Showing posts with label incarceration. Show all posts
Showing posts with label incarceration. Show all posts

Sunday, August 31, 2014

Shut Down The Psychiatric Gulags - Don't Build More!



On my drive home from work yesterday, I heard an outrageous story about a judge ordering LA County jail to build 3,200 psychiatric beds to treat mentally ill inmates in that facility.  As is typical of MPR, I could not find the link today but I did find the link to this LA Weekly story , that basically brings people up to speed.  It is a typical journalistic approach with the human interest component.  In this case the human interest portion was interesting to me, because I have heard these stories hundreds of times from people I have treated who have been incarcerated with a few variations.  The most significant variations have to do with suffering acute alcohol or drug withdrawal and not being assessed or treated for that problem and not having access to maintenance medications that have proven effective for the specific mental illness.  The current plight of the mentally ill in the LA County jail system and increasing judicial pressure on the basis of rights violations for the lack of treatment led county supervisors to vote to build what was called the most expensive building project in county history.  From the article:

"That day, county supervisors ........ voted to spend nearly $2 billion on a long-sought jail to replace notorious Men's Central, a facility that federal investigators say is plagued by suicides, abusive conditions and violence. The funds will build a two-tower compound given the ungainly name "Consolidated Correctional Treatment Facility."

According to the article it will be a 4,860 bed facility,  3,260 (67%) beds of which will be dedicated to treating prisoners with mental illness.  My most recent post on the matter includes information that LA County jail has 19,386 inmates and that recent epidemiological surveys suggest that 30-45% of inmates have problems due to severe mental illness and impaired functional capacity.   That suggests that unless public policy changes, the most expensive building project in LA County could be overwhelmed by demand before it gets started.  The author in this case points out the folly of building this tower.  It is basically the folly of building any large psychiatric facility in the absence of any other infrastructure, but in this case compounded by the fact that this is in fact a jail and not a treatment facility.  There is really no evidence that the problematic aggressive or suicidal behavior will be any better in a new "two-tower compound" with the same jail atmosphere and mentality.

I have previously posted about the plight of the mentally ill being incarcerated in America and the fact that county jails are currently our largest mental institutions.  It is a basic collusion between governments at all levels and the business community to enrich corporations that have been set up to "manage" the American healthcare system.  As usual, the most vulnerable people are "cost shifted" out.  Cost shifting refers to cost center accounting that basically leads divisions within the same organization to try to save money on their budget by shifting the costs to somebody else.  In managed care systems it can lead to all kinds of distortions in care.  It also happens with outside agencies.  I was told about a situation where workers in one county actually dragged an  intoxicated patient over the county line and into another county so that patient would no longer be their  financial responsibility!  Cost shifting is the end result of these perverse incentives.

There is perhaps no better example than incarceration rather than hospitalization.  There are estimates as recent as from a few days ago that treatment and possible hospitalization may cost $20,000/year as opposed to incarceration costing $60,000/year.  In both cases the taxpayers pick up most of the tab.  The cost shifting has occurred from insurance companies and health care systems to the correctional system.  If an insurance company can dump a patient with a severe mental illness into jail, it doesn't cost them a thing.   If that same patient is hospitalized they may receive a one-time DRG (Diagnosis Related Group) payment of about $5,000 irrespective of how long the patient stays.  The hospital incentive is to get them out in 5 days whether they are stable or not to maximize profit.  When they are discharged, the patients are generally expected to go to appointments to discuss their medications.  Clinic profits on these visits are minimal but the main problem is that many of these appointments are missed - in some cases up to 50-60%.  Many of these patients lack stable housing and they frequently end up back in the emergency department and back in the hospital.  Hospitals now have bottlenecks in the emergency department and many people are discharged back to the street.  The cycle of ineffective care continues.

I can attempt a brief analysis of the problem as I watched it unfold during 23 years of inpatient practice.  I will demonstrate how things have changed to the detriment of patients with severe mental illness.  Consider the hypothetical case of Mr. A.  He has diagnoses of depression, schizophrenia and alcohol dependence.   He recently ran out of his usual medications and started drinking.  He became progressively depressed and stopped talking with his family members.  They went over to see him and noticed he has a loaded handgun on his table and was talking about shooting himself.   They called the police who came, confiscated his handgun, noted that he was acutely intoxicated and sent him to the local hospital emergency department.  How has the management of this scenario changed over the past 30 years and why?

In the early 1980s, Mr. A would have been assessed as a person who was high risk for ongoing suicidal behavior (depression, schizophrenia, alcoholism and acute intoxication) and admitted to a psychiatric unit.  The psychiatrist there would have done everything possible to stabilize all three conditions even if it meant civil commitment to a long term care institution.  The length of stay (LOS) would have been on the order of 20-30 days comparable to many current psychiatric LOS in the European Union.

By the late 1980s, a managed care company would have called the hospital or psychiatrist in charge.  They would initially demanded that the patient be discharged to a county detox facility.  They would claim that alcohol withdrawal detoxification was not a psychiatric problem, and therefore the patient does not meet their "medical necessity criteria" for inpatient hospitalization.  If that was ineffective they might say that he was no longer "acutely suicidal" or "imminently dangerous" two additional medical necessity criteria.  In the end they always win, because they just stop paying and the administrators force the clinicians to discharge the patient.  The length of stay is now down to less than 1 week and the patient may not be stable at all at the time of discharge.

