A psychiatrist says higher rates of injection use at Bellevue may stem from having patients who are more acutely psychotic than those at other hospitals.

Adi Talwar

A psychiatrist says higher rates of injection use at Bellevue may stem from having patients who are more acutely psychotic than those at other hospitals.

Doctors in Bellevue Hospital’s psychiatric emergency room order forced injections of psychiatric medication to sedate and overrule patients who refuse to have blood drawn during the hospital’s admission process, according to documents and testimony reviewed by City Limits. As alleged, the practice would violate state law governing the use of involuntary medication.

Lawyers from the Mental Hygiene Legal Service, the public defender service for psychiatric patients in New York State, filed a complaint in March 2015 to the New York Justice Center for the Protection of People with Special Needs, the state’s oversight body that investigates allegations of patient mistreatment at psychiatric facilities. The complaint alleged that there was “a standard policy in Bellevue’s psychiatric emergency room: the administration of emergency intramuscular medication to force compliance with routine admissions procedures and blood work.”

Involuntary medication is legal in two circumstances in New York for adult patients: in an emergency when there is immediate danger to the patient or others around them, or on an ongoing basis after a court finds that the patient lacks the capacity to make decisions about their treatment. The former, emergency medication, can consist of forcibly injecting high doses of antipsychotic and anti-anxiety medication to calm a violent patient, often causing them to fall asleep. Under title 14, part 527 of the New York Codes, Rules, and Regulations, it is legal only “where the patient is presently dangerous,” and only “as long as necessary to prevent dangerous behavior.”

Adult patients who don’t meet the criteria for either emergency or court-ordered medication over objection have the legal right to refuse treatment. That right covers antipsychotic injections, and holds true even when a patient is committed to a hospital involuntarily. The statute describing patients’ right to object to treatment considers blood testing a routine procedure and excludes it from the definition of treatment, but Michael Neville, director of the Second Judicial Department of the Mental Hygiene Legal Service, says this exclusion means only that patients have an absolute right to refuse blood work unless a court orders the procedure. The regulations “define ways that patients can be overruled,” says Neville, and in all other circumstances “a patient retains full rights to control their medical treatment.”

Regardless of whether blood work falls under the right to refuse treatment, emergency medication still is only legal in cases of present dangerousness.

Medicated to permit bloodwork

The Justice Center complaint referred to excerpts of medical charts from Bellevue’s psychiatric emergency room detailing instances in which forced intramuscular medication was used to induce compliance with the admissions procedure. A source familiar with the documents told City Limits that more than 10 such records were included with the complaint spanning a nine-month period from June 2014 to March 2015. To comply with hospital guidelines and accreditation standards, the records are required to describe the specific reason that the injection was ordered, which should comply with the state standard for emergency medication.

In one case, according to information relayed by the source from the medical records, a patient asked to speak with an attorney and was given an injection “to complete a medical evaluation.” In another, a patient given an injection under emergency circumstances was also given a second sedative dose “because he refused blood work.” In another, an injection was ordered because a patient “continued to refuse” blood work, and was discontinued when the patient said he was ready to have blood drawn. None of the records included in the complaint mention violence or present dangerousness, according to the source.

The practice continues today. At a hearing on October 27, 2015, in the courtroom on Bellevue’s 19th floor, Dr. Danielle Kushner of the hospital’s forensic psychiatry department testified about a patient who recently received an intramuscular injection for refusing blood work. Dr. Kushner told the court that the patient “refused the medical workup that they were doing in the emergency room, and he required IM [intramuscular] medication for that purpose.”

The cross-examining attorney later asked for clarification about the incident. “That was for the admission blood work?” he said.

“Yes,” said Dr. Kushner.

“That was an emergency medication under the regulations?” the attorney asked.

“Yes,” said Dr. Kushner, “to get the actual medical clearance for admission.” (The court ultimately ordered ongoing forced medication for the patient.)

Dr. Kushner’s testimony echoed an earlier hearing at the hospital on June 17, 2014,in which another psychiatrist from Bellevue’s forensic unit indicated that ordering antipsychotic injections to force compliance with the hospital’s admissions process is standard practice in Bellevue’s psychiatric emergency room. According to the transcript from the hearing, Dr. Loren Roth was asked about the use of emergency medication because a patient “refused to comply with admission blood work.” She said, under oath, “in our emergency room when someone is to be admitted and they are refusing to comply, the procedure is that they receive—they receive—they are evaluated for the need for IM medication.”

“Due to the refusal to do the admission blood work?” Dr. Roth was asked again.

“Yes,” she replied.

