Reasonable or Random: 72-Hour Limits to Psychiatric Holds

Seventy-two-hour limits on emergency psychiatric detention have a nuanced history, as exemplified in California. At the end of the 1930s, California law permitted emergency psychiatric detention for up to 48 hours—or 72 hours in case of holidays—before requiring the presentation of a petition to a magistrate. Expanded to 72 hours during the 1950s, these limits were not particularly strict. Judicial hearings typically lasted just minutes and could lead to commitments of indeterminate lengths (4, 5). As California legislators reexamined civil commitment during the 1960s, the 72-hour limit became a point of contention. For example, during a California Senate hearing, a psychiatrist argued for lengthening the 72-hour limit, stating, “This is much too short a time…[12 days] would achieve a great deal of real value both for the patient and the patient’s prognosis and for us” (6). A district attorney countered: “Now, we use the 72-hour emergency detention a great deal. We like it. I wouldn’t recommend it be made longer.” Signed into law in 1967, the Lanterman-Petris-Short Act (LPS) introduced strict 72-hour limits to emergency psychiatric holds, specific criteria for detention, additional time limits for extended commitment, and greater judicial oversight of the process. Described as “the Magna Carta of the mentally ill” (4), LPS became “the model for virtually every state in the Union” (7). A 1975 article noted that “one of the major innovations of LPS [was] the imposition of time limits on the duration of involuntary treatment” (8), and, by 1979, another article pointed out that “the constitutionality of the 72-hour hold period has never been successfully attacked” (9). In 2014, 72 hours had become the most common standard for emergency psychiatric holds in the country and was used by 22 states (2).

These 72-hour limits may be sensible for several reasons. First, limiting psychiatric hold duration can safeguard against prolonged and potentially unnecessary detention of patients. Psychiatric holds can entail considerable coercion and disruption to patients’ lives; therefore, restricting holds to shorter periods may protect patients’ liberties and encourage clinicians to act quickly to stabilize patients and return them to the community. A 1966 article described “increasing awareness of the negative effects of long-term hospitalization” (10), and, within 2 years of LPS enactment, the average duration of involuntary psychiatric care in California reportedly fell from 180 to 15 days (8).

Second, many patients with psychiatric needs can be evaluated, stabilized, and discharged within 72 hours, although some relevant studies are outdated or have methodological limitations. A 1969 paper described 3-day psychiatric hospitalization as “a model for intensive intervention,” reporting that rehospitalization rates for 100 patients with average hospital stays of 3 days were similar to those of patients in other studies, with average hospital stays of 3 weeks to 8 months (11). Health care facilities soon developed various models, including psychiatric emergency services and observation units, for providing short-term psychiatric care (12–15). Some psychiatric emergency services have reported discharging over 60% of patients within 1–3 days; however, these studies have not always examined subsequent outcomes (e.g., long-term readmission rates, criminal justice involvement, or mortality) (12, 13). A 2019 Australian study of more than 2,000 patients found that those admitted to a specialized 3-day psychiatric unit had 42% lower readmission rates (10.6% versus 18.4%) over 28 days than diagnosis-matched patients admitted to standard acute mental health beds (14).

Third, some evidence supports the use of 72-hour holds versus other time limits. A 2000 article reported that most German states limited psychiatric detention to 24 hours before a court must be consulted, but one state used a 72-hour limit; the authors estimated that 72-hour holds allowed for more stabilization time and reduced the number of patients committed by court for further treatment by approximately 50% compared with 24-hour holds (16). In 2012, researchers published a study of 500 patients in Virginia that lent some support to 72-hour limits (17). Virginia limited temporary detention orders (TDOs) to 48 hours before court hearings, but hearings could occur within 24 hours, and weekends and holidays sometimes delayed hearings; these variations enabled a naturalistic study that compared TDO lengths and hearing outcomes. The predicted probability of subsequent hospitalization was lower for patients after a 3-day TDO (0.76) than for patients who had been on 2-day (0.84), 1-day (0.89), or <1-day (0.93) TDOs.

