Tuesday, August 26, 2008

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.

Tuesday, August 19, 2008

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.

Wednesday, August 6, 2008

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.

The public health framework might work well in addressing mental health and substance use problems
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.

Tuesday, August 5, 2008

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.

Monday, August 4, 2008

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."

Saturday, August 2, 2008

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.