What to Expect When Your Patient Goes to Jail

Transcription

1 What to Expect When Your Patient Goes to Jail Evelyn Coggins, M.D. UBMD Psychiatry, Clinical Assistant Professor Chief Psychiatrist, Erie County Forensic Mental Health

2 This doesn t really apply to my patients, does it?

3 The majority of psychiatric beds in the US are now found in correctional settings There are ten times more seriously mentally ill people incarcerated than in hospitals 40 percent of people with a history of mental illness have been in jail at some point In 2012 there were 350,000 inmates with severe mental illness in prisons and jails and approximately 35,000 in state hospital bed

4 Toward Enlightenment Mentally ill persons filled our jails and prisons in the early 19th century The reform movement sparked by school teacher Dorothea Dix led to more humane treatment of the mentally ill By the middle of the 19th century all states treated mentally ill in psychiatric hospitals rather than incarcerating them.

5 Effect of Deinstitutionalization In 1955 there was one psychiatric hospital bed for every 300 Americans By 2005 there was one bed for every 3000 Americans- a 90% reduction In 1964 nearly 500,000 people were living in State Hospitals. By 2014 the number was reduced to 35,000

6 Limited Resources Hundreds of thousands of seriously mentally ill were emptied into the community without access to adequate housing, treatment or services. With no humane alternatives available, mentally disordered behavior has been criminalized.

7 Just Like 1840 We have now returned to the conditions of the 1840 s by putting large numbers of mentally ill people in jails and prisons

8 Prisoners of today in need of care 20% of men incarcerated have a history of serious mental illness 40% of incarcerated women have a history of serious mental illness 65 % have been treated for less severe mental health issues 60-70% have a history of substance abuse

9 Erie County Corrections Erie County Holding Center is a maximum security facility Population includes both arraigned and unarraigned detainees awaiting adjudication as well as sentenced individuals Special housing units including mental health housing, protective custody, detoxification units, classification, veterans unit

10 Erie County Corrections Inmates serving misdemeanor sentences usually of less than a year are housed at Erie County Holding Center or Erie County Correctional Facility Convicted felons are housed at the holding center until transfer to Prison 1400 bookings per month in 2013/2014 Average daily census (ECHC/ECCF) is 1,230

11 Erie County Corrections Average # of inmates on FMH caseload is 384 Approximately 35 % of those are seriously mentally ill (mainly schizophrenia or bipolar) Co-occurring addictions approximately 85% 85 inmates per month identified at risk for suicide

12 Mental Health Services Psychiatric staffing through University Practice Plan Psychiatrists, Psychologists and Psychiatric Nurse Practitioners QMHP (Qualified Mental Health Professional) staff is made up of Social Workers, Mental Health Counselors, MICA specialist, discharge planners

13 Why do our patients get arrested Substance related charges Stealing or theft Violence, sexual crimes, scaring people- menacing, stalking, threatening Trespassing, burglary, disorderly conduct, resisting arrest, harassment Any imaginable offense

14 Why did they bring this guy here? He belongs in (fill in the blank) A) a hospital B) jail The answer depends on where you work when a mentally ill offender is admitted to your service

15 Arrest Depending on location, the defendant may be detained in a local jail until arraignment Arraignment is the formal reading of charges in court Arraignment of mentally ill inmates - fraught with problems

16 Upon Arrival to ECHC Mental Health screen including suicide screen by a nurse Housing is determined- Referral to Forensic Mental Health Service if indicated-routine, urgent or emergent Bridge Medication ordered

17 Suicide Screen Positive or Failed suicide screen triggers an emergent referral for mental health evaluation by a QMHP Masters prepared, well trained, painstakingly credentialed by Psychiatry staff Constant Observation until a Comprehensive Suicide Risk Assessment has been completed

18 Mental Health Housing Inpatient at ECMC 9 zone 2 Lockup Constant Observation- 1:1, 2:1, 4:1 Residential Treatment Unit Outpatient Mental Health Housing in jail- Delta units located near medical area

19 Residential Treatment Unit State of the Art specialized treatment unit for SPMI inmates Dedicated treatment team, group and individual psychotherapy Intensive discharge planning Enhanced evaluation and testing Specially selected deputies

20 Timely Treatment Most mentally ill inmates are seen by mental health staff within one or two days of arrival Assessment done by QMHP is extensive and usually excellent quality The more acutely ill or high risk inmates are usually seen by the psychiatrist or NP on the day of arrest or the next day

21 They wouldn t give me my medication Bridge medication for all verified prescriptions are ordered on the day of arrival to last until appointment with the psychiatry staff occurs Approved substitutions for nonformulary medication will be ordered by the admitting nurse practitioner Non-formulary exceptions are common

22 Formulary Extensive Formulary at ECHC/ECCF Medications are excluded based on cost abuse potential diversion potential inmate safety

23 What about my Xanax? Benzodiazepines are avoided. Detoxification/taper is started on arrival. Psychiatrist has the option of continuing the medication at the first visit Stimulants are rarely used in jail

24 Concerns in Corrections Substance use disorders are common Illegal drugs are hard to come by Both controlled and noncontrolled drugs are choice substitutes

25 Special Concerns in Corrections Prisoners are motivated to reduce jail discomforts: boredom, insomnia, self reflection, reality, confinement Medications can be a source of currency, coercion

26 Hypnotics Hypnotics are in high demand Short term use up to one or two weeks is acceptable Psychiatrist has the ability, in unusual circumstances to use discretion and extend duration sleeping pill use

27 Drugs in Demand Seroquel- Quell, Susie Q, Baby Heroin IV/inhaled/smoked Wellbutrin- Wellies, Dubs, Barnies stimulant when snorted or smoked Neurontin- Johnies Artane- smoked; with coffee or tobacco

28 Drugs in Demand Zyprexa, Thorazine TCA s, other antidepressants Benadryl, Cogentin, Vistaril, Trazodone, Remeron, mood stabilizers, Lyrica, Baclofen, Decongestants

29 Medication Changes in Jail If your patient really didn t get his medication, there is likely to be good reason for this Careful clinical judgement behind the decision

30 Discharge planning Housing Medication Treatment Benefits, Finances, Other

31 Forensic Assessment Competency Criminal Responsibility Dangerousness Treatment Recommendations

32 Incompetent Defendants Many patients are restored to competency simply by starting treatment or completing detox in jail Incompetent individuals with minor charges are sometimes sent to BPC or ECMC for treatment with dismissal of charges Some defendants are sent to a state hospital with a forensic unit for restoration

33 Mental Health Defense Diminished Capacity defense can result in criminal conviction of a lower level offense Not Guilty by Reason of Insanity rarely results in acquittal

34 Resources Erie County Forensic Mental Health Service, 120 West Eagle SUNY Buffalo Forensic Psychiatry Division

35 Selected References Roskes, Erik, MD: Assisting Inmates in Transitioning Back to Their Communities Tamburello, Anthony, MD, FAPA: Assessment and Prescribing in Correctional Settings 2014 Torrey, EF et al: The Treatment of Persons With Mental Illness in Prisons and Jails: A State Survey 2014

36 Selected References Anasseril, David, M.D: Care of the Mentally Ill in Prisons: Challenges and Solutions 2007