Decriminalization of the Mentally Ill

NAMI Board Advocates for Decriminalizing Mental Illness
In a move designed to draw attention to the critical problem of criminalization of people with mental illnesses, the NAMI National Board of Directors has released a report calling for more jail diversion, improved services for people at risk of criminal justice involvement, and better collaboration between criminal justice and mental health professionals. The report, entitled "Decriminalizing Mental Illness: Background and Recommendations," provides a concise analysis of the history and scope of criminalization, and includes public policy recommendations to address these critical problems. Go online to access the full report and an executive summary.

Texas Wins Again! (for the most uninsured)

Texas again leads the nation with the highest percentage of uninsured residents, according to a U.S. Census Bureau report released on Tuesday.

One out of every four residents, or 24.8 percent, was uninsured between 2006 and 2007, up slightly from 23.9 percent between 2004 and 2005.

You can read the full report from the Census Bureau here.

Inside the Nation's Largest Mental Institution - Unlikely Mental Health Advocate

Morning Edition, August 14, 2008 · The largest mental institution in the country is actually a wing of a county jail. Known as Twin Towers, because of the design, the facility houses 1,400 mentally ill patients in one of its two identical hulking structures in downtown Los Angeles.

On a recent morning, we took a visit to the floor devoted to the "sickest of the sick." As we arrived, a dozen deputies were working to restrain a patient and inject him with an anti-psychotic drug. The entire ordeal was videotaped — to protect the patient as well as the deputies. It was the first hint at the complexities that emerge from creating a mental hospital inside a jail.

The End Of Public Mental Hospitals

Until the 1970s, the mentally ill were usually treated in public psychiatric hospitals, more commonly known as insane asylums.

Then, a social movement aimed at freeing patients from big, overcrowded and often squalid state hospitals succeeded. Rather than leading to quality treatment in small, community settings, however, it often resulted in no treatment at all.

As a consequence, thousands of mentally ill ended up on the streets, where they became involved in criminal activity. Their crimes, though frequently minor, led them in droves to jails such as Twin Towers, says Los Angeles County Sheriff Lee Baca.

"Incarcerating the mentally ill is not the right thing to do," he says.

But if they are housed in Twin Towers, Baca says he is determined to make sure they are treated for illness.

Waking Up To A Big Bowl Of Ants

Mornings at Twin Towers begin with a meeting of medical staff from the county's Department of Mental Health; case workers and guards, who often function as de facto case workers, sit in a large circle.

An inmate who won't eat is the first order of business on this particular day.

"He says there are ants in his cereal," a case worker explains.

Dr. Arakel Davtian, one of the psychiatrists sitting in this large circle, takes a moment to explain just who they are dealing with; about half those locked up at the Twin Towers are in for serious crimes, he says.

What he finds striking, however, is how little it takes for the other half to end up there: "Indecent exposure, having open containers, something very, very minor — peeing on the street, disturbing the peace."

Often, the crimes these people commit are the result of their mental illness, Davtian says.

He offers the example of an inmate who was arrested for false identity. The police asked him his name, and he gave them a series of different ones.

"In court he does the same thing — he talks gibberish; the judge said [he is] incompetent to stand trial. The next court date is six months from the time he got arrested."

This means at least half a year at Twin Towers. Although being locked up is not the ideal way to enter treatment, Davtian says something good did come out of the altercation: he's begun treating the man for schizophrenia.

In Search Of Treatment

Some of the inmates at Twin Towers say they are glad to get treatment. Scott, 21, was incarcerated for shoplifting. He didn't want to give his last name, but he says he's aware he has "mental problems, mostly caused by life."

"I got ran over when I was 7," he says. "I'm schizophrenic-paranoid. I think everyone is watching me. I think I'm being judged, which is kind of true and kind of not."

Not everyone is so open to treatment. An inmate named Lawrence (Twin Towers requested his last name be withheld for privacy reasons) says he was picked up for stealing sweaters out of a car on a very cold day.

"In order to get a lesser charge, I pretended I was nuts. So ever since then, I've been hooked up with the mental facilities."

Claiming to be crazy is a problem here. There is a perception that life in the "insane" tower is easier than life in the "sane" one — partly because the cells in the mental health side are newer than cells in the other side. Consequently, inmates are carefully screened before they are admitted to the psychiatric wing.

When I ask Lawrence what he's going to do when he gets out, he offers, "I have some friends, Mr. Carl Icahn, he's a billionaire ... I've got some money, lots of money. I've been working with him since 1968, helping him build his empire, so I'm gonna go back there. Just live good."

Socialization And Suicide Gowns

The "crazy wing" of Twin Towers may look like a greener pasture to those in the other wing, but it's still an unsettling sight.

Walking into the "high observation" area, patients stare out through the glass walls of their cells, many nearly naked.

"They just don't want to get dressed," explains Deputy William Hong.

Across the way, about a dozen inmates are engaged in a "socialization" exercise. Some participants are chained to benches — "for civilian workers' safety," as Hong explains it. Others sit listlessly at tables, in long draping ponchos that deputies refer to as "suicide gowns."

"They can't rip it," explains Hong. Clothes can prove dangerous tools to a depressed or paranoid inmate.

"They've tried to flush it down — clog the toilet, flood the area. Or they've tried to harm themselves," he says.

Suicide gowns are more durable.

It shouldn't be this way, Baca says.

"They're here, and they're going to be cared for, but is this what we want in the way of a policy? Are we saying the legal system is the solution for the mentally ill in L.A. County? I don't think so. I'm saying criminals belong in jail, not the mentally ill."

Baca has been saying this since he took over Twin Towers a decade ago. And the mentally ill just keep coming, filling up the hospital to maximum capacity.

Substance Abuse Trends in Texas: June, 2008

Substance Abuse Trends in Texas: June, 2008 (click for full report)

This report updates indicators of drug abuse in Texas since the June 2007 report and describes trends by calendar year from 1987 through 2007. Important changes include increases in heroin inhalation by younger Hispanics. This was first noticed with the "cheese heroin" situation in Dallas, but further investigation has found that heroin inhalation is increasing statewide. Some treatment admissions are young teenagers, many of the users are not novices and are using other illicit drugs, and those in their twenties are shifting to injecting. Another change is decreases in methamphetamine indicators since 2005, with supplies down, price increasing, and purity decreasing. The influx of Mexican methamphetamine to replace the locally-produced product has not been as great as expected. With the higher price of Ice, the profit motive may encourage local manufacturers to return to cooking using over-the-counter pseudoephedrine. Other changes include continuing shifts in demographics of cocaine users and ecstasy users, severity of problems among non-coerced marijuana treatment admissions, increasing problems with alprazolam and carisoprodol, and possible reappearance of GHB. The majority of HIV and AIDS cases continue to be persons of color and more cases are now due to infection through the heterosexual route than due to injection drug use.

