Existing law, known as Lauras Law, requires a county or group of counties to provide assisted outpatient treatment as part of mental health services, unless a county or group of counties opts out by a resolution passed by the governing body, as specified. For participating counties, existing law authorizes a court to order a person who is the subject of a certain petition to obtain assisted outpatient treatment if the court finds, by clear and convincing evidence, that various conditions are met, including, among others, that the person is experiencing a mental illness and that the person has a history of lack of compliance with treatment for their mental illness, as specified. Existing law sets forth certain rights of the person relating to the hearing and imposes conditions on an extension to an initial treatment order.

This bill would authorize the county behavioral health director, or their designee, to file a petition for an order authorizing the use of involuntary psychotropic medication independent of, or concurrently with, a petition for assisted outpatient treatment. The bill would authorize a court to issue an order for the use of involuntary medication if the court finds, by clear and convincing evidence, that the facts stated in the required verified petition are true and establish that, among other things, a licensed mental health treatment provider has determined the person who is the subject of the petition has a serious mental disorder. The bill would specify rights that the person who is the subject of the petition is entitled to, including the right to demand a court or jury trial on the issue or issues of whether the person has a serious mental disorder, the person does not have the capacity to refuse treatment with psychotropic medications, or the psychotropic medications are necessary to prevent a relapse or deterioration that would be likely to result in grave disability or serious harm to the person or to others. The bill would provide the procedure for filing of the petition and setting of a trial date. The bill would prohibit any order for involuntary medication until the conclusion of the court or jury trial. The bill would authorize a licensed mental health provider who is a member of the assisted outpatient treatment services team to request that first responders take the subject of the petition into custody and transport the person, or cause the person to be transported, to a designated facility for the administration of the court-ordered medication if specified conditions are met. If the court grants the petition for involuntary psychotropic medication, the bill would require the county behavioral health director, or their designee, to file an affidavit with the court, as specified, affirming that the person who is the subject of the order continues to meet the criteria for the involuntary medication order and whether any medication changes pursuant to authorization occurred during the prior 60 days. By expanding the scope of the crime of perjury, this bill would impose a state-mandated local program.

The bill would also prohibit criminal or civil liability for an individual authorized to take custody of and transport individuals with an involuntary medication order issued pursuant to these provisions exercising this authority in accordance with the law.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law, known as Lauras Law, requires a county or group of counties to provide assisted outpatient treatment as part of mental health services, unless a county or group of counties opts out by a resolution passed by the governing body, as specified. Existing law requires a county or group of counties choosing to provide assisted outpatient treatment services to offer specified services, including a service planning and delivery process and a clearly designated mental health personal services coordinator for each client.

This bill would make technical, nonsubstantive changes to these provisions.

Date of Hearing: April 14, 2026

ASSEMBLY COMMITTEE ON HEALTH

Mia Bonta, Chair

ABPCA Bill Id:AB 1676

Author:(Stefani) – As Amended Ver:March 24, 2026

SUBJECT: Mental health services: assisted outpatient treatment: involuntary medication.

SUMMARY: Authorizes a county behavioral health director, or their designee, to file a petition for an order authorizing the use of involuntary psychotropic medication independent of, or concurrently with, a petition for assisted outpatient treatment (AOT) and authorizes a court to issue an order for the use of involuntary medication if a licensed mental health treatment provider has determined the person who is the subject of the petition has a serious mental disorder. Specifies the rights that the person who is the subject of the petition is entitled to and the procedure for filing of the petition and setting of a trial date. Authorizes a licensed mental health provider who is a member of the AOT services team to request that first responders take the subject of the petition into custody and transport the person, or cause the person to be transported, to a designated facility for the administration of the court-ordered medication if certain conditions are met, and specifies the length of the order and the process for continuing the order. Specifically, this bill:

