By Arvin Akhavan
Illustration by Elise Walker, BME graduate student, Northwestern University.
A year ago, I met a man at a psychiatric hospital in greater Chicago. He was pleasant, polite, well-groomed, educated, and seemed to have a strong will to fix a life that was derailed less than a decade earlier by the onset of mania in the context of bipolar disorder, and complicated by a slew of psychotic features. ‘Andy’ also had HIV, and had continuously refused treatment while in and out of jail for the past several years. His manic episodes expressed themselves as threats to the president and other elected officials, assaults on police officers, and harm to loved ones. Needless to say, these episodes landed him in jail multiple times throughout the past decade. ‘Andy’ reported little to no mental health treatment while in jail, and had now presented himself, while in remission, to get the help he needed.
The press has extensively documented the shift of our mentally ill from institutions to correctional facilities—and for good reason. The number of jail and prison inmates who are mentally ill is remarkable. Studies show that up to 15% of newly presenting inmates in county jails have severe mental illness [1]. Over half of all jail inmates can be classified as mentally ill [2]. These staggering numbers cannot be ignored. They demonstrate why Cook County Sheriff Tom Dart has called jails “the new insane asylums” [3]. These numbers show that jails are mental health institutions and they should have the ability to act as such.
Initial Barriers
Many of the barriers to the implementation of mental health care in the jail system involve the identification of inmates or their illnesses in central intake, when the arrested person is evaluated on initial presentation to the jail. The lack of health records is an obvious problem, as psychiatric evaluations are time-consuming and diagnoses may have been made previously. Records of such previous diagnoses would provide health care professionals with the opportunity to focus on acute exacerbations of illness as opposed to performing a redundant initial diagnosis. Electronic county health records go a long way towards solving this problem, especially when they are tied to the public hospital system. Furthermore, diagnostic codes for reimbursement are limited to fewer diagnoses in the public sector than they are in the private sector. This can affect the diagnosis and treatment of mentally ill individuals in places where these restrictions keep physicians or providers from practicing with a holistic biopsychosocial model, which takes into account the biological, psychological, and social factors that play a role in illness.
After mentally ill inmates present to the jail, their treatment is limited by the type of personnel available and qualified to provide care. Many successful institutions have found that having dedicated police personnel for the jail’s psychiatric census is essential to providing a healing environment. As one jail psychiatrist remarked to me, police officers are rightfully trained to detain, not to heal. While this training is sufficient to work with inmates, it is not appropriate for working with patients. Dedicating personnel to mentally ill inmates allows for a shift in jail culture regarding mental illness, and reduces rates of incidents and accidents related to those illnesses. In one jail system, this new training was so successful in affecting cultural change that the program was extended to include all officers.
Hospital Collaboration
Even if diagnosis and identification are made and if officers are trained to treat patients, jail medication formularies are sometimes insufficient to cover severe mental illness. Most jails only have access to older psychiatric medications, as newer and more effective drugs take time to become generically available. For example, although selective serotonin reuptake inhibitors (SSRIs) are now present on most jail formularies, newer antipsychotic medications have yet to become generic, and inmates are given older antipsychotic drugs that are less effective and have more serious side effects. Similarly, hospitals and other health care providers must be accredited by the Joint Commission in order to receive federal funding, including funding from programs such as Medicare and Medicaid. This means that they must meet national standards for medical and psychiatric care in order to get paid. County jails, on the other hand, have inspections from the Department of Justice, state oversight, and the National Commission on Correctional Health Care (NCCHC), but they do not have any mandate to follow the recommendations provided nor do they lose potential funding for not meeting certain standards. For example, the NCCHC provides recommendations, but has no legal power to penalize correctional facilities for not following them. Legally, the approach to psychiatric care in jails is closer to that of a correctional institution than a hospital.
In speaking with psychiatric health workers at different jails, it became apparent that certain institutional frameworks seem to better approach these problems. The Dallas County Jail system, for example, was at one point a model of medical and mental health disaster, having failed seven state inspections in a row. The jail’s screening and care process, along with non-medical issues of safety, was so poor that it led to a higher than usual number of inmate deaths that prompted a federal civil rights investigation [4]. In the middle of that seven-year stretch, the county jail made a drastic change in the way it runs its health care, and has now passed three county inspections in a row, likely saving hundreds of millions of dollars in the process.
In 2006, this jail system partnered with its county’s hospital system, tasking the hospital with providing all medical and mental health services. In doing so, the hospital was able to bring on staff, such as officers and health care workers, that were dedicated to mental health inmates only. All of these personnel, officers included, took courses on how to manage and handle psychiatric patients with treatment in mind, as opposed to detainment—a welcome change in culture at the jail. This program was so successful that the county now requires most of its officers to take this course. Furthermore, this dedicated staff inherently provides devoted care for the inmates that screen positive for mental health issues. Psychiatric faculty at the jail, who are also employees of the hospital system, have thus made great strides in obtaining dedicated psychiatric space and facilities. Since the hospital has full treatment responsibility for these inmates, the psychiatric and medical services at the jail now have full access to the county hospital’s electronic medical record and medication formularies. This way, the jail can better identify repeat mental health inmates at intake and also treat them with the same resources that hospitals are required to have available under federal regulation.
Towards Treatment
The paucity of resources that address mental health in correctional facilities is central to the problem with many current jail systems and their approach to the mentally ill. The question we have been asking is whether mentally ill inmates should have access to resources. Rather, we should be asking how to get them those resources in a way that keeps them safe and out of correctional facilities.
In a jail system more focused on mental health diagnosis and treatment, ‘Andy’ would never have made it three years without an aggressive plan for his condition. Once a successful, college-educated member of society, his life had been derailed by the strange and sudden onset of an illness over which he had no control. As a result, he ended up in the correctional system. Once there, the help he received and the resources available to him were insufficient. He stayed there for years, wedged into a situation where it was impossible for him to right his life. In a system of detainment, ‘Andy’s’ story is the rule rather than the exception. His tale represents the nearly one-third of detainees that present to major city jail systems in dire need of psychiatric help. Like ‘Andy’, many of them do not get that help. They are detained. As mental health service is made an integral part of correctional facility operations as opposed to a necessary adjunct, the rule should fortunately evolve from detainment towards treatment.
References
- Lamb, H.R. and L.E. Weinberger, Persons with severe mental illness in jails and prisons: a review. Psychiatr Serv, 1998. 49(4): p. 483-9
- US Department of Justice, Mental Health Problems of Prison and Jail Inmates. Bureau of Justice Statistics Special Report, 2006.
- Secretary of State John Kerry, Schizophrenia and America’s mental health system. 60 Minutes (Bill O’Reily) CBS: 29 Sep 2013. Television.
- Krause, Kevin, After seven years, Dallas County jails pass state inspection. Dallas Morning News: 12 Aug 2010, dallasnews.com. Web. Accessed 23 Feb. 2014.
About the Author
Arvin Akhavan
Arvin Akhavan is studying toward his MD at Northwestern’s Feinberg School of Medicine. He is a native Texan who has found a new home in Chicago. He enjoys exploring the city, writing, staying active, and watching the Texas Longhorns win football games.