Public Health Approach to Substance Abuse and Mental Health

What, mental health care does not use a public health approach? After reading this, I've decided it does not. I guess I was not familiar with a public health approach.

CONSIDERING A PUBLIC HEALTH APPROACH
The public health framework might work well in addressing mental health and substance use problems
by RONALD W. MANDERSCHEID, PHD
The term “public health” is mentioned infrequently in mental health and substance use service circles. Hence, I took special notice when Terry Cline, PhD, administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA), used this term in his remarks at the American College of Mental Health Administration's annual Santa Fe Summit. Dr. Cline said that public health may be a useful framework for addressing the problems our fields are confronting.

Public health is a population-based approach to tackling important healthcare issues, with emphasis on prevention efforts. Public health has had a long and successful history in the United States. The U.S. Public Health Service was created in 1798. PHS provided health checks to millions of immigrants who arrived at Ellis Island, and the PHS led the national response to the 1918 flu pandemic. Virtually every state and county has a public health department. Several of the federal agencies in the Department of Health and Human Services (the Health Resources and Services Administration, Indian Health Service, SAMHSA, and CDC) deliver public health services. The American Public Health Association advocates for better public health infrastructure. In a terrorist attack, avian flu pandemic, or natural disaster, state and local public health agencies would be among the first responders.



Although some overlaps exist, mental health and substance use care differ from the public health model in several important ways. First, the mental health and substance use care fields principally are concerned with interventions that focus on the person rather than those that focus on an entire population. In effect, we work from the inside outward; public health works from the outside inward.

Second, with the notable exceptions of advances being made in substance abuse prevention and suicide prevention, the mental health and substance use care systems have little focus on prevention activities, either at a person or population level. By contrast, public health practice seeks to identify the causes of problems in populations and to eradicate them before they occur.

Third, public health looks at all of the health problems confronting a population, not just one or two of them. As a result of these differences, policy work in the mental health and substance use care fields tends to have an individual or subgroup focus that does not encompass an entire community or the full range of problems that a community is confronting.

What is it about public health infrastructure and practice that may make them particularly useful to the mental health and substance use care fields? Below I describe several attributes of public health worthy of emulation by the mental health and substance use care fields. Specifically:

Most people understand public health. For example, they understand the role vaccination of an entire population plays in community disease prevention.

Public health works with entire populations and communities. As a result of this broad focus, public health is able to identify the full range of health problems confronting communities and to create community collaboratives to address them.

Public health recognizes that different communities have different problems. Importantly, as a result, solutions are adapted to these differences. A tradition of local “public health advocates” exists. These advocates work with local politicians, consumers, health professionals, family members, and community groups to arrive at consensus-based solutions to community problems.

Public health identifies the source of a problem and seeks to eradicate it, preferably through prevention activities. Hence, the best care for an avian flu pandemic would be to prevent it in the first place through vaccinations of an entire population and a program of risk-reduction activities, such as hand washing and social distancing.

Public health transcends particular disciplines and is comfortable with multidisciplinary approaches. Physicians, epidemiologists, public health officers, and information technology specialists can work together effectively on a common problem.

Public health recognizes that the person holds the key to health. Hence, training is employed to improve knowledge so that one can better manage one's own health and disease.

Public health measures outcomes. This strong measurement tradition promotes accountability and allows early modification of approaches when desired results are not achieved.



Public health gives our fields a prevention-oriented framework for linking community dynamics, disease, service response, and outcomes. This framework encourages us to intervene and change community dynamics that lead to health problems. It also can promote better understanding by members of the community about mental illness and substance use disorders.

Clearly, the public health model alerts us to identify the actual health problems of entire communities and to craft specific solutions that focus on the problems' causes. This can be done best by creating a broad-based community collaborative that spans the consumer, family, provider, social, and political groups in the community and that works with them to identify the sources of problems and practical solutions.

Improving Responses to People with Mental Illness: The Essential Elements of a Specialized Law-Enforcement based Program

Improving Responses to People with Mental Illness: The Essential Elements of a Specialized Law-Enforcement based Program. Just released from the Consensus Project.
The ten essential elements for specialized law enforcement-based programs are described. These elements are: collaborative planning and implementation; program design; specialized training; call-taker and dispatcher protocols; stabilization, observation, and disposition; transportation and custodial transfer; information exchange and confidentiality; treatment, supports, and services; organizational support; and program evaluation and sustainability.

Another Preventable Tragedy

From the Oregonian:
The death of Andrew Hanlon is a story that's all too familiar. Once again, a psychotic person doesn't receive adequate care for his mental illness and is killed by a police officer. Sadly, Hanlon's death was preventable.

Hanlon, a 20-year-old Irishman living near his sister in Silverton, had schizophrenia, a disabling disease of the brain that affects more than 3 million people in the U.S. Untreated, individuals with schizophrenia act bizarrely, are delusional, cannot function in society and are at high risk of committing suicide.

Fortunately, we now have highly effective treatments for schizophrenia. Hanlon had been taking medications for his illness, but he had stopped using them. That's not uncommon for those with schizophrenia, but it's less likely to occur if the individual is receiving ongoing outpatient care by a mental health professional.

After stopping his medication, Hanlon predictably became psychotic again. His family sought help, but help for mental illness is hard to come by in our community. In desperation, the family called 9-1-1 in April for help. The responding police officer took the appropriate actions -- and should be applauded for how he handled the situation -- and drove Hanlon to a local hospital for evaluation. Since our health care system inadequately funds care for mental illness, it's not surprising that Hanlon did not receive ongoing care for his schizophrenia. His illness remained untreated, and his psychotic behavior continued.

Ultimately, Hanlon met a fate he shares with too many others with mental illness in our community. A Silverton police officer confronted the psychotic young man, who was then shot to death as he reportedly charged the officer.