1. Authorizes the county behavioral health director, or their designee, to file a petition for an order authorizing the use of involuntary psychotropic medication independent of, or concurrently with, a petition for AOT.
2. Authorizes a court to issue an order authorizing the use of involuntary medication for a person who is the subject of an AOT petition if the court finds, by clear and convincing evidence, that the facts stated in the verified petition are true and establish that all of the following criteria, at a minimum, are met:
   1. A court has ordered the person to participate in AOT;
   2. A licensed mental health treatment provider has determined that the person has a serious mental disorder;
   3. A physician or nurse practitioner has determined that the psychotropic medications are necessary to prevent a relapse or deterioration that would be likely to result in grave disability or serious harm to the person or to others, as described 1) of Existing Law below and the person does not have the capacity to refuse treatment with psychotropic medication;
   4. A physician or nurse practitioner has prescribed one or more psychotropic medications for the treatment of the person’s disorder, has considered the risks, benefits, and treatment alternatives to involuntary medication, and has determined that the treatment alternatives to involuntary medication are unlikely to meet the needs of the patient;
   5. The person has been advised of the risks and benefits of, and treatment alternatives to, the psychotropic medication, and refuses, or is unable to consent to, the administration of the medication; and
   6. The use of these medications is a component of the written treatment plan required in the AOT determination and is accompanied by a medication assessment prepared by the physician or nurse practitioner.
3. Requires the petition for involuntary medication to state all of the following:
   1. Whether the petition is filed concurrently with a petition for AOT;
   2. All of the criteria for authorizing the use of involuntary medication set forth in 2) above;
   3. Facts that support the petitioner’s belief that the person who is the subject of the petition meets each criterion, provided that the hearing on the petition be limited to the stated facts in the verified petition, and the petition contains all of the grounds on which the petition is based, in order to ensure adequate notice to the person who is the subject of the petition and that person’s counsel; and,
   4. That the person who is the subject of the petition has the rights specified in 7) below.
4. Requires the petition to be accompanied by an affidavit of the provider or providers that made the determinations of the person’s mental illness and need for medication that includes statements that: they personally examined the person who is the subject of the petition no more than 10 days prior to the submission of the petition; the facts and reasons why the person who is the subject of the petition meets the criteria; that they made appropriate attempts to elicit the cooperation of the person who is the subject of the petition, but have not been successful in persuading that person to voluntarily take the recommended medication; and, that they recommend the involuntary use of medication, and that they are willing and able to testify at the hearing on the petition.
5. Requires the court, if an involuntary medication petition and AOT petition are filed concurrently, to fix and consolidate the hearing dates for both petitions and conduct the hearing consistent with the existing requirements for an AOT petition, and requires the court to make a determination on the petition for AOT before its determination on the petition for involuntary medication.
6. Requires the court, if an involuntary medication petition and AOT petition are not filed concurrently, to fix the hearing date and conduct a hearing consistent with the requirements as specified in the current AOT process.
7. Requires the subject of a petition for involuntary medication to have the following rights, in addition to those specified in 3) of Existing Law below: the right to demand a court or jury trial on the issue or issues of whether the person has a serious mental disorder, does not have the capacity to refuse treatment with psychotropic medications, or the psychotropic medications are necessary to prevent a relapse or deterioration that would be likely to result in grave disability or serious harm to the person or to others.
8. Requires a demand for a court or jury trial to be made within five days following the hearing on the petition, and requires, if the person demands a trial before the date of the hearing, the demand to constitute a waiver of the hearing. Requires the trial to commence within 10 days of the date of the demand, but requires the court to set the trial date for a period not to exceed 15 days upon the request of counsel for person who is the subject of the petition. Prohibits any order for involuntary medication from taking effect until the conclusion of the trial, if demanded. States that failure to commence the trial within this period of time is grounds for dismissal of the proceedings. Requires a person that demands a trial to be entitled to counsel.
9. Requires the petitioner to promptly cause service of written notice of the trial date, to be made personally on the person who is the subject of the petition and demanded the trial, and requires a copy of the notice to be sent to the county office of patient rights, to the current health care provider appointed for the person who is the subject of the petition, if the provider is known to the petitioner, and to the petitioner’s counsel, if applicable.
10. Authorizes a court to order the person who is the subject of the petition to receive involuntary medication for the duration of the order requiring the person to obtain AOT and any subsequent order after hearing all relevant evidence, if the court finds that the person who is the subject of the petition meets the criteria for involuntary medication. Requires the order to receive involuntary medication to remain in effect until one of the following occurs, whichever occurs first:
    1. An order requiring the person to obtain AOT is terminated or has expired; or,
    2. The person is determined to have the capacity to refuse treatment with psychotropic medication, by either a physician or nurse practitioner who has determined the person’s capacity has been restored or the person no longer meets the criteria for an involuntary medication order specified in this bill, or a court or hearing officer who has determined the person’s capacity to refuse treatment with psychotropic medication is restored.
11. Permits a licensed mental health provider who is a member of the AOT team to request that first responders, specified to mean a peace officer, firefighter, paramedic, or emergency medical technician (EMT), take the subject of the petition into custody and transport the person, or cause the person to be transported, to a designated facility for the administration of the court-ordered medication if, in the clinical judgment of the licensed mental health provider, all of the following requirements are satisfied:
    1. The person who is the subject of the petition has failed or has refused to comply with the medication ordered by the court;
    2. Efforts were made to solicit the compliance of the person who is the subject of the petition; and,
    3. The person who is the subject of the petition is in need of evaluation at a designated facility for the purposes of administering the court-ordered medication.
12. Deems that failure to comply with an order of involuntary medication alone may not be grounds for involuntary civil commitment or a finding that the person who is the subject of the petition is in contempt of court.
13. Requires, if the county behavioral health director, or the director’s designee, determines that the condition of the patient requires further treatment with involuntary medication, and the county behavioral health director has also applied for an order authorizing continued AOT, the director to apply to the court, prior to the expiration of the period of the initial involuntary medication order, for an order authorizing continued administration of involuntary medication for a period not to exceed 180 days from the date of the order.
14. Requires the period for further involuntary medication authorized by a subsequent order to remain in effect until one of the following occurs, whichever occurs first:
    1. An order requiring the person to continue obtaining AOT is terminated or has expired; or
    2. The person is determined to have the capacity to refuse treatment with psychotropic medication, made by either a physician or nurse practitioner who has determined the person’s capacity has been restored or the person no longer meets the criteria for an involuntary medication, or a court or hearing officer who has determined the person’s capacity to refuse treatment with psychotropic medication is restored.
15. Requires the county behavioral health director, or the director’s designee, at intervals of not less than 60 days during an involuntary medication order, to file an affidavit with the court that ordered the involuntary medication affirming that the person who is the subject of the order continues to meet the criteria for the involuntary medication order. Requires the affidavit to specify whether any medication changes pursuant to the authorization occurred during the prior 60 days. Requires the person who is the subject of the order to have the right to a hearing on whether or not the person still meets the criteria for involuntary medication if they disagree with the director’s affidavit and requires the burden of proof to be on the director.
16. Permits the person who is the subject of the order, during each 60-day period specified, to file a petition for a writ of habeas corpus, requiring the director to prove that the person who is the subject of the order continues to meet the criteria for involuntary medication if they believe that they are being wrongfully medicated against their wishes.
17. Permits a person ordered to receive medication who was not present at the hearing at which the order was issued to immediately petition the court for a writ of habeas corpus. Prohibits the administration of involuntary medication under the order until the resolution of that petition.
18. Requires the court to dismiss the petition if, after hearing all relevant evidence, the court finds that the person who is the subject of the petition does not meet the criteria for involuntary medication.

