Involuntary commitment reform in NC without breaking the system

The state’s current involuntary commitment process allows people to go to a magistrate and express concern about someone with a “serious mental illness” being a danger to themselves or others. The magistrate can order police to take that person to a facility for a “first evaluation,” which is primarily done in hospital emergency departments, Reeder said.

If that person is deemed a danger to themselves or others, they can be admitted to a psychiatric facility against their will. A second exam is done by a psychiatrist at the facility, and if they also agree, that person can be admitted to the hospital involuntarily, against their will, Reeder said.

“You’re admitting someone to the hospital against their will potentially,” he said. “That’s why there’s that process, because you wouldn’t want to take somebody’s rights away.”

Iryna’s Law recognized that some people with mental illness are in the criminal justice system, which is why it calls for evaluations to be conducted on those in the system as well. In fact, it takes a more proactive approach by proposing screening and evaluations for more people than before to catch undiagnosed illnesses, Reeder said. 

But while the law has passed, its mental health and involuntary commitment requirements have been delayed — initially until December 2026, but more recently pushed to July 2028 — to give legislators time to figure out how to best implement them, according to the latest version of HB 1104.

As Iryna’s Law is written now, defendants who have been involuntarily committed in the three years before an arrest for a violent crime, or who judicial officials believe to be a danger to themselves or others, must be transported to an emergency room or another crisis facility for an initial mental health exam. 

The issue with this is that it could overwhelm already crowded emergency rooms, which have to care for patients dealing with a wide range of medical problems. On the flip side, it would also require more jail staff to transport defendants to the hospital and wait with them.

Currently, anyone in the custody of the jail can be brought to the emergency room if jail staff believe they need a medical or psychiatric evaluation, but the involuntary commitment provisions from Iryna’s Law haven’t been enacted yet, Reeder said.

Recognizing the gaps in Iryna’s Law, legislators put together a committee to help find solutions: the House Select Committee on Involuntary Commitment and Public Safety. Reeder was selected as one of the chairs of the committee, his background in emergency medicine giving him a little insight into the situation, he said.

“We deal with mental illness on a daily basis,” he told Carolina Public Press.

The committee came up with HB 1104, with its focus on studies targeting different aspects of the mental health system. The results from these studies can help inform how requirements from Iryna’s Law should be carried out — one of those studies being the telehealth pilot program in the jails.

The pilot program will use telehealth to conduct first evaluations for suspected mental health issues in the jails, rather than bringing defendants to the emergency rooms as it’s currently written in Iryna’s Law.

“For many emergency departments around the state, that evaluation for the patient with depression or schizophrenia is done currently by telehealth,” Reeder said.

“That’s a very common thing, so we felt like you could use that same technology, the same services, in the safety of a jail.”

Reactions to involuntary commitment law

The pilot program has received mixed reactions, earning approval from the healthcare community while prompting a more cautious response from the law enforcement side, namely the Sheriffs’ Association.

Lauren Earnhardt, executive vice president of the Sheriffs’ Association, shared the organization’s primary concern with CPP.

“While we know that the interaction between the mental health and criminal justice systems needs to be improved upon, we do not want jails to become hospitals,” she said.

“Currently, jails are often housing people who are charged with offenses but also need serious mental health treatment. Many of these individuals should be treated in a hospital or healthcare setting where their mental health needs can be addressed.”

Despite its concerns, the organization is still willing to participate in the involuntary commitment program.

“The Association is willing to help establish a pilot program as required by HB 1104, evaluate the results and provide our analysis to the General Assembly,” Earnhardt said.

Meanwhile, the North Carolina Healthcare Association has had a more enthusiastic response to the proposed program.

Stephanie Strickland, executive director of communications, said the organization “appreciates lawmakers’ willingness to address stakeholder concerns.”

“Delaying the implementation of Iryna’s Law provisions that would have required individuals arrested for violent crimes to be transported to hospital emergency departments for court-ordered mental health evaluations helps maintain a safer environment for patients and healthcare workers,” she told CPP.

A question of safety

Conducting mental health evaluations for potential involuntary commitment in jails could have certain benefits as opposed to holding them in emergency rooms, which could present a number of issues. One of those is a strain on resources.

According to Dr. Scott Klenzak, a psychiatrist and former president of the North Carolina Psychiatric Association, if the person is already in jail, jail staff have to escort the inmate to the emergency room. They’re checked in, triaged, given a bed and then they wait for a psychiatric evaluation, which is usually done through telehealth.

“They’re gonna wait in the emergency room for hours, potentially longer, maybe a day for this evaluation, taking up an emergency room bed that someone having a medical emergency such as a heart attack or a stroke or a broken leg needs,” he said.

There are also safety risks that come with allowing inmates who have been charged with violent crimes to be around hospital staff and the general public, Strickland said.

“Conducting appropriate evaluations through telehealth in secure detention settings allows for the provision of medical care in a secure setting,” Strickland said.

“Additionally, this approach will likely improve safety, reduce unnecessary transports to emergency departments, and help ensure hospitals remain focused on caring for patients with medical emergencies.”