One is left to wonder whether the police officer, a former fighter and still-active coach in the region's cage-fighting circuit, could have used non-lethal force to subdue the smaller, unarmed young man. Don't misunderstand: My father was a police officer, so I'm sympathetic to the risks that our police officers face every day. I'm fully aware that it's easy for people, from the safety of our homes, to second-guess the instantaneous decisions a police officer has to make on the street. But many of our police officers seem woefully unprepared to deal with people suffering from schizophrenia or other serious mental illnesses.

Hanlon should be alive today. His death was preventable. Had he received appropriate treatment, he wouldn't have been pounding on a stranger's door at night and the police wouldn't have been called. If the officer on the scene had been better trained to deal with a mentally ill person, Hanlon wouldn't have been killed.

As a society, we need to recognize that serious mental illnesses -- schizophrenia, bipolar disease and depression -- are diseases of the brain. People suffering from these illnesses need the same level of care that we provide to people with cancer, diabetes and other chronic health problems. And our police need much better training in recognizing psychotic behavior and in the use of nonlethal force in handling the mentally ill.

Abuse of Seroquel in Prisons Reported.

AstraZeneca "pushed" Seroquel contracts with large correctional healthcare firms, by offering it at about half the cost available in free world pharmacies. With continuity of care programs, AstraZeneca is aware that the free world doctors are most likely to continue the Seroquel upon the defendant's release. I would not be surprised if there is both a physical and psychological dependence on Seroquel. Just to note, Seroquel is one of the highest costing psychotropic medication there is.

Abuse of Seroquel in prisons reported
Antipsychotic medications are generally thought to have little potential for abuse. But a handful of psychiatrists have raised concerns about patients abusing and becoming addicted to Seroquel.


In separate letters in The American Journal of Psychiatry, psychiatrists in California and Ohio detail drug-seeking behavior, abuse and addiction to Seroquel among inmates at prisons in those two states.

According to a 2004 letter, staff members at the Los Angeles County jail said as many as 30 percent of the inmates seen by psychiatrists faked psychotic symptoms in order to obtain Seroquel. The psychiatrists said some inmates would take Seroquel by pulverizing the tablets and sniffing the powder.

In a letter published in the journal last year, psychiatrists Emil Pinta and Robert Taylor said inmates in Ohio threatened legal action or suicide when faced with ending their treatment of Seroquel, which is not an approved medication in Ohio prisons. Pinta wrote that in 35 years as a prison consultant, he could remember similar behavior only to obtain controlled substances.

In an interview, Taylor said Seroquel may be especially valued in prisons -- where sleeping can be difficult -- for its tranquilizing properties. He said he worked in the state mental health system for two years before moving to a prison in 2005.

"Within two weeks, it was apparent there was a Seroquel abuse problem in the prison that I had not seen in the state mental hospital," Taylor said.

Samantha Taylor, 29, of Claymont, said she started taking Seroquel while serving time at Delores J. Baylor Women's Correctional Institution near New Castle. Taylor said she thought a majority of the inmates in the prison were on Seroquel.

Delaware Department of Correction spokesman John Painter said about 42 prescriptions are written for Seroquel each month, which is "on the low end" of prescription drugs in Delaware prisons.

AstraZeneca would not comment on Seroquel's prevalence in prisons. Seroquel's label states that the drug has not been systematically studied for its potential for abuse, and patients should be observed closely for signs of misuse or abuse of Seroquel.

Although the problem seems to be most prevalent in prisons, a letter published last month in the psychiatry journal describes a 29-year-old man in California who checked himself into a psychiatric treatment unit with reported schizophrenic symptoms, for which he was treated with Seroquel.

The next morning, the man showed no signs of schizophrenia, and he admitted to abusing and reselling Seroquel after being confronted by a doctor.

The letter's authors said that prescriptions of Seroquel and other atypical antipsychotics for conditions like anxiety and insomnia have expanded their use to a broader patient population. If evidence of abuse becomes more widespread, they wrote, federal regulators may designate Seroquel as a controlled substance.

"Should such an unfortunate eventuality come to pass," the authors wrote, "we will be able to confidently lay the blame at the feet of our collective prescriptive imprudence."

The Police and People with Mental Illness

From the Treatment Advocacy Center:
The Police and People with Mental Illness
From coast to coast, mentally ill people, without reliable access to the costly on-demand care they need, are left to fend for themselves. In the aftermath of the movement in the 1970s to close large mental asylums, many of today's mentally ill are left to their own devices; they are often homeless and without full-time advocates. With government unable or unwilling to properly serve this population, the criminal-justice system is left to pick up the slack.



Is the above passage from a Treatment Advocacy Center report? You might think it was, but it is from a recent web article from Newsweek.

“Experts on treatment say the police for the most part do a good job handling the millions of interactions they have each year with the mentally ill,” the article continues. “But is it irresponsible to ask them to undertake duties that perplex even trained, savvy professionals?”

A very good question indeed.

None of us are immune from the effects of Mental Illness

None of us are immune from being affected by mental illness.

Posted from the blog : Life at the Harris County Criminal Justice Center

An Update on My Friend

Earlier this month, I told you all about my friend "Jim" from high school who had shown up at the CJC looking for me after a six-year absence. If you will recall, Jim had some serious mental issues that had arisen from years of drug use, and had now manifested in a deep sense of paranoia. The target of Jim's paranoia was his father.

I had called Jim's dad after Jim left the CJC and just let him know what was going on. For all I knew, Jim's dad could have been looking for him. Jim's dad was keenly aware of all of Jim's problem, but like me, he had no idea what to do about it. He was frustrated and saddened, and had no idea why his son had so much hatred for him. He also had no clue as to what to do to help his son.

I talked to him for awhile about civil commitments and mental health warrants, which I know virtually nothing about. I told him to talk to a family lawyer, or even a psychiatrist about what could legally be done about Jim.

Jim's dad called me last week and told me that Jim had shown up at his home, demanding that he (Jim's dad) accompany him to the police department to take a polygraph examination about the plot against Jim's life. Jim's dad obliged him, and they went to the police station.

Once they explained the story to the police, Jim was taken away to a psychiatric hospital for a 72 hour observation. For some reason, the hospital released him in about 12 hours.