EXISTING LAW:

1. Establishes the Lanterman-Petris-Short (LPS) Act to end the inappropriate, indefinite, and involuntary commitment of individuals with mental health disorders, developmental disabilities, and chronic alcoholism, as well as to safeguard their rights, provide prompt evaluation and treatment, and provide services in the least restrictive setting appropriate to their needs. Permits involuntary detention of an individual deemed to be a danger to self or others, or “gravely disabled,” as defined, for periods of up to 72 hours (known as “5150 holds”) for evaluation and treatment; for up-to 14 days after certification of the need for initial intensive treatment; and up-to 30 days for additional intensive treatment in counties that opt in to provide additional intensive treatment. [Welfare & Institutions Code (WIC) § 5000, et seq.]
2. Defines “antipsychotic medication” as any medication customarily prescribed for the treatment of symptoms of psychoses and other severe mental and emotional disorders. [WIC § 5008(l)]
3. Permits antipsychotic medication to be administered to any person subject to various involuntary detention lengths, as specified, if that person does not refuse that medication following disclosure of the right to refuse medication, as well as information required to be given to persons, as specified. [WIC § 5332]
4. Requires medication, if any person subject to various specified involuntary detention lengths and for whom antipsychotic medication has been prescribed orally refuses or gives other indication of refusal of treatment with that medication, to be administered only when treatment staff have considered and determined that treatment alternatives to involuntary medication are unlikely to meet the needs of the patient, and upon a determination of that person’s incapacity to refuse the treatment in a capacity hearing (known as a “Riese hearing”) held for that purpose. [WIC § 5332]
5. Requires persons subject to capacity hearings, as specified, to have a right to representation by an advocate or legal counsel. Requires capacity hearings to be heard within 24 hours of the filing of the petition whenever possible. [WIC § 5333 and § 5334]
6. Requires any determination of a person’s incapacity to refuse treatment with antipsychotic medication to remain in effect only for the duration of the up-to 72 hours of detention for evaluation and treatment and the initial up-to 14 days of involuntary detention for intensive treatment, or both, or until capacity has been restored according to standards developed, as specified, or by court determination, whichever is sooner. Provides an order for treatment with antipsychotic medications will remain in effect at the beginning of a detention period under exigent circumstances. Permits the extension of treatment with antipsychotic medication until a new capacity hearing is held on the basis of an attestation of exigent circumstances to be invoked for a person only one time during the applicable detention period covered by the existing capacity determination Sunsets the extensions allowed under exigent circumstances on January 1, 2030. [WIC § 5336]
7. Implements AOT (known as “Laura’s Law”) statewide, whereby an entity can petition for a court to order a person over the age of 18 with a mental illness to receive AOT if the court finds the individual meets specified criteria, including: a clinical determination that the person is unlikely to survive safely in the community without supervision; the person has a history of noncompliance with treatment for their mental illness; the person's condition is substantially deteriorating; and, participation in AOT would be the least restrictive placement necessary to ensure the person's recovery. Permits a county or group of counties that do not wish to implement Laura’s Law to opt out of the requirements of AOT services through a specified process. [WIC §§ 5345 – 5349.1]
8. Requires the subject of a petition to have specified rights, including to cross-examine witnesses, receive adequate notice of the hearing, and be present at the hearing, unless the subject of the petition waives the right to be present. [WIC § 5346(c)]
9. Prohibits AOT from being ordered unless the licensed mental health treatment provider recommending AOT to the court has submitted to the court a written treatment plan that includes the specified AOT services. [WIC § 5346 (e)]
10. Prohibits involuntary medication for a person receiving AOT services absent a separate order by the court following the specified process for capacity hearings. [WIC §5348 (c)]
11. Requires a county that operates an AOT program to provide specified data to the Department of Health Care Services (DHCS) and requires DHCS to report to the Legislature on or before of May 1 each year. Requires the report include, at a minimum, an evaluation of the effectiveness of the strategies employed by each AOT program in reducing homelessness and hospitalization of persons in the program and in reducing involvement with local law enforcement by persons in the program. [WIC § 5348 (d)]
12. Establishes the CARE Act to help connect an individual (known as a “respondent”) with a court-ordered CARE agreement or CARE plan for up to 12 months, with the possibility to extend for an additional 12 months, that provides individualized, appropriate community-based services and supports, which include clinically appropriate behavioral health care and voluntary stabilization medications, housing, and other supportive services. [WIC § 5970, et seq.]
13. Defines “first responder” to mean an employee of the state or a local public agency who provides emergency response services, including any of the following: a peace officer, firefighter, paramedic, public safety dispatcher, or public safety communicator. [Government Code § 8562]