Bellevue’s 37-page Medication Policies and Procedures handbook 2013, obtained by City Limits under the Freedom of Information Law, does not contain explicit instructions about the legal circumstances in which psychiatrists are authorized to order emergency forced medication, saying only that a nurse has to call a doctor who must “assess the patient if he/she requires psychotropic medication.”

“Bellevue Hospital Center complies with the NY State Mental Hygiene Laws governing use of involuntary psychotropic medication,” wrote Evelyn Hernandez, a spokesperson for the hospital, in an emailed statement. “A psychiatrist who assesses a patient to be presently dangerous can prescribe involuntary IM medication.”

‘A powerful cocktail’

Most of the forced injections at Bellevue are cocktails of Haldol and Ativan, an antipsychotic and a sedative, according to a psychiatrist at Bellevue who requested anonymity because the psychiatrist didn’t have permission from the hospital to speak to press.

Dr. Jon Berlin, who is the former medical director of the Milwaukee Psychiatric Emergency Services and is a past president of the American Association for Emergency Psychiatry, told City Limits that the medication at its normal dose is “a powerful cocktail.”

“It would not be uncommon to see someone sleep for a few hours and then be groggy after that,” says Dr. Berlin.

The Haldol/Ativan cocktail is one of the combinations commonly used for emergency medication because both drugs are cheap and widely available. Like most drugs of their class, both carry some risk: long-term patients on Haldol, an older antipsychotic, may sometimes experience a Parkinson’s-like neuromuscular condition called tardive dyskinesia, and Ativan bears dependency risks and can cause suicidal thoughts. Rare cases of sudden cardiac death have been linked to Haldol as well.

Settling on a maintenance antipsychotic prescription sometimes involves a process of trial and error; patients can react very differently to different medications in the class. For some people, Haldol may be dangerous or simply ineffective.

Dr. Berlin says that many emergency psychiatry departments in the U.S. have started using newer antipsychotics because Haldol’s sedative effect is so strong. “It’s very reliable in terms of calming a person down, but it can be overly sedating and the side-effects can be considered unpleasant by patients.”

Berlin adds that all emergency medication and force should be “an absolute last resort” and should only be used “for someone who is really mentally ill, who is really dangerous, and someone who doesn’t respond to non-coercive verbal or nonverbal interventions.” He also notes that it’s often possible to engage a patient in conversation and convince them to take medication voluntarily, even in an emergency.

In addition, Berlin says that blood work isn’t necessarily taken for every psychiatric emergency room patient. Studies have disputed the value of pre-admission medical evaluations for psychiatric patients; one 2012 chart review looked at 502 psychiatric patients in Georgia and found that laboratory screening in the emergency room would have affected the initial treatment plan in only one case. “There is no need for routine medical screening” for psychiatric patients in emergency departments, the study concluded.

The legal guidelines

New York State courts have set clear guidelines for when hospitals can force medication on psychiatric patients. In the landmark Rivers v Katz case in 1986, which established the current standard of forced treatment, Judge Fritz Alexander of the state court of appeals wrote a unanimous decision citing patients’ “fundamental liberty interest to reject antipsychotic medication,” including patients committed involuntarily to a hospital like the case’s eponymous Mark Rivers.

“In our system of a free government, where notions of individual autonomy and free choice are cherished, it is the individual who must have the final say in respect to decisions regarding his medical treatment,” wrote Judge Alexander. “This right extends equally to mentally ill persons who are not to be treated as persons of lesser status or dignity because of their illness.”

The decision ensured that a court must find patients to be dangerous or incapable of making treatment decisions before their right to refuse medication can be nullified. Before Rivers v. Katz, any patient committed involuntarily to a hospital in New York had to petition to reject medication; now, medication cannot be forced without judicial review. The case also confirmed the state’s ability to use its police power to force medication in emergency situations, but only, Judge Alexander writes, “where the patient presents a danger to himself or other members of society or engages in dangerous or potentially destructive conduct within the institution.”

The New York City Health and Hospitals Corporation, which runs Bellevue, provided City Limits with the total number of intramuscular injections administered and the number of patients who received injections at each of its hospitals for the past 10 years in response to a Freedom of Information Law request. The data show the remarkable growth of Bellevue’s use of emergency psychiatric intramuscular medication, which comprises all but a “handful” of the injections, according to Ana Marengo of the Health and Hospitals Corporation’s press office.

In 2005, Bellevue used about as many intramuscular injections as other major facilities in the Health and Hospitals Corporation system: 42,401 there, compared with 44,498 at Elmhurst Hospital in Queens, 42,694 at Kings County Hospital in Brooklyn and 37,098 at Woodhull Hospital, also in Brooklyn.