Earnhardt also acknowledged that conducting involuntary commitment exams in the jails would avoid the transport issue entirely, Earnhardt said.

“Providing evaluations within the jail would eliminate the need to transport inmates to the hospital for mental health evaluations, improving the safety of officers, inmates, and the public,” she said.

Ultimately, legislators believed the jail was the best, most secure location for these kinds of evaluations, but recognized there were still concerns from some stakeholders. The pilot program acts as a compromise to first try this approach and see what results they get and how they can learn from them before implementing anything more permanent, Reeder said.

History of tension

While there are potential benefits to conducting these evaluations in a more secure setting like the jail, the proposal has previously been a point of contention between stakeholders from jails and hospitals. 

The challenge legislators have been trying to tackle over the past several months is how to best address mental health issues of those in the system while recognizing the limitations of each setting — and making sure both sides are on board with any proposed solutions.

“The hospitals would say bringing someone who has violent behavior out of a secure setting into the emergency departments that are already crowded and holding people, that is worrisome,” Reeder said.

“The sheriffs who operate jails would say, ‘What if they need other medical interventions? We’re not set up to do that.’”

Klenzak told CPP the history of tension between jails and hospitals regarding mental health could be a “book-length essay.” It all comes down to their different missions, he said.

“The hospital, especially the emergency room, is focused on true medical emergencies,” Klenzak said.

“Are you dying or not? Are you acutely psychotic? Are you suicidal? If someone’s not having a medical or psychiatric emergency, they don’t need to be in an emergency room.”

Then, there are the jails.

“Jails have a fundamentally different purpose,” Klenzak said.

“People are in the criminal justice system. Their rights are being taken away from them. They’re being forced into jail.”

When inmates face serious medical problems that the jails can’t address onsite, they are typically sent to the emergency room, stabilized, and then sent back to jail, Klenzak said. This also applies to mental health emergencies, Reeder said.

Enacting the involuntary commitment provisions of Iryna’s Law as it is could strain resources on both sides, which is problematic considering both hospitals and jails have been facing high volumes of patients and residents. 

While there’s no set definition for overcrowding at hospitals, it appears that the number of ER visits statewide relative to the population has remained pretty consistent through the past several years, Strickland said. 

However, as the state’s population continues to grow, so does the number of overall ER visits, “creating additional need for service from hospitals,” she said.

Emergency department visits statewide dropped in 2020 during the pandemic to just over 4 million for the year. Since then, that number has been creeping back up, with total visits in 2025 just shy of 5 million, according to emergency department visit trend data from NC DETECT.

Additionally, North Carolina ranks seventh in the nation for longest emergency room visit times, with patients spending three hours and 15 minutes on average in the emergency department, the Carolina Journal reported in June.

Meanwhile, some jails around the state are also struggling to keep up with growing populations, with one example coming from Mecklenburg County. 

The county is planning on reopening Detention Center North — which previously served as a juvenile detention center — to remedy “unprecedented” overcrowding at its existing facility, Detention Center Central. Its population was 2,080 as of June, well above its capacity of 1,791 inmates, CPP previously reported.

The Wake County jail was also almost 100 inmates over its capacity in April, WRAL previously reported.

The Sheriffs’ Association has been supportive of Iryna’s Law, but initially said it opposed any rule that would require initial mental health exams to be conducted in the jails, WRAL reported in January.

Eddie Caldwell, the former executive vice president of the Sheriffs’ Association, told WRAL that hospitals are better suited to deal with those experiencing a “mental crisis” because they have easy access to equipment that the jails simply don’t have, allowing hospitals to “do the mental health part and the physical part much more efficiently and much more thoroughly than it can be done in the jail.”

However, law enforcement officials’ sentiment changed once it was clarified that a telehealth model would be used for the pilot program to screen for possible involuntary commitment, lessening the burden on jail staff to provide actual mental healthcare. The Sheriffs’ Association will remain “open” to the program as long as the state provides the doctors for telehealth, Earnhardt said.

Outlook for involuntary commitment reforms

One of the criticisms of HB 1104 is how many studies versus actual solutions it proposes. Reeder said it’s because mental health is not a simple issue.

“The reality is that the issues that we’re dealing with were complicated, and so we wanted to make sure that we had the right information for that,” Reeder said.

For the pilot program, Reeder said they’ll try to implement it with sheriffs who want to be included, but the goal is to get a mixture of participating jails from urban and rural counties to learn as much as possible.

“It’s almost doomed to failure if you go to somebody who isn’t interested in doing a pilot, right? That’s just human nature,” Reeder said. 

“I’m hopeful that we’re going to get a grouping of sheriffs.”

The Sheriffs’ Association will submit the proposal for the pilot program by March 1, 2027, to oversight committees on justice and public safety and health and human services, according to the bill.

While Reeder is hopeful that the pilot program and the overall bill will produce helpful results, he said this won’t be an issue that’s resolved anytime soon.

“It has taken us decades to create the broken mental health system that we have,” Reeder said. 

“We’re not going to solve the entirety of the system in the next six months.”

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