FISCAL EFFECT: Unknown. This bill has not been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, this bill is a direct response to California’s ongoing behavioral health crisis of insufficiently treated mental illness, substance use disorder, and homelessness. By strengthening implementation of Laura's Law, this bill ensures that AOT is robust enough to effectively support individuals with serious mental illness in stabilizing within less restrictive, community-based settings. Importantly, the bill prioritizes voluntary engagement in treatment, reinforcing a patient-centered approach before any court involvement. While current law allows courts to order participation in AOT, it lacks key tools needed to ensure treatment is fully effective which leads to cycles of deterioration that often result in psychiatric holds, hospitalization, or conservatorship. The author argues this bill closes these gaps by enabling earlier, more effective intervention while maintaining strong due process protections, including judicial oversight and clear legal standards that safeguard individual civil rights. By reducing reliance on more restrictive and costly levels of care, this bill advances a more humane, and prevention-focused behavioral health system that promotes stability and recovery.
2. BACKGROUND.
   1. AOT. As an alternative to an LPS conservatorship, current law provides for court-ordered outpatient treatment through Laura’s Law, or the AOT Demonstration Project, established by AB 1421 (Thomson), Chapter 1017, Statutes of 2002, and made permanent with the passage of AB 1976 (Eggman), Chapter 140, Statutes of 2020. In participating counties, the court may order a person into an AOT program if the court finds that the person either meets existing involuntary commitment requirements under the LPS Act or the person meets non-involuntary commitment requirements, including that the person has refused treatment, their mental health condition is substantially deteriorating, and AOT would be the least restrictive level of care necessary to ensure the person’s recovery and stability in the community. AOT is available only in those counties in which the county board of supervisors, by resolution, have not opted out of its application and makes a finding that no voluntary mental health program serving adults and no children’s mental health program may be reduced to implement the law.

Laura’s Law is designed to provide counties with tools for early intervention. It allows family members, relatives, cohabitants, treatment providers, or peace officers to initiate the AOT process with a petition to the county behavioral health director or designee. The health director must then determine how to proceed. If the individual is found to meet the AOT eligibility requirements, an individual preliminary care plan is developed to meet that person’s needs. If this process results in the person voluntarily engaging with treatment, then the patient is deemed to no longer meet the criteria and the petition is no longer available. However, if the client declines their preliminary plan, then a public defender is assigned and the petition proceeds. It is then up to the judge to either grant or reject the AOT petition. If an AOT petition is approved by the court, treatment ordered is valid for up to 180 days. The law allows for a county to opt out of the requirements of Laura’s Law if by resolution adopted by the county’s governing body stating the reasons for opting out and any facts or circumstances relied upon in making that decision.

DHCS publishes an annual report on AOT implementation, with the most recent dated September 2025 for the period of July 1, 2022 through June 30, 2023. Consistent with past years, participation in AOT is largely voluntary, with 82% of eligible participants responding to the initial invitation for voluntary services and not requiring a court petition or process. AOT seems to be an effective intervention, with DHCS reporting the following outcomes: homelessness decreased by 29%; hospitalization decreased by 43%; contact with law enforcement decreased by 37%; 36% of participants were able to secure employment or participated in employment and/or educational services; victimization decreased by 68%; violent behavior decreased by 52%; and substance use decreased by 24%. During this reporting period, 2,103 individuals were referred to AOT services across 26 of the 30 operational counties. 1,081 individuals (889 voluntary) were found eligible for AOT, and 710 individuals were found ineligible. A total of 192 participants were enrolled through a court process within the following 17 counties: Alameda, Contra Costa, Humboldt, Kern, Los Angeles, Mendocino, Napa, Nevada, Orange, Sacramento, San Diego, San Francisco, Santa Clara, Stanislaus, Tehama, Tulare, and Ventura.