But by 2007, Bellevue had dramatically surpassed its counterparts, administering 84,120 injections to Elmhurst’s 44,453, Kings County’s 40,918, and Woodhull’s 50,482. Bellevue’s departure from the other hospitals continued to grow. In 2014, Bellevue used 95,959 injections to Elmhurst’s 53,774, Woodhull’s 50,955, and Kings County’s 27,728, where injection use declined significantly after the hospital overhauled its treatment policies.

Elmhurst, Woodhull, and Kings County Hospital all have large psychiatric departments with dedicated psychiatric emergency rooms like Bellevue’s. Since 2004, the number of inpatient psychiatric beds at Bellevue has not increased, and the number of discharges from the inpatient ward has declined by a quarter. From 2005-2014, the number of emergency intramuscular injections at Bellevue more than doubled, and the number of patients receiving IM emergency medication at the hospital more than quadrupled.

The Bellevue psychiatrist notes that when doctors believe patients need medication, they have to consider “the risk of not doing something.”

“Part of the way we’re trained to see it is it’s doing them a disservice not to do it,” the doctor says.

The psychiatrist also told City Limits that higher rates of injection use at Bellevue may stem from having patients who are more acutely psychotic than those at other hospitals. “Other hospitals at this point are sending their sickest patients to Bellevue.”

This may or may not be true. It is difficult to establish clear metrics to compare the severity of the psychoses of different hospital populations. But data on the psychiatric facilities of the Health and Hospitals Corporation suggest that Bellevue’s patient population may not be substantially more acute than that of other municipal hospitals. With very psychotic patients, hospitals may expect more frequent readmissions after release, according to a lawyer who has experience working at several psychiatric facilities in the city, including Bellevue and Mount Sinai Beth Israel Hospital. In 2014, the percent of readmissions within thirty days for Bellevue’s psychiatric patients was only slightly higher than average for HHC: 24.3 percent, to the overall system’s 23.4 percent.

In addition, the lawyer told City Limits that regardless of the acuity of the patient population, doctors resort to forced injections more readily at Bellevue than elsewhere. “They’re not as quick to pick up the needle” at Beth Israel, says the lawyer.

One patient’s experience

Mike Dote has been treated for schizophrenia in several New York City hospitals, including Bellevue and Beth Israel. When I first meet him at Bellevue’s 19th floor court, he’s wearing an oversized tweed jacket he says came from a friend’s ex-wife’s grandfather who wore it in a photograph with President Truman. Dote has thick glasses and a dry sense of humor. He’s a professional portrait photographer, and until his recent hospitalization he was a part-time fencing coach at a charter school in the Bronx. He hasn’t been asked back to the school after missing the days he was in the hospital.

Dote says he was also hospitalized at Bellevue for about four months eight years ago and was given involuntary injections “too many times to count.” He recalled one time when he took a doctor’s pen and put in in the mail slot – “it was like a minor nuisance, not a danger to others” – and got emergency medication. “I don’t even know what was in [the injection]. I assume it was Haldol because that’s what they were shooting everybody else with.”

Dote says he was also hospitalized at Bellevue for about four months eight years ago and was given involuntary injections 'too many times to count'

Adi Talwar

Dote says he was also hospitalized at Bellevue for about four months eight years ago and was given involuntary injections 'too many times to count.'

At Beth Israel, Dote says, he’s never been given an emergency injection. Whenever he’s had problems on the unit, doctors offered him oral medication and he took it voluntarily. “At Beth Israel, they were much better about it,” he says. “At Bellevue you just look at someone wrong and they shoot you up with Haldol.”

The attorney familiar with treatment at both hospitals adds that doctors at Beth Israel often talk down agitated patients instead of ordering injections. “I’m thinking, ‘If they were at Bellevue, they would be medicated by now.'”

“It might be Bellevue has a culture where people don’t think it’s wrong anymore,” says the lawyer.

Dr. Julie Holland ran Bellevue’s psychiatric emergency room on the weekends from 1996-2005. She told City Limits that when she was working at the hospital, emergency medication was sometimes used to compel blood work during the admissions process.

“I was definitely aware of a sort of coercion going on,” she says. The admissions evaluation would take a long time and tended to happen late at night because the psychiatric department would have to wait for a team to come from the medical emergency room for parts of the process on the weekends. “No one was in a very good mood.”

So when patients didn’t want their blood drawn “for delusional reasons,” says Dr. Holland, or simply because they “weren’t consenting to invasive medical procedures,” doctors would order emergency medication to force compliance.

“There were definitely times where it was like ‘We need your blood because you’re going upstairs, so you can either give it voluntarily or not,'” says Dr. Holland.

Some doctors, she adds, would argue that forcing blood work met the law’s present dangerousness standard because they needed to be sure the patient wasn’t experiencing critically low blood sugar levels or similar health risks. “I think it was a rationalization,” she says.

