Diagnostic Uncertainty in Involuntary Commitment

Facts of the Case

Kara K. was admitted to API in March 2021. After improvement on an antipsychotic, she was discharged against medical advice, with the treating psychiatrist assessing that she did not meet criteria for involuntary commitment at that time. Ms. K. was brought five days later to an emergency department and placed on emergency detention in accordance with Alaska Stat. § 47.30.705(a) (2024). She was transferred to API and evaluated by the same treating psychiatrist, after which API petitioned the superior court for a 30-day involuntary commitment order in accordance with Alaska Stat. § 47.30.730 (2024).

In April 2021, a standing master held a commitment hearing in accordance with Alaska Stat. § 47.30.735 (2024). At that hearing, Ms. K. declined to testify, and the sole witness was the treating psychiatrist. He testified that he had made a “provisional” diagnosis of “bipolar I disorder …mixed with psychotic features” (Kara K., p 33). He cited her “grandiose and paranoid and somatic delusional beliefs,” including delusions of reference and pseudocyesis (Kara K., p 33). He also recounted disorganized and potentially deleterious behaviors, including waiting outside of a school to which she had no connection for hours in subfreezing temperatures, as well as refusing to eat or drink because of fear that her API food was “tainted and poisoned.” In presenting his provisional diagnosis, the psychiatrist elaborated on three possible causes of Ms. K.’s psychotic symptoms. First, her reported recent sexual harassment by a supervisor, if true, may have caused a stress-induced psychotic episode. Second, given Ms. K.’s long history of depressive episodes, this may have been bipolar disorder declaring itself at her age of 38. Third, based on evidence of a “malar rash or butterfly rash” on both cheeks and “significantly impaired kidney function” during her first admission, undiagnosed lupus might explain her psychosis (Kara K., p 33). When asked, the psychiatrist concluded that a confirmed lupus diagnosis would ultimately not change his recommendations for treatment of Ms. K.’s psychosis and for a 30-day involuntary commitment.

The standing master found that there was clear and convincing evidence that Ms. K. was mentally ill and gravely disabled, recommending that the superior court approve her commitment to API for 30 days. Regarding the nature of her psychotic illness, the master reasoned that “although there may be an organic cause [to the mental illness] …the symptoms, the manifestation right now demonstrates a mental illness currently with the psychotic features” (Kara K., p 34).

Ms. K. objected to the master’s findings, arguing that API had failed to prove that she had a mental illness under Alaska Stat. § 47.30.915(17) (2024). She argued that “it is just as likely” that she was “suffering from a medical condition and not a mental health crisis,” and this uncertainty meant that the psychiatrist’s testimony did not constitute clear and convincing evidence of a mental illness. API argued that “the source of the mental illness does not matter” (Kara K., p 34). The superior court ordered Ms. K.’s 30-day involuntary commitment to API, adopting the master’s recommended findings and endorsing the view that, if the presence of a mental illness is established by clear and convincing evidence, the “source does not matter.” Ms. K. appealed to the Alaska Supreme Court.

Ruling and Reasoning

The Alaska Supreme Court affirmed the lower court’s order for her involuntary commitment. The court concluded that “the statutory definition of ‘mental illness’ does not exclude mental or emotional impairments that result from a physical condition, and that due process does not obligate courts to ‘rule out’ physical medical conditions as the cause of a mental illness” (Kara K., p 35). The court noted that, in the text of the controlling Alaska law, Alaska Stat. § 47.30.915(17) (2024), lupus was not one of the five excluded conditions (intellectual disability, developmental disability, epilepsy, drug addiction, and alcoholism) that “do not per se constitute mental illness” (Kara K., p 36) and that there was no legislative evidence to support the exclusion of additional conditions not listed. The court also cited 1981 Alaska Senate Bill 100 (S.B. 100) to demonstrate that the legislature had placed sufficient protections against confinement based on physical medical conditions. S.B. 100 provided this due process protection by requiring that a patient be examined by a physician within 24 hours after arrival at a facility, rather than requiring a “rule out” workup before a patient can be transferred to a facility.

The court further clarified what they described as “imprecision” in their previous ruling in EP v. Alaska Psych. Inst., 205 P.3d 1101 (Alaska 2009). The court explained that the statement that excluded conditions “do not per se constitute mental illness” means that “excluded conditions do not by themselves, standing alone, constitute mental illness” but that a mental illness may nonetheless be present “apart from or more than an excluded condition” (Kara K., p 39). Given that API had provided clear and convincing evidence that Ms. K. was experiencing a mental illness, the court affirmed the superior court’s dismissal of the relevance of lupus as the potential cause of this illness.

Finally, the court affirmed the superior court’s conclusion that the state had met its burden of clear and convincing evidence that involuntary commitment at API represented the least restrictive alternative treatment. The court stated that its previous reasoning in this case rejected a requirement that a medical cause of mental illness be “ruled out” prior to commitment. In the absence of a requirement for such a “rule out,” the court affirmed the superior court’s assessment of the record in this case as adequately justifying involuntary commitment as the least restrictive alternative treatment.