Yesterday, I got another call from Jim's father.

Jim's father had been closing up his business for the evening and was the only person there, when Jim showed up at the lot.

"Either you're going to die tonight, or I am," Jim told him. Jim's dad tried to walk away, but Jim attacked him and assaulted him. He was able to call the police and Jim, yet again was arrested.

This time, there's a Class A Misdemeanor of Assault-Family Violence charge against Jim.

Jim's father has no desire to see his son punished for attacking him, but he doesn't know how to protect himself or help his son anymore. Sadly, it's getting thrown to the criminal courts to deal with, and nobody has ever really given the criminal system a Gold Star for dealing with the mentally ill.

But at this point, I don't know that any of us have any other options in mind. Hopefully, Jim will get sent away for an evaluation, and maybe somebody will force him to get some help. This time he doesn't have the option of walking away from the psychiatrist like he has apparently done in the past.

We shall see. For now, I'm just glad that nobody was seriously injured.

That's a blessing in and of itself, because inside of Jim's car, the police found a hammer that he had purchased a few minutes before arriving at his father's business. Thankfully, he left it in the car.

I'll keep you posted as things develop.

10 things lawyers need to do better

Judge Russell addresses the Smith County Bar Association. From Tylerappeals.com we can view his handout here:
http://www.tylerappeals.com/Top%2010%20Things%20Lawyers%20Could%20Do%20Better!.pdf

Frequent flyers in the Harris County Jail

From the Houston Chronicle:

July 21, 2008, 9:19AM
Finding escape behind bars
When jail is the only place mentally ill inmates get treatment, they come back, and it costs $87 million



Snapshot of mental illness in Harris County Jail
Former inmate's struggles At the Harris County Jail, deputies and health care workers have a name for them — frequent fliers.

They are mentally ill homeless people who return to jail so often, sometimes on minor charges, that they become familiar to the psychiatric staff.

During a recent survey, county officials found that more than 400 of the jail's 11,000 inmates were homeless and suffered from a major mental illness: schizophrenia, bipolar disorder or a chronic depressive-psychotic disorder. They were among 1,900 inmates on psychotropic medications.

When the mentally ill homeless leave jail — and leave behind its mental health care staff — many stop taking medication and end up on the street again. Treatment resumes only when they commit a crime and return to jail or their dementia overwhelms them and they are brought to an emergency psychiatric center.

Treating the mentally ill as they cycle through jail and emergency psychiatric wards is expensive. A county budget analyst estimates that it costs $80,000 a year, per person.

At the jail, spending on mental health care has risen to $24 million annually, and the combined cost of incarcerating and treating the mentally ill is $87 million annually.

"The jails have become the psychiatric hospitals of the United States," said Clarissa Stephens, an assistant director of the county's budget and management services office who has been studying the jail's mental health costs.

The Commissioners Court is so concerned about the rising costs that it has retained a consultant — psychiatrist Avrim Fishkind — to study whether providing outpatient services and supervised housing would reduce the numbers of mentally ill revolving through the jail.

"The costs of reincarcerating and court costs far outweigh what the costs would be if you housed, clothed and supervised the mentally ill," Fishkind said.

A June survey of more than 11,000 inmates revealed:
•About one-quarter suffer from mental illness or once suffered from it.
•Of those on medication, 978 suffered from schizophrenia, bipolar disorder or a severe depressive-psychotic disorder.
•Of the 978 with a major mental health disorder, 423 likely were homeless.
•Of the 423 homeless with a major mental health disorder, 97 percent had been arrested at least once before during their lifetimes; 43 percent had a prior arrest during the last 10 years.

On the day of the survey, the jail's mentally ill homeless inmates included:

•A 39-year-old woman booked 45 times since 2001.
•A man, 26, booked 30 times since 1999.
•A man, 52, booked 33 times since 1992.
•A man, 25, booked 20 times since 2001.

Some of the mentally ill — many of whom also are substance abusers — keep committing crimes and getting rearrested, in part, because few are properly supervised when they are released, said David Buck, a Baylor College of Medicine associate professor and president of Healthcare for the Homeless-Houston.

Houston isn't alone in facing this issue. After many mental hospitals were closed in the 1970s and 1980s, countless patients were released in cities that were ill-equipped to house those who needed such care.

"What happens here happens in many communities. We are criminalizing mental illness," said Betsy Schwartz, president of Mental Health of America of Greater Houston, a nonprofit that promotes effective treatment for the mentally ill.


Left to find her own way
Patricia George, 34, said her thinking always becomes clearer when she returns to jail and gets back on medication.

In the past 20 years, George, who says she is bipolar and schizophrenic, has been charged with 12 felonies and 31 misdemeanors, with most of the bookings in Harris County. In all, she has spent nine years in jail.

Like other mentally ill inmates, George has been expected to find her way — with no car and little money — to mental health providers, to line up counseling and to fill prescriptions for her medication in the weeks after her release.

In the meantime, medications she was taking in jail wear off, she said during an interview three days after her July 5 release from jail.

"Just walking down here (for the interview), I'm starting to hear voices," said George, who finished a six-month sentence for prostitution.


Not filling prescriptions
Many of the mentally ill never fill their prescriptions or return to counseling, said Steven Schnee, director of Mental Health and Mental Retardation Authority of Harris County, a government agency that provides mental health care locally. They just return to their former lives, usually on the streets.

George, who often is homeless between jail stints, hopes she can avoid a return to jail this time. She has been working with Healthcare for the Homeless-Houston, which started a program that helps released mentally ill inmates find housing and reach appointments with mental health providers and counselors.

Michael Seale, director of the county jail's health services, said the mental health staff becomes frustrated because inmates stabilized in jail drift into psychosis when they get out.

"Whatever good work we've done may not have any value two or three weeks after they get out," Seale said.

The jail — which has come under scrutiny recently for inmate deaths and was inspected by federal investigators earlier this month — spent about $10 million on mental health care in 2004. Two years ago, only 600 inmates were on psychotropic medications.

But staffing and funding then wasn't nearly adequate for the increasing numbers of mentally ill inmates.

Since mental health wards have been expanded, the jail now has beds for 244 mentally ill inmates, including 70 who are acutely ill.

The jail contracts with Harris County Psychiatric Center for 24 more beds.