An ongoing investigation

The press office at Bellevue did not answer follow-up questions about the use of emergency injections for blood work in the psychiatric emergency room— including questions about any recent incidents of emergency medication being administered to nonviolent patients who refuse blood work and whether any doctors have been disciplined for ordering emergency injections in inappropriate circumstances. In an emailed response to the questions, Hernandez reiterated her earlier statement. More than eight months after the complaint was filed by the Mental Hygiene Legal Service, the Justice Center’s investigation is ongoing.

The courtroom at Bellevue holds hearings every week to adjudicate the hospital’s requests for court orders to forcibly medicate patients on an ongoing basis– the other legal form of involuntary treatment besides emergency medication. This fall, the court’s calendar was routinely overbooked with requests from the hospital to treat patients over objection.

Emergency injections don’t need to be authorized in court, but they’re frequently discussed in hearings to adjudicate requests for ongoing treatment over objection, where lawyers for the hospital bring them up as evidence that continuing involuntary treatment is necessary. The justification that doctors give for these injections during their testimony is often “agitation,” which in a clinical context describes increased motor activity and heightened negative emotion, says Dr. Berlin.

Dr. Berlin adds that agitation by itself does not connote immediate dangerousness, and doesn’t meet the standard for involuntary treatment. Forced medication, he says, “comes up when agitation is combined with dangerousness and lack of cooperation.”

Lawyers from the Mental Hygiene Legal Service say that agitation as a reason for emergency medication falls in a legal grey area: whether it describes dangerousness may depend on the severity of the behavior, a fact often unclear from the medical record. A 2010 guidance memo from the Office of Mental Health, which licenses Bellevue’s psychiatric department, is less ambiguous. While medication may be used to treat agitation on a voluntary basis, the memo stipulates, “agitation, however, in and of itself, is not an emergency situation that warrants treatment over objection.”

Bellevue is not the first New York City hospital to be accused of using forced medication illegally. In 2007, the New York Civil Liberties Union, the law firm of Kirkland and Ellis LLP, and Mental Hygiene Legal Service sued Kings County Hospital over conditions in the psychiatric ward, including an alleged pattern of doctors using forced intramuscular injections as punishment for difficult patients.

The complaint filed in the Kings County Hospital case cited four specific incidents of illegal intramuscular medication over eight months, less than half as many as the Bellevue complaint to the Justice Center. One doctor at Kings County, who requested anonymity because she was not authorized to speak to the press, says that the number of incidents at Bellevue is alarmingly high. “Even three or four in the last couple of years would be a huge deal,” she told City Limits.

The Health and Hospitals Corporation settled the Kings County lawsuit in part by consenting to at least five years of supervision of Kings County Hospital by the U.S. Department of Justice, the NYCLU, MHLS and Kirkland & Ellis. “HHC throws all their money at us because of DOJ and totally ignores really horrific conditions at the other hospitals,” says the same Kings County doctor.

Susan Stefan, an attorney and former director of the Emergency Department Project at the Center for Public Representation in Newton, Mass., says she’s particularly troubled by the use of emergency injections for noncompliant patients in dedicated psychiatric emergency rooms like Bellevue’s, which should be better prepared to handle people in psychotic crisis than general emergency departments. “There’s a real problem with informed consent,” she says. “People are subject to force when they don’t do what they’re told to do in emergency departments.”

She adds that even when patients aren’t physically forced to take medication, they may be coerced to accept the treatment through intimidation or by threatening to keep them longer at the hospital. “This is how involuntary medication tends to happen,” she says. “In many states, patients have the legal right to refuse treatment, and there are relatively strict legal limitations on the use of restraint, but neither of these are understood to limit either shows of force or threats to rescind privileges.”

Stefan, who wrote a 2006 book on the treatment of psychiatric patients in emergency departments, says another problem is the stressful environment of many departments, where delays can be long and patients often feel they are losing control. Because of that, she says, people may come in calm but go into crisis and get forced medication after hours of waiting and frustration.

She notes that psychiatric patients, especially those with histories of trauma, often become hesitant to seek treatment at hospitals where they’ve experienced forced medication. A 2011 review of studies in Clinical Psychology Review found prevalence of trauma among people with serious mental illness ranging from 49-100 percent.

“People with trauma histories really need to feel like they’re maintaining control,” Stefan says.

Dr. Holland says that bad patient experiences in the psychiatric emergency room are built into the environment. “It’s hard to have a large group of psychotic people who are depressed or agitated all in one place and call it therapeutic,” she says.

“Bring me 10 stories of people who had good therapeutic experiences in the psych ER and I’d be shocked,” says Dr. Holland.

This article was reported in partnership with the Investigative Fund at the Nation Institute, with support from the Gertrude Blumenthal Kasbekar Fund.