Sunday, July 12, 2009 | 2 a.m.
CASE STUDIES: HIGH COSTS, POOR OUTCOMES
If Nevada was willing to invest in providing more psychiatric care outside of jail, not only would it do more to help the mentally ill, it would also cost taxpayers less than arresting and incarcerating the mentally ill, experts say.
Consider the jail and medication costs for the following three mentally ill inmates — and this does not take into account the additional court costs and other bills.
Dr. Keith Courtney, chief psychiatrist at Clark County Detention Center, withheld the inmates’ names to comply with patient privacy laws.
Inmate No. 1 suffers from autism and occasional psychotic episodes. When he’s out on the street, he gets in fights, takes drugs, attempts robbery, winds up at the detention center. He has been in jail 539 days since 2006. That means taxpayers have spent about $123,000 on keeping him jailed and medicated.
Inmate No. 2 is a 20-year-old man who has spent at least 520 days behind bars, mainly for armed robberies, since coming of age two years ago. The system has spent more than $120,000 in incarceration and psychotropic medication costs, Courtney says. The young man also winds up in the hospital after suicide attempts, which costs taxpayers even more. He was raped at 15 and now hurts himself repeatedly in the same part of his body.
Inmate No. 3 is a 32-year-old woman whose 441 days behind bars cost an estimated $100,000-plus. She is a victim of severe abuse and suffers from borderline personality disorder, often attempting suicide, Courtney says. She only takes her prescribed medication when she is jailed, preferring methamphetamine when she is not. She is often arrested for prostitution, sometimes burglary.
“She’s never here long enough to get adequate care,” Courtney says. She needs a safe house, treatment for drug abuse, ongoing intensive therapy. There is no one place where she can get all that. “I fully expect her to die soon,” the doctor says with resignation.
— By Timothy Pratt
- Inmate's case raises mental health issues (1-9-2006)
- System creates delays in moving inmates to psychiatric facility (9-1-2005)
- No longer under the radar (3-25-2005)
- Mentally ill landing in jails across nation (7-12-2004)
Here he comes again, his hands covered in heavy black mittens, his head stuffed into a net that makes him look like a beekeeper, his legs and wrists closed in shackles.
Clark County Detention Center officers dress him this way because he has been known to spit, throw punches and kick.
The inmate shuffles through a sliding door, a large officer follows and, nearby, other members of the jail staff step back, as if sensing danger. The inmate, seemingly unaware, tells the officer, “I don’t want a plane crashing into me, you know.” The detention officer nods and nudges him toward an isolation cell, where the inmate will have to remove his clothes. He will be left with what’s known as a suicide blanket, which can’t be torn apart and used as a noose.
He is not yet 20, but he has been in jail three times, for 71 days, since coming of age last year.
The detention center’s chief psychiatrist, Keith Courtney, says the young man has what’s known as reactive attachment disorder. Those who suffer from the condition have trouble relating to others. It’s often a sign of early abuse.
The inmate who was moved into the isolation room doesn’t take medication for his condition when he is on the streets, but he does take illegal drugs. Then he gets in trouble and is locked up, mostly for crimes such as burglary, attempted robbery with a deadly weapon. In jail, he throws feces, attacks the staff. So he goes to one of the isolation rooms, for inmates who are a danger to themselves or others.
On a recent morning, the 19-year-old was one of 621 inmates at the detention center — of 3,066 total — diagnosed as mentally ill and prescribed psychotropic medications. That’s one in five. On some days, the ratio is closer to one in four.
By way of comparison, the state’s Rawson-Neal Psychiatric Hospital in Las Vegas has space for 204 patients.
So the jail, Courtney notes, is “the largest mental health facility in Southern Nevada.”
It is also the most expensive and least effective. Providing mental health care is not the purpose of a jail, after all.
The last hope for help
Nevada has always lagged other states in numbers of public psychiatric hospitals and clinics. But private hospitals in the Las Vegas Valley began closing their psychiatric wings in the 1980s. Jails have become the last hope for help, leading to a cycle of futility.
Psychologically troubled people who commit crimes are brought to the jail, where they are held, evaluated and medicated — and eventually returned to the streets, where they either stop taking the drugs that eased their troubles in jail or lose access to those drugs. Ongoing, intensive therapy is even more scarce. Their minds unravel again, they commit new crimes, go back to jail and the cycle continues.
The word for a system like this is “crazy.”
To be sure, Nevada is not alone in experiencing this problem. Most states closed public mental hospitals in recent decades, leaving many mentally ill patients to fend for themselves. The valley had none to close when this was happening, but the same thing occurred with private hospitals. Many states, however, have taken steps to break the cycle of crime, jail, treatment and release. Nevada has not.