The jail's mental health team delivers medications to an additional 1,650 inmates through outpatient treatment.

The team is big, employing 82 health care workers. That includes eight psychiatrists, 18 psychiatric registered nurses, 34 psychiatric technicians, seven licensed vocational nurses and 12 employees who screen incoming inmates.

Chief Deputy Mike Smith of the Sheriff's Office said the jail's mental health operation is comparable to the biggest non-jail mental health hospitals in the state.

Smith, as head of the jail, is among those credited with upgrading its mental health services.

"I've had people say I better watch what I say or I'll come across as a liberal," he said. "We shouldn't be treating our mentally ill in the jails. We should be treating them in the free world."

Advocates say the number of mentally ill cycling through jails and psychiatric wards can be greatly reduced.

Many need to be placed in permanent supervised housing, Schwartz said.

Those who are less ill could be placed in apartments and monitored at least weekly by case managers.

But in Harris County, there are fewer than 1,500 rooms or apartments where the mentally ill can receive supervision or services, Schwartz said.

About 10,000 such units are needed.

"If these kind of housing opportunities existed, there would be far fewer mentally ill in jail," she said.

Bexar County Jail Diversion on You Tube

My new favorite line, "It's a 59 cent Coke!"



Great Job, Bexar County!

Mentally ill don't belong in jailhouse

Our friends at Preventionnotpunishment.blogspot.com shared this story:

Temple-Telegram.comhttp://www.temple-telegram.com/story/2008/07/27/51055
Mentally ill don’t belong in jailhouse
by Paul A. RomerPublished July 27, 2008
BELTON - Before Carolyn Law was sent to prison in March 2006 for killing her mother, she was a college educated woman who had worked in real estate and tried to control her schizophrenia through medication.
At one point, she was so successful at controlling her illness, the state used her in a video that promoted the services that helped her cope.
“She was a poster child for services offered through the (Central Counties Center for Mental Health Mental Retardation),” said Eldon Tietje, executive director for MHMR.
Tietje said Ms. Law could still be considered a symbol for the mentally ill, only now she would be a symbol for what is wrong with the state’s treatment of the issue.
“She is someone who did pretty good for a long time,” Tietje said. “She could and did take advantage of services when they were available, but she deteriorated over time and didn’t comply with treatment.”
Much like Ms. Law’s condition, the state’s funding for mental health programs has eroded over time, Tietje said.
And Tietje is not the only local official voicing concern over the treatment options for mentally ill in the state.
Judge Martha Trudo, 264th State District Court, sentenced Ms. Law to 45 years in prison for murder. Judge Trudo thinks it’s time for the state to do a better job addressing mental health issues.
“It isn’t a problem to be hidden,” she said. “We really need to be doing something about (the mentally ill). They end up being warehoused in the pen.
“We do not do a good job of taking care of the mentally ill in Texas. There are tremendous waiting lists, doctors won’t see them unless they get picked up and put in jail. Then we are obligated to do it.
“A lot of people can function and work if they have support.”
In March 2006, Ms. Law addressed the court before her sentencing and said that mentally ill people such as her are misunderstood. She also said she hoped to see advancement in the treatment of mental patients.
“You have heard from many people here who have been hurt. I’ve been hurt for the last 20 years,” she said. “I’m the biggest victim of all, as I see it.”
The local mental health picture
In his 16 years at the top post at Central Counties MHMR, Tietje said referrals have doubled as the population in the area has increased.
“The prevalence of mental illness may not be greater but we have more people and the resources are less, also during that time most of the private hospitals have closed, so there are fewer in-patient services,” he said.
A 2003 state budget crunch took more than $100 million out of the community MHMR system. But rather than this being an anomaly, it looks more like a pattern. In 1994, Tietje said his budget was $16.5 million. It was slashed to $12 million in 1995, a 25-percent cut.
“A result of that budget cut, we lost a Fort Hood work program that served 200 people,” Tietje said.
Closely supervised program participants cleaned buildings and restocked the commissary on base.
Budget constraints have also contributed to the closing of a three-quarter-way house in Gatesville that helped get people back on their feet. It had 30 beds and was a place where people could stay and look for work while they stabilized on their medications.
“It was a structured environment that made sure they got meds and food,” Tietje said.
And the Gatesville center has not been the only facility that has been shuttered.
Clinics in Bell, Coryell, Hamilton, Lampasas, and Milam counties have all been closed.
Patricia Roy-Jolly, MHMR supervisor who works with community support services, said she has witnessed a general pattern with many of the mentally ill she attempts to help.
She said mentally ill people often commit a crime and are incarcerated in Bell County Jail, which, in turn, ships them to Austin State Hospital. In Austin, the person gets stabilized on medication and usually within about a month is sent back to the area with three weeks of medication and the charge to regularly visit a doctor.
Ms. Roy-Jolly said usually the patient makes one or two appointments before he or she stops taking their medication and disappears for a while until he or she is rearrested and the process starts all over again.
“We’re just in a terrible predicament. A lot of these people do not have family members or they have family members who can’t help them anymore,” Judge Trudo said.
“It’s probably time for Texas to look at having group homes or do something.”
One funding cut came at the hands of the Texas Commission on Alcohol and Drug Abuse when the agency overextended funds by not regulating properly.
“Our funding from substance abuse services went from $80,000 to $15,000. We gave up our patient substance abuse services,” Tietje said. “We got rid of it because we couldn’t afford it.”
Right now the best option for temporary inpatient care for mentally ill patients is the Austin State Hospital, but up until about eight years ago Temple was able to provide inpatient crisis stabilization.
“We had to give it up because it became too expensive for us to run,” Tietje said.
And the Austin State Hospital is often near capacity. For at least two weeks this month the hospital was so full it was on diversion and recommending people go to San Antonio for services. The other option for jails was to warehouse the prisoners until a slot opened at the hospital.
Other programs or services impacted by budget constraints include: two-day treatment services in Temple and Killeen that served 30 to 40 people, access to counseling services, transportation and noon meals.
“There’s a whole lot less mental health services in these five counties than there was 13 years ago,” Tietje said. “When there are no support services, people are less likely to seek or stay up on treatment.”
This year’s budget for Central Counties MHMR is $14.5 million.
“We have fewer resources today and inflation has eroded our spending ability. We have had no inflationary increases from any funding groups, county or state,” Tietje said. “As a result, our services have eroded and more and more people with mental illness show up in jails or emergency rooms.”
The impact on the community
The struggles of the state in answering the question on how to deal with people who struggle with mental illness is often shared by the families and church communities of these individuals.
In Ms. Law’s case her former minister Joe Baisden, Belton Church of Christ, said he spent a tremendous amount of time ministering to her in the years preceding the killing of her mother.
“Carolyn used to be a member of my Bible class. I was called in many times when her mother and her had problems,” he said. “She freely talked about mental illness and gave us a great deal of insight. When she was on her meds she came to support group and was smooth as silk - other times she was erratic.”
Baisden said he will never forget when his church community was having a fellowship day in Yettie Polk Park in Belton and he was called to help Law’s family.
She had dropped her boys off at a mall in the Austin area and was later arrested at the State Capitol building when she pulled a fire extinguisher off a wall and sprayed paintings on display in the building.
“It grieved me that she had this kind of destiny in this life,” Baisden said about Ms. Law. “It’s sad.”
Copyright © 2008, Temple Daily Telegram
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Mental Health Court Approved for Smith County!

