA reports that in every state, in line with that decision, a person may be committed only if found to meet the criteria by at least that standard. Some states set the bar higher still.

A great deal. SAMHSA says each state sets its own rules for civil commitment. That covers both the criteria and the steps required.

The criteria that come up most often are:

• Being a danger to yourself or to others
• Grave disability, meaning you cannot meet basic needs for food, clothing, or shelter
• A need for treatment
• Getting seriously worse without treatment

Most states also use a least restrictive means rule. In plain terms, you should not be kept in hospital if your needs can be met somewhere freer.

Involuntary care is also rarer than people assume. SAMHSA reports that in 2015, about 9 out of every 1,000 people with serious mental illness were involuntarily committed. State rates ranged from 0.23 to 43.8 per 1,000, lowest in Hawaii and highest in Wisconsin.

None of that is a promise about your case. It is a reason not to assume the worst.

A mental health unit is not set up to run chemotherapy. That is the practical problem to solve early, and it can be solved.

Make sure the mental health team is given:

• Your cancer type, current treatment, and where you are in the cycle
• The name and number of your oncologist and your cancer nurse
• Every medicine, including oral chemotherapy, hormone therapy, steroids, anti-sickness drugs, and pain drugs
• Any device: a port, a central line, a stoma, a feeding tube, a drain
• Allergies, and any recent low blood counts

Then ask these questions:

• Who manages my cancer symptoms while I am here?
• What happens to my booked treatment, and who tells my cancer team?
• Will my pain medicine carry on at the same dose?
• Who flushes or cares for my line?
• What happens if I get a fever here?

Fever matters. During some cancer treatments a fever is an emergency. Staff on a mental health unit may not watch for it the way a cancer ward would. Say it out loud.

Ask whether the two teams can speak directly. One phone call between them prevents most of the problems on this list.

Leaving is not the end of the risk. Good units treat it that way.

SAMHSA's guidance on care transitions asks for a follow-up call within 24 hours of discharge. It also asks for active follow-up, and a set plan for what happens if someone misses an appointment.

Before you leave, try to have in writing:

• A named person to call, with the number, plus the crisis number
• The next appointment, with a date on it, not "we will be in touch"
• A checked medicine list, matched against your cancer drugs
• Confirmation that your cancer team knows you are out and what changed

You can write down what you want in advance. SAMHSA describes psychiatric advance directives as a way to put your wishes for treatment in writing. They apply if you later become too unwell to say what you want.

Such a plan can name the medicines you do and do not want. It can name a preferred hospital. It can name who to call.

SAMHSA notes these are underused, partly because clinicians are not familiar with them. That is not a reason to skip one. If you already have advance directives for your cancer care, this fits naturally alongside them.

• Legal Tools Throughout the Behavioral Health Care Continuum — SAMHSA
• Civil Commitment and the Mental Health Care Continuum — SAMHSA
• Best Practices in Care Transitions for Individuals with Suicide Risk — SAMHSA
• 988 Suicide and Crisis Lifeline — 988 Lifeline