• 1. LPS. The LPS Act provides for involuntary detentions for varying lengths of time for the purpose of evaluation and treatment, provided certain requirements are met, such as that an individual is taken to a county-designated facility. Designated facilities are mental health treatment facilities that are designated by the county for evaluation and treatment, approved by DHCS, and licensed as a health facility. A designated facility may include, but is not limited to, a licensed psychiatric hospital, a licensed psychiatric health facility, and certified crisis stabilization units. Typically, one first interacts with the LPS Act through a hold initiated pursuant to WIC § 5150 by a peace officer or other person authorized by a county, who must determine and document that the individual meets the standard for a hold. A county-designated facility is authorized to then involuntarily detain an individual for up to 72 hours for evaluation and treatment if they are determined to be, as a result of a mental health disorder, a danger to self or others, or gravely disabled. The professional person in charge of the county-designated facility is required to assess an individual to determine the appropriateness of the involuntary detention prior to admitting the individual. Subject to various conditions, a person who is found to be a danger to self or others, or gravely disabled, can be subsequently involuntarily detained for an initial period of intensive treatment up to 14 days, an additional period of 14 days (or up to an additional 30 days in counties that have opted to provide this additional up-to 30-day intensive treatment episode), and ultimately a conservatorship, which is typically for up to one year and may be extended, as appropriate. A person can also be released prior to the end of intensive treatment if they are found to no longer meet the criteria or are prepared to accept treatment voluntarily.
  2. Recent changes to LPS. SB 929 (Eggman), Chapter 539, Statutes of 2022 mandates additional data collection and reporting regarding the operation of the LPS Act. It also requires recommendations for improving the operations of the LPS Act, and an assessment of the disproportionate use of detentions and conservatorships on various groups. SB 43 (Eggman), Chapter 637, Statutes of 2023, expanded the definition of “gravely disabled” to also include a condition in which a person, as a result of a severe substance use disorder (SUD), or a co-occurring mental health disorder and SUD, is unable to provide for their personal safety or necessary medical care, in addition to the inability to provide for basic personal needs of food, clothing, and shelter. SB 43 also defined these additional criteria, but ultimately implementation by the counties and consideration of these criteria by hearing officers and the courts will determine how they are interpreted in practice. SB 1238 (Eggman), Chapter 644, Statutes of 2024, expanded the definition of “designated facility” or “facility designated by the county for evaluation and treatment” to include additional settings and requires DHCS to update facility designation regulations to reflect the inclusion of SUD in the gravely disabled definition.
  3. CARE Act. In 2022, the Legislature enacted SB 1338 (Umberg), Chapter 319, Statutes of 2022 (known as the “CARE Act”). The CARE Act established a new civil court process to provide clinically appropriate, community-based services and supports that are culturally and linguistically competent, to Californians with schizophrenia spectrum disorders or bipolar I with psychotic features (referred to as the “respondent” in the CARE process), while also preserving these individuals’ self-determination to the greatest extent possible.

Under the CARE Act, a county behavioral health agency, spouse, parent, sibling, child, or grandparent of the respondent, a treating behavioral health professional, the county public guardian or public conservator, and others, as specified, may petition to begin the CARE process. If the original petitioner is not the county behavioral health agency, the county behavioral health agency will replace the original petitioner as the CARE petition proceeds. There are two paths to court-ordered services: if the respondent and the behavioral health agency are able to agree on a plan, it is known as a “CARE agreement” and if they are unable to reach an agreement, one or both parties may present a proposed “CARE plan” to the court and the court may accept a proposed plan or adopt a modified plan, which becomes a court order that lasts for up to one year. The CARE Plan/Agreement may provide for behavioral health services and housing supports, as well as other services, and counties may face financial penalties for failure to provide the required services. The court may allow the original petitioner to participate in the respondent’s CARE proceedings, to the extent that the respondent consents.

• 1. Involuntary Medication. Under current law, if a person who is the subject of an AOT petition refuses to take prescribed medications, there is not a specific process set up to provide medications involuntarily. Treatment teams can try several strategies to elicit voluntary medication compliance, which can include collaborating with trusted treatment partners, psychoeducation, motivational interviewing, and more. Only if a person’s condition deteriorates to the point where they are a danger to self, danger to others, or gravely disabled, as defined in the LPS Act, can they be detained on a 5150 and transported for evaluation and treatment.

DHCS’s website includes the handbook “Rights for Individuals in Mental Health Facilities,” which states that a capacity hearing, also called a Riese hearing, may be held to determine whether an individual can refuse treatment with medications. The capacity hearing is conducted by a hearing officer at the facility where the individual is receiving treatment or by a judge in court. The hearing officer will determine whether the individual has the capacity to consent to or refuse medication as a form of treatment. An individual’s representative helps them prepare for the hearing and will answer questions or discuss concerns that they may have about the hearing process. If an individual disagrees with the capacity hearing decision, they may appeal the decision to a superior court or to a court of appeal. Their patients’ rights advocate or attorney can assist them with filing an appeal.