From Tyler Paper:

Pilot Program for Mental Health Court Approved
By ROY MAYNARDStaff WriterSmith County commissioners today laid the groundwork for a pilot mental health court, which will seek to divert non-violent mentally ill arrestees from the criminal justice system.
“It’s a crisis every county in Texas is facing now,” said Dr. David Self, chief forensic psychiatrist for the Rusk State Hospital. “Far too many mentally ill people are finding their way into the criminal justice system.”
Budget cuts at the state and federal levels have reduced resources for care for those with serious mental illnesses, he said.
“If they’re not being served in mental health system, they’re finding their way into the criminal justice system,” Self said. “Jail populations are typically 25 to 33 percent persons who are experiencing mental illness. Smith County falls right in there.”And jails aren’t where the mentally ill should be, he added.“Jails don’t do a good job of treating the seriously mentally ill, but that’s not their fault,” Self said. “That’s not what they’re designed for.”Most mentally ill inmates are in jail on non-violent misdemeanor offenses, he said.Valerie Holcomb, with the Andrews Center, said such inmates are much more expensive to incarcerate.“It costs twice as much to keep a mentally ill inmate (in jail) and they stay in jail three times longer,” she said.But a mental health court, which would focus on intensive supervised probation, can save the county money.“How much does it cost? The short answer is, it depends,” she said. “How much does it cost, versus how much does it cost to house a mentally ill inmate in jail? Research indicates there is improved public safety, and it reduces recidivism and jail costs.”Commissioners responded positively to the idea.“I’m very interested in the program,” County Judge Joel Baker said. “This ties in with (consultant) Carter Goble Lee’s recommendations on ways to maintain a lower jail population. I’ll do anything I can to help.”“I’m in support,” agreed Commissioner Bobby Van Ness. “It would be a win-win situation for both the jail and for public safety.”Commissioners voted unanimously to create a pilot program. No funding was provided, because participation by Smith County officials will be voluntary. Baker himself, who handles probate and mental competency hearings already, will serve as the court’s judge. A task force will be created to research other mental health courts and begin applying for grants. The pilot program will be limited to five to 10 participants during the first year.“We’re all focused on the jail population, and that’s a nice side benefit, but the focus of this is getting these people proper care,” said Commissioner Bill McGinnis. “And that’s what I’d like to see.”

Some psych patients wait days in hospital ERs

MH patient dies while waiting for crisis services in psychiatric emergency room: (from msnbc.com):
NEW YORK - When staffers at a Brooklyn hospital spotted a middle-aged woman lying face-down on a waiting room floor last month, it hardly seemed like cause for alarm.
The sight, after all, was common in the psychiatric emergency room at Kings County Hospital Center. The unit is so routinely backed up with people waiting hours, or even days, for services that patients often spend the night nodding in chairs or sprawled in a corner.
It took an hour before a nurse realized the prone woman was in trouble. By then, she was dead.
see the rest of the story here:
http://www.msnbc.msn.com/id/25520178/

Cost of Mental Health Care Overwhelming to County Jails

Costs of Mental Health Care is overwhelming to all jails, not just Harris County. Take any jail and that is the largest population of mentally ill consumers in any given county.

From our friends at Prevention not Punishment:

