Three months before Robert R. Card II killed 18 people in Maine’s deadliest mass shooting, he was released from a psychiatric facility where he had been involuntarily committed for 14 days. It was a determination that indicated, under New York law, that the Army reservist no longer represented an imminent danger to himself or others.
On Oct. 25, that would prove to be a deadly miscalculation.
Experts say cases like Card’s are extreme examples of a critical gap in the mental health system. People who meet the high bar for involuntary commitment are offered treatment while hospitalized. But once a patient leaves, there are few checks in place to make sure they are getting whatever additional help they need.
“It’s not a great system, to be honest with you,” said Martin Buccolo, who retired in 2017 as the CEO of Four Winds Hospital in Katonah, N.Y., the 175-bed psychiatric hospital where Card was committed.
Card’s display of paranoia and delusions while stationed with his unit in New York triggered the part of the mental health system that does have the ability to compel people into emergency care. Card was escorted to Keller Army Community Hospital in West Point, N.Y., by police, evaluated by a psychologist, and sent to Four Winds for treatment and evaluation, according to a Sept. 15 police report released by the Sagadahoc County sheriff’s department.
The length of involuntary commitments varies by state, and in some states can be only a matter of days. But in New York, where Card was initially committed, people can be held for up to 15 days on an emergency basis. Longer hospitalizations require additional legal or medical sign-off. Four Winds officials did not respond to requests for comment, and have not said whether they pursued any options to extend his hospitalization.
Because of lack of access or, in some cases, a patient’s unwillingness to follow up, discharge can represent the end of care.
Especially for people exhibiting symptoms of psychosis — which can prevent people from trusting or seeking medical care — involuntary stays represent “kind of their only chance to be treated,” said Lisa Dailey, executive director of the Treatment Advocacy Center, a Virginia-based nonprofit that focuses on mental illness care.
At any point during a person’s hospitalization, a person can be discharged if the hospital feels the person no longer meets the standards for commitment.
“It’s a lot more subjective than people think it is,” said Dailey. “We see some very baffling decisions where somebody’s decided that they’re ready for outpatient treatment when I think most people would think that that’s not correct.”
Ideally, discharge planning starts the moment someone is admitted, said Bob Fleischner, a legal aid lawyer for more than 45 years, given that many people hospitalized for weeks at a time have lost their income, jobs, and some even their apartments.
Upon discharge, however, patients and their families are often left to their own devices. People are sometimes provided with a few days worth of medication, a prescription to get more, and a list of referrals to outpatient treatment facilities or clinicians, said Virginia A. Brown, a research scholar in health equity and population health at the Hastings Center, a New York think tank focused on bioethics.
“It’s that wrap-around service and handoff, that is the question,” Brown said. “What happens at discharge? Where do people go? Who picks them up, metaphorically, and connects them back into the system? That’s the biggest gap in health care that we have — that handoff.”
Four Winds says on its website that it provides “discharge planning coordination with outside community service providers.” However there have been no publicly released details as to what, if any, this follow-up care entailed in Card’s case.
“To my knowledge he has not sought any more treatment since being released,” said Kelvin L. Mote, a training supervisor in Card’s Army Reserve unit, in a letter sent to a Maine sheriff’s department.
Another hurdle for Card’s care was the fact that he had received inpatient care in a different state from where he lived.
“Linking someone with services in another state is obviously more difficult and more prone to things falling through the cracks,” said Dr. Paul S. Appelbaum, a professor of psychiatry, medicine, and law at Columbia University in New York.
Even if a person wants further treatment, it’s not always easy to receive. A nationwide shortage of clinicians means people often struggle to get appointments.
No state is in a position where every person who wants or needs follow-up care will get it, said Steven Schwartz, legal director at the Center for Public Representation, a national public interest law firm representing people with disabilities.
And there is no requirement as part of the civil commitment process to provide any follow-up care — it starts and stops at the doors of the hospital.
However, there is evidence that people who get involuntary treatment avoid mental health services in the future, out of concern that they might be placed in involuntary commitment once again.
“The fear of forced treatment, particularly if the experience was a bad one, drives them away from seeking out help,” Fleischner said. “They fear the people they are getting help from would force them into an institution.”
Clinicians in New York and Maine sometimes have other tools, including involuntary outpatient commitment.
Sometimes referred to as assisted outpatient therapy, it allows courts to mandate outpatient treatment, which often revolves around taking medication. Brown, of the Hastings Center, said that such tools are one of the few “warm handoffs” courts and psychiatric hospitals can utilize to keep people engaged in care.
However many patient care advocates are vehemently opposed to such methods, and say they do not always ensure a person complies with treatment.
Often, family members are the ones left responsible to get their relatives the care they need. Even when family is willing, they may not be able to convince a discharged patient to stay in treatment.
“There can be a lot of drama, a lot of harm that has happened in families that make them not the best person for this,” Brown said. “It’s very complicated.”
And though patients may leave a facility in stable condition, they can quickly deteriorate, said Dailey, of the Treatment Advocacy Center. It is particularly difficult, she added, to ensure the long-term wellbeing of a patient who has exhibited symptoms like paranoia or hearing voices, as Card was reported to have shown.
“If you discharge somebody who is still in active psychosis, and then the onus is on that person to know that they require additional care,” said Dailey, “that is a system that is designed to fail.”
Globe Staff member John Hilliard contributed to this reporting.