By the 1990s, the patient might not even make it to the inpatient unit.  By now psychiatric departments are continuously burned by managed care companies, especially in the case of any patient who is acutely intoxicated at the time of admission.  Many have closed their doors.  Many departments have strongly suggested that the emergency departments send any intoxicated patients directly to county detox units if they are available.  The counties respond by refusing to take any patients on any intoxicants than than alcohol and even then the patient has to blow a number on a breathalyzer consistent with acute alcohol intoxication.   At any point in this process a decision can be made to just send the patient home.  There are various ways the patient can access more firearms at that point or even get the original firearm that was confiscated.  There are also various ways that the patient can end up incarcerated including going back home, drinking and getting arrested for disorderly conduct or public intoxication.  A more complicated situation occurs if the patient is intoxicated and wanders into a neighbor's home or place of business.  I have seen people end up in jail for months on trespassing charges in these situations.   And that brings us in to the 2000s where it is much more likely that a person with severe mental illness will be incarcerated than even make it to the emergency department.  In the 2000s the patient may end up stranded in the emergency department for days or sent home with a bottle of benzodiazepines to handle their own detox if they can deny that the are "suicidal" consistently enough.  There is also the mater of inpatient bed capacity.  Fewer beds are full constantly because bed capacity has been shut down due to managed care rationing and people are often released because there will be no open beds in the foreseeable future.  The LOS in many cases is now zero days, even for people with severe problems.

How did all of this happen?  How did the care of mental illness and addictions fall to such a miserable standard?  It is documented in many posts on this blog.  Professional guidelines were compromised and treatment infrastructure was destroyed by the managed care industry and the politicians who actively supported and continue to support it.  Professional organizations don't stand a chance against pro business state statutes,  commissions stacked with industry insiders, and federal legislation that protects these companies from lawsuits for interference with care.  Even a travesty as basic as prior authorization for generic drugs is unassailable.  I don't understand why these basic facts are so incomprehensible to people in the field.  Just a few hours ago, 1BOM posted a Hall of Shame of entities the original authors claim are failing people with severe mental illness.  This list completely misses the mark and is probably a good example of how deeply entrenched the mechanisms are to prevent treatment  and shift costs away from states and health care companies.

There are countless easy solutions to the problems, but the companies in power literally do not want to spend a dime.  The patient with severe mental illness can receive comprehensive community services and be maintained in their own housing at a cost of $10, 000 to $20, 000/year for clinical services.  That same patient costs corrections departments $60,000 per year.  That patient currently costs managed care companies nothing if they can transfer their care to a local state-funded Assertive Community Treatment (ACT) team.  Managed care companies incur the same cost if the patient is transferred to the correctional system.  If ACOs come to fruition and all of the chronically mentally ill are enrolled, it should be an easy matter to make the managed care companies responsible for both the costs and the patient.  A simple court order to pick up the patient from jail and stabilize them in the community could suffice.

Erecting more gulags won't work.  They are effective only for enriching health care companies that profit by denying care for those with severe mental illnesses and addictions.  They are also another hidden health care tax on the taxpayers who are already paying far too much in hidden health care taxes.




George Dawson, MD, DFAPA

Graphics Credit:  ConceptDraw Pro - this graphic was included as an example with this software.

Tuesday, June 10, 2014

DOJ Sanctions America's Largest Psychiatric Hospital

The Department of Justice came out with a report this week on the way that psychiatric problems are being managed in the LA County Jail.  The conclusion was that prisoners were prevented in getting their constitutionally-required care for  mental illness and they cited deplorable environmental conditions, deficient care for inmates with obvious needs, inadequate supervision, and failure to provide adequate suicide prevention services.  There were 15 deaths by suicide in 30 months and the conclusion was that several of those deaths were preventable.  By previous agreement, the county had demonstrated compliance with suggested measures including the development of a robust electronic health record.  The resulting Memorandum of Agreement Between the United States and Los Angeles County, California Regarding Mental Health Services at the Los Angeles County Jail (MOA) is an interesting read and could be viewed as a blueprint for transferring psychiatric services from managed care hospitals to correctional facilities.  Unfortunately there is no obviously available detailed report on the findings at this time, but I have requested it through their web site.

The issue of psychiatric services being provided in county jails is a national scandal that hardly anyone seems to care about.  In terms of awareness it is probably well below the issue of mass shootings by people with mental illnesses.  Why is that important?  There are several issues that never seem to be mentioned in the press.  The first and foremost is how psychiatric services have been excised from clinics and hospitals by managed care companies - especially complex psychiatric issues.  Anyone who cannot be seen in a 15-20 minutes brief discussion about medications usually gets the message that they need to get services elsewhere.  Many people who end up in jail these days have chronic mental illnesses have been involved in minor violations (trespassing, disorderly conduct, drug possession/paraphernalia charges, etc) that are a product of mental illness.  Their stays are often complicated by a lack of available legal and financial resources that increase their stay times in jail.  The following table is based on data in Forbes magazine and corroborated by other sources describing the total populations in these facilities.