Costs of Mental Health Care Overwhelm Harris County Jail
Today's Houston Chronicle features the following article about the revolving door of severely mentally ill homeless offenders in the Harris County Jail ("Finding escape behind bars," July 21, 2008). Many of these inmates have been arrested on dozens of occasions; many have substance abuse disorders in addition to mental disorders. As the number of these chronic inmates continues to increase, the cost of both incarceration and treatment has soared to $87 million annually. While some organizations have launched new programs aimed at providing support for severely mentally ill homeless people immediately upon their release from jail, the demand for services still far outpaces the limited resources available.Here's the article in full:"At the Harris County Jail, deputies and health care workers have a name for them — frequent fliers.They are mentally ill homeless people who return to jail so often, sometimes on minor charges, that they become familiar to the psychiatric staff.During a recent survey, county officials found that more than 400 of the jail's 11,000 inmates were homeless and suffered from a major mental illness: schizophrenia, bipolar disorder or a chronic depressive-psychotic disorder. They were among 1,900 inmates on psychotropic medications.When the mentally ill homeless leave jail — and leave behind its mental health care staff — many stop taking medication and end up on the street again. Treatment resumes only when they commit a crime and return to jail or their dementia overwhelms them and they are brought to an emergency psychiatric center.Treating the mentally ill as they cycle through jail and emergency psychiatric wards is expensive. A county budget analyst estimates that it costs $80,000 a year, per person.At the jail, spending on mental health care has risen to $24 million annually, and the combined cost of incarcerating and treating the mentally ill is $87 million annually.'The jails have become the psychiatric hospitals of the United States,' said Clarissa Stephens, an assistant director of the county's budget and management services office who has been studying the jail's mental health costs.The Commissioners Court is so concerned about the rising costs that it has retained a consultant — psychiatrist Avrim Fishkind — to study whether providing outpatient services and supervised housing would reduce the numbers of mentally ill revolving through the jail.'The costs of reincarcerating and court costs far outweigh what the costs would be if you housed, clothed and supervised the mentally ill,' Fishkind said.A June survey of more than 11,000 inmates revealed:•About one-quarter suffer from mental illness or once suffered from it.•Of those on medication, 978 suffered from schizophrenia, bipolar disorder or a severe depressive-psychotic disorder.•Of the 978 with a major mental health disorder, 423 likely were homeless.•Of the 423 homeless with a major mental health disorder, 97 percent had been arrested at least once before during their lifetimes; 43 percent had a prior arrest during the last 10 years.On the day of the survey, the jail's mentally ill homeless inmates included:•A 39-year-old woman booked 45 times since 2001.•A man, 26, booked 30 times since 1999.•A man, 52, booked 33 times since 1992.•A man, 25, booked 20 times since 2001.Some of the mentally ill — many of whom also are substance abusers — keep committing crimes and getting rearrested, in part, because few are properly supervised when they are released, said David Buck, a Baylor College of Medicine associate professor and president of Healthcare for the Homeless-Houston.Houston isn't alone in facing this issue. After many mental hospitals were closed in the 1970s and 1980s, countless patients were released in cities that were ill-equipped to house those who needed such care.'What happens here happens in many communities. We are criminalizing mental illness,' said Betsy Schwartz, president of Mental Health of America of Greater Houston, a nonprofit that promotes effective treatment for the mentally ill.Left to find her own wayPatricia George, 34, said her thinking always becomes clearer when she returns to jail and gets back on medication.In the past 20 years, George, who says she is bipolar and schizophrenic, has been charged with 12 felonies and 31 misdemeanors, with most of the bookings in Harris County. In all, she has spent nine years in jail.Like other mentally ill inmates, George has been expected to find her way — with no car and little money — to mental health providers, to line up counseling and to fill prescriptions for her medication in the weeks after her release.In the meantime, medications she was taking in jail wear off, she said during an interview three days after her July 5 release from jail.'Just walking down here (for the interview), I'm starting to hear voices,' said George, who finished a six-month sentence for prostitution.Not filling prescriptionsMany of the mentally ill never fill their prescriptions or return to counseling, said Steven Schnee, director of Mental Health and Mental Retardation Authority of Harris County, a government agency that provides mental health care locally. They just return to their former lives, usually on the streets.George, who often is homeless between jail stints, hopes she can avoid a return to jail this time. She has been working with Healthcare for the Homeless-Houston, which started a program that helps released mentally ill inmates find housing and reach appointments with mental health providers and counselors.Michael Seale, director of the county jail's health services, said the mental health staff becomes frustrated because inmates stabilized in jail drift into psychosis when they get out.'Whatever good work we've done may not have any value two or three weeks after they get out,' Seale said.The jail — which has come under scrutiny recently for inmate deaths and was inspected by federal investigators earlier this month — spent about $10 million on mental health care in 2004. Two years ago, only 600 inmates were on psychotropic medications.But staffing and funding then wasn't nearly adequate for the increasing numbers of mentally ill inmates.Since mental health wards have been expanded, the jail now has beds for 244 mentally ill inmates, including 70 who are acutely ill.The jail contracts with Harris County Psychiatric Center for 24 more beds.The jail's mental health team delivers medications to an additional 1,650 inmates through outpatient treatment.The team is big, employing 82 health care workers. That includes eight psychiatrists, 18 psychiatric registered nurses, 34 psychiatric technicians, seven licensed vocational nurses and 12 employees who screen incoming inmates.Chief Deputy Mike Smith of the Sheriff's Office said the jail's mental health operation is comparable to the biggest non-jail mental health hospitals in the state.Smith, as head of the jail, is among those credited with upgrading its mental health services. 'I've had people say I better watch what I say or I'll come across as a liberal,' he said. 'We shouldn't be treating our mentally ill in the jails. We should be treating them in the free world.'Advocates say the number of mentally ill cycling through jails and psychiatric wards can be greatly reduced.Many need to be placed in permanent supervised housing, Schwartz said.Those who are less ill could be placed in apartments and monitored at least weekly by case managers.But in Harris County, there are fewer than 1,500 rooms or apartments where the mentally ill can receive supervision or services, Schwartz said.About 10,000 such units are needed.'If these kind of housing opportunities existed, there would be far fewer mentally ill in jail,' she said."

New Private Mental Health Defenders Office in Lubbock

(From Prevention not Punishment): KCBD, NewsChannel 11 in Lubbock reports that officials in Lubbock County have received funding for a new program aimed at diverting offenders with mental illness from jail and providing them with quality legal representation ("New Program Addresses Lubbock County Inmate Mental Health," July 10, 2008). While both Travis and Bexar Counties provide public mental health defenders to those who have committed misdemeanor offenses, Lubbock's Private Mental Health Defenders office will be the first of its kind in Texas. The program will use county funds to pay a nonprofit organization to oversee cases defended by private attorneysHere's the full story:
"Efforts are underway in Lubbock County to save taxpayers money and increase public safety. A $400,000 state grant will help Lubbock County open a Private Mental Health Defenders office. The goal is to address the mental health of Lubbock County inmates could save the county thousands of dollars at the same time.If you commit a crime in the Hub City, you will most likely end up in the Lubbock County Jail. But Lubbock County Director of Court Administration David Slayton says, for some, crime is a by-product of mental health illness. 'These individuals need help, we understand that but we don't want there to be a public safety risk by releasing them back out on the street. To figure out how to best deal within the justice system has been really tricky,' Slayton said.Slayton says, come this fall, the county will try something new - a Private Mental Health Defenders office. The office initially will be funded mostly by the state, but by the fifth year Lubbock County will pick up the entire bill. '[What] We anticipate is the savings in the jail cost will be enough to pay for this over, probably multiple times over,' Slayton added.The state grant will put experts in the jail to help identify inmates with mental health issues. Something Sheriff David Gutierrez says will help the problem. 'We as sheriffs have had problems throughout the decades with mental health issues in the jail. The reality is that now we are trying to bring this across through the judicial system to identify them prior to intake,' Sheriff Gutierrez said.Slayton says as part of the program the court will have the option to appoint specially trained attorneys to defend those identified with mental health problems.Defense Attorney Ted Hogan says it will help move people more efficiently through the court system. 'It's a way of dealing with folks that aren't your traditional criminals. Helping folks get back on their feet who hopefully don't come back and enable us to do it much more efficiently than what the old system has allowed us to do,' Hogan added.The idea, and its potential savings, has some Lubbock County commissioner's support. 'Take the grant money and do what needs to be done. Take care of these folks and give them [sic] learned council and keep those folks from possibly going to jail which will save us tax dollars,' Commissioner Bill McCay said.But not all are in support. District Attorney Matt Powell tells NewsChannel 11 his office is already taking steps to make sure those with mental issues have good representation.Still Slayton says many could benefit from the new office. 'It's good from the perspective of the tax payer, it's good for the defendant and they can get the mental help they need with their mental illness,' Slayton added.This will be the first program of its kind in the state and one of the few in the country. It's expected to be up and running by the beginning of October."