The first of these hearings typically occur during the initial 72-hour hold. When a patient’s condition necessitates an additional hold beyond the initial 72 hour and 14-day periods, a certification review hearing is held to determine that the patient still meets the criteria to be held at the beginning of each proposed hold. In addition to a certification review hearing, a new Riese hearing may be held to determine the patient’s incapacity to refuse treatment prior to each new hold. SB 1184 (Eggman), Chapter 643, Statutes of 2024, requires, under exigent circumstances, an order for treatment with antipsychotic medication to remain in effect at the beginning of the 14-day period, or the additional 30-day period after the 14-day intensive treatment period, or the second 30-day period, provided that a petition for a new determination on the question of capacity has been filed, and would require the order to remain in effect until a hearing on that petition for that detention period is held and a decision issued.

• 1. Antipsychotic v. Psychotropic Medication. Both terms are used in various sections of law. Antipsychotic is more common throughout the LPS statutes, and psychotropic is more common in statutes referring to dependent children and foster youth. Psychotropic or psychiatric medications includes several classes of drugs to treat an array of behavioral health conditions. These include antidepressants, antipsychotics, mood stabilizers, anti-anxiety medications, and stimulants. According to UC Irvine, antipsychotic medications, also known as neuroleptics, are an effective treatment for mental health conditions such as schizophrenia and bipolar disorder. They are categorized into two classes—first-generation, or "typical," antipsychotics, and second-generation, or "atypical," antipsychotics. According to the National Institutes of Health (NIH), first-generation antipsychotics were initially developed in the 1950s primarily for the treatment of psychosis, such as schizophrenia. In addition to psychotic illnesses, first-generation antipsychotics have been approved by the US Food and Drug Administration (FDA) for treating and managing acute mania, agitation, bipolar disorder, Tourette syndrome, and hyperactivity. Second-generation antipsychotics have also been FDA-approved to treat and manage psychosis and treatment-resistant schizophrenia, bipolar disorder, schizoaffective disorder, agitation, and irritability.

NIH also notes that first- and second-generation antipsychotics are used in various neuropsychiatric conditions, which are currently considered off-label. These include behavioral disturbances in dementia, geriatric agitation, depression, eating disorders, personality disorders, insomnia, generalized anxiety disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and substance use and dependence disorders. NIH cautions that for many of these conditions, the evidence is inconclusive, and clinicians should use their judgment when considering the prescription of neuroleptics.

1. SUPPORT. San Francisco Mayor Daniel Lurie is the sponsor of this bill and states in support that San Francisco continues to see individuals with severe mental illness repeatedly cycle through emergency rooms, jails, and homelessness without obtaining lasting stability. This repeated instability places individuals at risk and strains emergency and public safety systems. Current law allows the court to order participation in AOT, but does not allow the authorization of medication, even when medical professionals say it is essential for stabilization. Mayor Lurie argues that this bill provides strong procedural protections, including judicial oversight, legal representation, and individualized consideration of each case. Mayor Lurie concludes that this bill does not mandate involuntary medications for all AOT participants, and will make AOT more effective and advance a health system that centers around treatment and stability.

NAMI San Francisco (NAMI SF) supports this bill stating that California faces a persistent behavioral health crisis of untreated or insufficiently treated mental illness. An effective treatment tool for individuals with serious mental illness is psychotropic medications. However, individuals may not accept this highly effective gold standard treatment due to their illness. California’s AOT program provides court-ordered, outpatient mental health treatment to individuals with serious mental illness who are declining and refusing care. While current law allows courts to include coordination of and access to medications in AOT treatment plans, it does not permit courts to order medication treatment itself. NAMI SF argues that this bill will help counties better treat individuals experiencing persistent behavioral health crises who are going through the revolving door of hospitalization and homelessness. Rather than waiting for someone to deteriorate to the point of needing conservatorship, the bill allows for the use of an effective tool that treats an individual in the community.

1. OPPOSITION. A coalition in opposition to this bill, including Disability Rights California, CalVoices, Black Men Speak, Senior & Disability Action, APTP, Venice Justice, Bazelon Center, Disability Rights Education and Defense Fund, Mental Health America of California, Heaven Helps Community Supports, Western Regional Advocacy Project, Buccola Family Homeless Advocacy Clinic, California Peer Watch, CAMHPRO, National Alliance to End Homelessness, and REMHDCO, states it would allow a court to grant a standing order to a community-based AOT provider to have their clients restrained and transported from the community to a locked psychiatric facility and forcefully medicated with potentially life-threatening drugs. They argue this bill is incredibly dangerous and counter to sound public health policy, and that psychotropic medications carry intense and potentially life-threatening side effects. The coalition contends that forced medication destroys the essential therapeutic relationship between a mental health provider and client, making it less likely that people will voluntarily seek mental health services, and it would disproportionately harm Black Californians, who are 6% of the state population, but 16% of people subjected to AOT. The further note a 2023 study found that Black patients were nearly twice as likely as white patients to be given first-generation long-acting injectable antipsychotics, which have higher risks. The opponents conclude that California should expand policies and funding that promote voluntary, community based mental health services and protect the civil rights of people with disabilities, rather than expanding involuntary systems that disproportionately harm the disability community.