Still, research on 72-hour holds is limited despite the prevalence of these policies. In a 1967 article describing 72-hour psychiatric detentions, two clinicians called for further study “by means of tabulated data and controls” into these models of care (18). Forty-five years later, the authors of the Virginia TDO study noted a continued lack of data regarding temporary detention and commitment outcomes (17). Although they are the most common standard for psychiatric holds in the United States, 72-hour limits are not universal: state limits on these holds vary from 23 hours to 10 days (2). Even among states that use 72-hour limits, states can have different criteria for placement of a psychiatric hold and may impose different requirements for extending commitment beyond an initial hold’s expiration. Despite decades of controversy over civil commitment, little research has compared the effects of these different policies on patients, clinicians, law enforcement officials, and others in the community.

Different time limits are not only feasible, but also may have benefits compared with 72-hour limits. For instance, an uncontrolled 2000 study of a Veterans Affairs psychiatric observation unit reported that 81 (88%) of 92 patients were discharged to outpatient settings within 24 hours (15). In the 2012 Virginia study, 3-day TDOs resulted in a lower probability (0.76) of further hospitalization than did shorter TDOs; yet, this probability was even lower for patients after 4-day TDOs (0.66) (17). Longer holds may benefit some patients by allowing for more stabilization time and reducing unnecessary hospitalization, and might benefit others by allowing clinicians to better observe their clinical needs and to provide necessary care (e.g., further hospitalization).

There is also concern that 72-hour and other short-term holds may foster neglect of patients and ineffective churn in mental health settings. Many view strict limits on involuntary psychiatric care as one reason that people with serious mental illness cycle in and out of emergency departments (EDs), jails, shelters, and other holding places (4, 5). For example, the clock starts ticking once patients are placed on short-term holds, and EDs may struggle to provide timely psychiatric care when faced with limited availability of mental health professionals and beds. These patients may end up boarding in EDs, staying in a “state of limbo” (13) and waiting to receive psychiatric care as the time allowed to provide that care winds down.

Research on 72-hour psychiatric holds may be difficult to conduct. Assessing the value of liberty preserved by briefer detention is not straightforward. Randomly assigning patients to different time limits may be challenging given the inflexibility of commitment statutes and the risks for adverse health-related outcomes. Multiple variables beyond time limits, such as availability of community services, shortages of mental health professionals, and patient characteristics, shape outcomes related to involuntary care. Moreover, the utility of these time limits is context dependent; for example, a patient detained on the basis of mistaken information might benefit from a short time limit, but the same limit could be detrimental to a patient with significant psychiatric needs who does not receive necessary longer-term care.

Nonetheless, many questions surrounding these policies need to be investigated. Are certain time limits associated with improved health-related outcomes (e.g., decreases in psychiatric symptoms, ED visits, medication nonadherence, violence, or suicide) compared with other limits? How do patients and clinicians view 72-hour holds versus longer or shorter holds? In what ways do 72-hour limits versus other limits affect the functioning of mental health systems, such as rates of psychiatric boarding, administration of psychotropic medication, and attendance at follow-up appointments?

Studying how these limits affect overall hospitalization rates and lengths of stay is necessary. Increasing limits from 24 hours to 48, 72, or 96 hours might decrease rates of continued hospitalization or involuntary commitments; however, with longer time limits, patients might be spending more overall time in the hospital (17). Examining hospitalization frequency is also key to mitigate the revolving-door phenomenon (5). If patients are held or hospitalized more frequently because of inadequate stabilization, shorter holds may be less useful than longer holds, which provide more time for stabilization. Finally, research into these time limits should involve collaboration between health and criminal justice systems, because health-related outcomes (e.g., readmissions and mortality) must be viewed alongside the effects of these policies on criminal justice outcomes (e.g., arrests and incarceration).

Seventy-two-hour psychiatric holds shape the lives of millions of people across the United States. It is time to make sure these policies are reasonable rather than random.