Mental Health Court for Smith County?

I received the following information today:
Good news--On Monday, July 28 at the meeting of the Smith County Commissioners, there will be a presentation regarding possible Mental Health Court being established in Smith County. Mental Health courts, which provided intensive supervised release for mentally ill probationers, have been found to be very effective at reducing not only return to jail but also in reducing psychiatric hospital stays with resources for enhancing outpatient treatment. When approximately 20% of Smith County jail inmates have been treated for mental illness in the past, the potential impact of such an intervention program is substantial not only in terms of dollars saved but also in terms of quality of life for individuals, family members, and other citizens who could be affected by subsequent crimes.

Dr. David Self, chief forensic psychiatrist at Rusk State Hospital, and Ms. Valerie Holcomb, Texas Corrections Office on Medically and Mentally Ill specialist at Andrews Center, will make a presentation to the Commissioners sometime early in the meeting which begins at 9 a.m. (July 28) at the courthouse annex (NE corner from courthouse--where early voting occurs). Come and show your support, come and learn about the plans. This project has the potential for closing a revolving door into jail and/or hospital for many people whose care for mental illness is not consistent at times.
Paul Andrews

Medication Reduces Violence in Some Schizophrenics

From US News & World Report:
Medication Reduces Violence in Some Schizophrenics
Treating psychosis alone may not end risk; older drugs as good as newer ones, study finds
Posted July 3, 2008

THURSDAY, July 3 (HealthDay News) -- Taking prescription medications can help reduce violent behavior in some schizophrenia patients, Duke researchers report.
It included 1,445 schizophrenia patients randomly selected to receive one of five antipsychotic medications: olanzapine, perphenanize, quetiapine, risperidone or ziprasidone.
Patient violence declined significantly when patients took their medications as prescribed, but only among patients whose prior risk for violence could be linked to psychotic problems. There was little or no improvement in a subgroup of patients with a history of childhood conduct problems who were more likely to be violent at the start of the study.
The study also found that older antipsychotics are as effective as newer drugs in reducing violent behavior.
"Contrary to the expectations of many clinicians and some research, this study found no benefit for newer medications over an older medication in reducing the risk for violence over the six-month study period," study author Jeffrey Swanson, a professor in psychiatry and behavioral sciences, said in a prepared statement. "In fact, one of the newer medications, quetiapine, performed worse than the first-generation drug perphenanize."
The findings were published in the July issue of the British Journal of Psychiatry.
"This is the first large randomized controlled study to compare the effectiveness of several commonly prescribed medications for schizophrenia on reducing community violence," Swanson said. "Serious violent behavior is not frequent among people with schizophrenia, but when it does occur, the results can be costly and tragic."
"In the past, we've not understood very well why a small proportion of patients with schizophrenia become seriously violent, while most do not -- and why medication seems to prevent violent behavior in some and not others," study co-author Marvin Swartz, a professor of psychiatry, said in a prepared statement.
"These findings tell us that people with schizophrenia may behave violently for reasons not directly related to their mental illness. If that's the case, then treatment for psychotic symptoms alone may not eliminate the risk of violence," Swartz said.

From the consensusproject.org :
Senate includes $12 million for the Mentally Ill Offender Treatment and Crime Reduction program
On June 19, the Senate completed the mark-up of its 2009 Commerce, Justice, Science (CJS) appropriations bill. In the bill, the Senate reserved $12 million for mental health courts and adult and juvenile collaboration program grants authorized by the Mentally Ill Offender Treatment and Crime Reduction Act (MIOTCRA).
In addition, on June 25, the House Appropriations Committee completed the mark-up of the 2009 appropriations bill, reserving $10 million for grant programs under MIOTCRA.
Senators Patrick Leahy (D-VT) and Pete Dominici (R-NM) worked closely with colleagues to ensure continued funding for the program in FY 2009. Other key supporters included Senator Ted Kennedy (D-MA) and Congressmen Bill Delahunt (D-MA) and Jim Ramstad (R-MN).
The grant program, called the Justice and Mental Health Collaboration Program, is administered by the Bureau of Justice Assistance (BJA) and provides grants to states to improve collaboration between criminal justice and mental health agencies. The program received $5 million in FY 06 and FY 07 and $6.5 million in FY 08.
Other criminal justice programs listed in the Senate appropriations bill include the Justice Assistance Grant program (JAG), which is slated to receive $580 million, and the Community Oriented Policing Services program (COPS), which is slated to receive $600 million. Additionally, $30 million was included for Drug Courts.
For more information on the Mentally Ill Offender Treatment and Crime Reduction Act, visit the Consensus Project Website or contact Elizabeth Dodd.

Woman Who Stoned Children to Death Will Remain in Mental Facility

From the Tyler Paper, Judge Kent orders Deanna Laney to spend another year in the state hospital. Last year, the court discovered that she was permitted to leave the hospital on passes to go eat and shop with family. This was ordered to stop. The question I pose: should defendants found not guilty by reason of insanity be allowed passes and furloughs? What about those defendants that are in the hospital found incompetent to stand trial? Here's the article: http://www.tylerpaper.com/article/20080708/NEWS01/807080317.

Welcome!

Welcome to the blogspot, "Stir Crazy in Texas." After reading many blogs, such as Grits for Breakfast, and Prevention not Punishment, I thought it was time to start my own blog. My goal is to discuss the cross roads of mental health and the criminal justice system in Texas. Although I hope to educate a few folks, I know that I will learn more from y'all than any wisdom I can bestow.