The California Public Defenders Association (CPDA) also opposes this bill stating that the administration of involuntary medication is a traumatic experience. If a person refuses the medication, multiple staff members take control of each of their limbs, lift them off the ground, take them to a flat surface, hold them down, and then forcibly inject them. CPDA argues that the subject of the AOT petition will need to be warned about the involuntary medication provision, and those that might otherwise have been willing to give AOT a try, will feel compelled to fight the petition. Even if the involuntary medication petition is not filed at the outset, but only later in the process, this will still drive people away from treatment. Instead of gradually working more and more closely with their AOT team members, people will hide from them for fear of being taken into custody. CPDA further argues that if a person is “taken into custody,” or transported to the hospital for the administration of involuntary medication by that hospital’s staff, the hospital will likely refuse to admit them if they do not meet criteria for hospitalization.

1. OPPOSE UNLESS AMENDED. The County Behavioral Health Directors Association (CBHDA) opposes this bill unless amended, stating that while loosely modeled upon a provision in New York State’s equivalent of AOT, it lacks key provisions included in New York’s Kendra’s Law, which allow that law to be successfully implemented. First, AOT in California is optional. This means that counties are not required and therefore not state funded to do AOT, which significantly limits the reach of AOT, and calls into question the viability of an outpatient medication framework tied to California’s version of AOT. CBHDA also states that California’s behavioral health directors would be left without a viable option for transportation and would have no jurisdiction to direct law enforcement to assist with transportation. CBHDA is also concerned with the lack of clarity around whether and how the courts would adhere to the requirement under current law, pursuant to Riese v. St. Mary’s Hospital for a hearing specifically to determine the individual’s capacity to make decisions regarding medications.
2. DOUBLE REFERRAL. This bill has been double referred; upon passage in this committee, it will be referred to the Assembly Judiciary Committee.
3. RELATED LEGISLATION.
   1. SB 331 (Menjivar) would define, for the purposes of the LPS Act, “mental health disorder” to mean a condition outlined in the current edition of the Diagnostic and Statistical Manuel of Mental Disorders, and would clarify that chronic alcoholism means alcohol use disorder and is a qualifying diagnosis for grave disability if the alcohol use disorder meets the diagnostic criteria of “severe.” SB 331 would authorize an original petitioner under the CARE Act to receive notice of proceedings and documents under specific circumstances. SB 331 is pending in the Assembly Health Committee.
   2. SB 1221 (Stern) would require the definition of “gravely disabled” to be evaluated based upon a person’s ability to provide for those basic personal needs outside of an incarcerated setting. Would authorize the district attorney to review all filed documents regarding the investigation, initiation, termination, or modification of, and to be present and represent public safety interests at all hearings that consider a conservatorship of a person who is gravely disabled with a pending felony involving death, great bodily harm, or a serious threat to the physical well-being of another person , to provide input to the court about appropriate placement or interim placement by the public conservator. SB 1221 is pending in the Senate Health Committee.
4. PREVIOUS LEGISLATION.
   1. SB 1184 (Eggman), Chapter 643, Statutes of 2024, permits, in "exigent circumstances," an order for involuntary treatment with antipsychotic medication that applied during the prior detention period to continue until a new hearing for a determination of the person's capacity to refuse treatment occurs; requires the capacity hearing to be held on an expedited basis; and requires a facility where such an extension of involuntary treatment occurs to report specified data to the county behavioral health director in the county in which they operate. Sunsets these provisions on January 1, 2030.
   2. SB 43 (Eggman) Chapter 637, Statutes of 2023, among other things, expands the definition of “gravely disabled,” for purposes of involuntarily detaining an individual under the LPS Act, to include an individual with a severe SUD, or a co-occurring mental health disorder and a severe SUD, or chronic alcoholism, who is unable to provide for food, clothing, shelter, personal safety or necessary medical care.
   3. SB 507 (Eggman), Chapter 426, Statutes of 2021, broadens criteria to permit AOT for a person who is in need of AOT services, as specified, without also requiring the person’s condition to be substantially deteriorating; permits specified individuals to testify at a court hearing via videoconferencing, as specified; and, permits a court to order AOT for eligible conservatees, as specified, when certain criteria are met.
   4. AB 1976 (Eggman), Chapter 140, Statutes of 2020, implements Laura’s Law statewide, effective July 1, 2021, and permits counties to opt out of providing AOT services, as specified.
   5. SB 40 (Wiener), Chapter 467, Statutes of 2019, made several changes to the process and timelines in the pilot program established by SB 1045, below.
   6. SB 1045 (Wiener), Chapter 845, Statutes of 2018, allows, until January 1, 2024, San Diego, San Francisco, and Los Angeles Counties to place in a conservatorship, as specified, a person who is chronically homeless and incapable of caring for his or her own health and well-being due to serious mental illness and substance use disorder.
   7. SB 585 (Steinberg), Chapter 288, Statutes of 2013, specifies that counties that elect to implement Laura’s Law may, to the extent permissible under state and federal laws, pay for those services using funds distributed to counties from the Mental Health Subaccount, the Mental Health Equity Subaccount, and the Vehicle License Collection Account of the Local Revenue Fund, funds from the Mental Health Account and the Behavioral Health Subaccount, within the Support Services Account of the Local Revenue Fund 2011, funds from the Mental Health Services Fund, and any other funds from which the Controller makes distributions to the counties, for those purposes.
   8. AB 1421 (Thomson), Chapter 1017, Statutes of 2002, enacted the AOT Demonstration Project Act of 2002, also known as Laura’s Law.
5. POLICY COMMENTS.
   1. Is the threshold for involuntary medication too low? The author states that the intention of this bill is to reduce the incidence of subjects of AOT petitions refusing to take their prescribed medications, resulting in potential deterioration to the point that they are a danger to self, others, or gravely disabled. While a laudable goal, existing law provides the process by which a person can be medicated involuntarily, provided they meet the LPS criteria and lack the capacity to refuse medication. While the bill retains the requirement that a person be determined to lack capacity, they would not be required to be a danger to self or others, or gravely disabled, just that a physician or nurse practitioner has determined that medication is necessary to prevent relapse or deterioration to that point. This would lower the bar for involuntary medication, suggesting that having a mental illness and the possibility of future deterioration is enough to limit a person's right to refuse treatment today.
   2. Medication can present risks. According to the Cleveland Clinic, first- and second-generation antipsychotics have decades of research and study supporting them. However, they also come with several possible side effects and complications, including: abnormal movements, constipation, dizziness and sedation, drug-induced movement disorders (such as Tardive Dyskinesia), heart and circulatory problems, high blood sugar, high cholesterol, immune disruption, jaundice, painful muscle contractions, type -2 diabetes, urinary retention, and weight gain. While all medications can carry some risk of side effects, those listed here may present reasonable rationale for a person to not want to take the medications, as they may reduce quality of life or lifespan. Regardless of whether a person has a mental illness or not, they have an interest in retaining the ability to make decisions about their own health care, and current law provides a process for medication if those decisions lead to danger or grave disability.
6. COMMITTEE AMENDMENTS. The committee may wish to amend this bill as follows:
   1. Authorize the involuntary medication process in this bill to only apply in the City and County of San Francisco, and only until January 1, 2031;
   2. Prohibit an involuntary medication order and an AOT order from being filed concurrently, and only allow for a medication order to be filed after at least 30 days of an AOT treatment order being in place if patient meets the following criteria, in addition to those already contained in the bill:
      1. Once in the last 12 months they determined not have the capacity to refuse treatment with psychotropic medication during a period of hospitalization through a Riese Hearing; and
      2. Is not complying with the recommended medication and exhibits evidence of further deterioration.
   3. Require the affidavit from the behavioral health director to be filed every 30 days rather than every 60;
   4. Require reporting to DHCS on the implementation of this bill; and
   5. Require San Francisco to provide a written report to the Assembly Committees on Health and Judiciary and the Senate Committees on Health and Judiciary summarizing the following: the number of individuals who received involuntary medication under an order issued pursuant to Section 5336.5 between January 1, 2027, and July 1, 2029; the diagnosis of those receiving involuntary medication; the total time those individuals were under an assisted outpatient treatment order; the total time those individuals were under an order for the administration of involuntary medication; the number of times involuntary medications were administered; the reason for termination of the order for involuntary medication; and the number of times, if any, that an existing order for the administration of involuntary medication was renewed.