         County Jail by Size                                                Population
  1.  LA County Jail
19,836
  2.  Riker’s Island (New York City)
13,849
  3.  Harris County Jail (Texas)
10,000
  4.  Cook County Jail (Chicago)
  9,900
  5.  Maricopa County Jail (Arizona) 
  9,265
  6.  Philadelphia, PA
  8,811
  7.  Miami Dade County Jail
  7,050
  8.  Dallas County (Texas)
  6,385
  9.  Orange County (California)
  6,000
10.  Shelby County (Tennessee)
  5,765

The epidemiology of mental illness in incarcerated populations varies by site, authors, and agencies involved but there is no dispute about it being significant.  In a 2005 survey by the Bureau of Justice Statistics, 64% of inmates reported a mental health problem.  Recent study of incarcerated women showed that 43% met lifetime criteria for severe mental illness and 33% met 12 month criteria.  Forty five percent of the women meeting 12 month criteria had severe impairment of functional capacity.  The authors of that study emphasized the need for assessment of mental health needs at the point of entry into the justice system in order to meet the complex needs of the patients.  The inherent problem is that the US justice system and American culture are set up to pay lip service to recognizing mental illness and diminished capacity and that has recently been complicated by essentially shutting down psychiatric services and offering jails as an alternative.

What are the basic problems here?  The first is a clash of paradigms - treatment versus punishment.  If a judge actually puts you in jail for trespassing when you are so confused you can't find your way off someone's property due to mental illness, substance use, or some combination that amounts to punishment for having a mental illness.  Some systems are more enlightened than others in dealing with that problem.  In some communities, the lack of psychiatric resources results in jail as an alternative to hospitalization or non-existent community services.  The hand off between corrections and medical systems of care is complex and it depends on a medical staff who know how to approach and treat patients from correctional systems.  It also depends on judges and prosecuting attorneys with resources to decide who can be adjudicated as unable to proceed and be diverted to treatment rather than trial.  Those resources need to include examiners who can see people in jail and make the necessary assessments about court versus jail.

The second problem is rationed services.  This is best illustrated not only by the collapse of the number of beds in community hospitals and the lengths of stay much shorter than comparable facilities in the European Union but by the underlying cause of all of these problems.  That cause was simply managed care.  Managed care has done an expert job of cost shifting by developing business friendly treatment criteria, abandoning the social and community mission of treating difficult problems associated with mental illness and addiction, and removing the element of humanism from psychiatric treatment.  When I first started to practice, discharging people from a hospital when a psychiatrist had serious concerns about whether or not they could make it or whether they would be safe was very uncommon.  Today those discharges are the rule rather than the exception largely due to the imaginary dangerousness criteria.  It frequently comes down to whether or not a person is "dangerous".  If they are not, they will find themselves whisked out the front door at their first request.  I have seen that happen when the patient could not find the front door.  The same dangerousness criteria allow for blocked admission from jails or law enforcement.

The third problem is the violent offender or criminal with mental illness.  The distinction is much less clear than most people think.  Psychiatrists Dorothy Ontnow Lewis and Harold Pincus published papers on the high prevalence of neurological abnormalities and histories of brain injury in death row inmates.  Many criminals start to use various substances early in their development and can develop psychiatric comorbidity s a result of this drug use.   In my experience treating criminals or more technically persons with antisocial personality disorder who develop mental illnesses as a result of their criminal lifestyle is a much different problem than a mentally ill person who runs afoul of the law due to their psychiatric symptoms.  The patient who is antisocial or a criminal first needs to be separated from patients without those characteristics to prevent exploitation of vulnerable patients.  Any psychiatric facility in a metropolitan area needs to have this type of capacity or it will diminish the ability of the inpatient service from caring for individuals who are violent and aggressive due to treatable psychiatric disorders.  These individuals are at high risk if they are cared for in correctional settings.

I hope that this post highlights the problem and the potential solutions.  I just read a piece in Nature this morning that highlighted the need to study suicidal behavior.  The Dutch psychiatrists who wrote it emphasize that research on suicide is underrepresented in the psychiatric literature relative to articles on schizophrenia.  In America today we currently have ten times as many mentally ill patients in jails than state hospitals.  We have mass shooting homicides and many of those aggressive individuals either had no resources for treatment or there was no identified path of care for those individuals.  We need an array of psychiatric services focused on violence prevention and treating people who have impaired functional capacity to the point that they run into problems with the law.  We need better systems of care for criminals with primary and acquired forms of mental illness.

Locking all of those people up in jail and restricting their access to medical care is good for business, but it is no way to treat human beings.



George Dawson, MD, DFAPA

Supplementary 1:  "In 2006 there were 228 state hospitals operating some 49,000 beds."

Fisher WH, Geller JL, Pandiani JA. The changing role of the state psychiatric hospital. Health Aff (Millwood). 2009 May-Jun;28(3):676-84. doi: 10.1377/hlthaff.28.3.676. PubMed PMID: 19414875.