REGISTERED SUPPORT / OPPOSITION:

Support

Mayor Daniel Lurie, City and County of San Francisco (sponsor)
California State Association of Psychiatrists (CSAP)

League of California Cities
NAMI San Francisco

Opposition

ACLU California Action

Anti Police-terror Project

Antiracist MD

Bazelon Center for Mental Health Law

Black Men Speak, Inc.

Buccola Family Homeless Advocacy Clinic

Cal Voices

California Association of Mental Health Peer Run Organizations

California Peer Watch

California Public Defenders Association

Canary Resistance

Coalition on Homelessness, San Francisco

Disability Community Resource Center

Disability Rights California

Disability Rights Education & Defense Fund

Heavin Helps

Housing Is a Human Right - Orange County

Ku Consulting Group, LLC

Mental Health America of California

National Alliance to End Homelessness

National Coalition for Mental Health Recovery

National Mental Health Consumers' Self-help Clearinghouse

Pennhurst Memorial & Preservation Alliance

Racial and Ethnic Mental Health Disparities Coalition

San Francisco Public Defender

Senior and Disability Action

SF Gray Panthers

SFV Alliance

Solano County Board of Supervisors

Venice Justice Committee

Western Regional Advocacy Project

Several individuals

Analysis Prepared by: Logan Hess / HEALTH / (916) 319-2097