The county spends $4 million a year on psychiatric treatment at the jail. It costs taxpayers $142 a day to keep an inmate at the jail and $85 on average to medicate each one diagnosed as mentally ill.
The inmate in the isolation room, for example, has cost the system at least $32,000 in the past year alone, which easily could have paid for his psychiatric care outside of prison.
Other costs, such as the cost society pays for their crimes, are harder to figure.
For many of the mentally ill behind bars, the doctor says, “there is a significant connection between their mental illness and their crimes.”
Courtney says most of the inmates with mental illnesses aren’t locked up long enough to get adequate care. And there is almost nowhere to send them outside the detention center’s walls. So their conditions will likely lead them to commit more crimes and be arrested again and again.
The result: Nevada taxpayers spend untold millions on incarcerating and temporarily caring for the mentally ill, the public suffers their crimes, and the mentally ill suffer their conditions, their lives becoming one long sentence in a prison of the mind.
Courtney points out that only four members of his staff of 13 can prescribe medications, a difficult situation when they are faced with hundreds of inmates. He notes that the most severely mentally ill among the prison’s population are “some of the sickest people in the city.” They are bipolar, schizophrenic, paranoid, delusional. In the absence of adequate care, many medicate themselves on the streets with drugs such as methamphetamine, or cocaine.
A rare case of success
Down a series of halls, in an auditorium-sized open room, some inmates shuffle around the 74 cots lined in rows. Others sit at a table playing cards or pop in and out of an adjacent room with a basketball hoop. About 20 of the 74 men who sleep in this unit are on psychotropic medications.
Down more halls, around more corners, another unit has separate cells with doors, a sign that the inmates housed there have more severe mental illnesses. A young, bearded inmate stands outside his cell, hand outstretched. He is in jail because, in a psychotic rage, he attacked a member of his family with a knife. “I thought people were trying to kill me,” he explains, slumping into a chair, his hands held together.
The soft-spoken inmate’s case appears to be the rare example of a mentally ill person’s life taking a turn for the better inside the system. Courtney has landed him one of the few spots in the Eighth District’s Mental Health Court, a program to substitute treatment for incarceration. The road that led to the mental health court, however, is typical of the path many have taken, slipping in and out of treatment, in and out of drugs, increasingly violent. Now barely out of his teens, the inmate took LSD when he was 17 and began hearing voices shortly afterward. He wound up at Monte Vista, a private psychiatric hospital, where he was an inpatient for a week and an outpatient for a month. But the medication that doctors prescribed knocked him out. He stopped taking it. He took cocaine instead. The voices got worse. He went back to a psychiatrist. But after one visit, he was at home and the voices started up again.
“I thought that what I was thinking was real,” he says calmly. Now, after a year behind bars, he says, “I didn’t get help until I got here.” The doctors at the jail worked through two prescriptions until they found a third medication that finally helped stabilize his mind.
And just as important, Courtney worked to develop a relationship with the young man. Recently, the inmate spoke to his mother for the first time since he was arrested.
Courtney hopes that when the young man gets out of jail, he gets into a Salvation Army-run program that includes group therapy. He has plans to attend college.
The inmate says he is certain of one thing. “I’m going to have to take medication for the rest of my life. If I don’t, it all comes slowly back.”
He says he wishes it was easier for people like him to get help, to know when something is really wrong.
Courtney says his case is an example of “when the system works right, when someone who’s mentally ill can be diverted to care in the community. But in my mind, he’s the minority.” Especially, he notes, because the Mental Health Court only has 75 slots.
A need for prevention
Metro Police Lt. Frank Reagan works at the detention center and serves as chairman of a coalition of mental health professionals that recently regrouped after several years of not meeting. At the beginning of its first meeting last month, Reagan urged the coalition to seek solutions to the large number of mentally ill inmates.
Reagan adds that public mental health care — the only choice for most inmates when they’re released because they lack health insurance — is often placed on the chopping block when states suffer budget crises — and based on what he sees at the jail, that’s a major mistake.
“We need to have preventive care, to maintain the mentally ill population as stable when they’re out of custody,” he says.
Stuart J. Ghertner, outpatient services agency director at Southern Nevada Adult Mental Health Services, says the state agency’s budget has been cut 15 percent this year. He points out that there tends to be two broad categories of people who wind up in jail instead of in treatment, and neither can find adequate care in the state system or the community at large.
One group usually has less severe conditions, such as depression, is often homeless and winds up arrested for such misdemeanors as trespassing or urinating in public.
Courtney had just seen a 70-year-old homeless man on the morning the Sun was allowed into the jail. The elderly man repeatedly gets arrested for such petty crimes and has nowhere to get treatment once he is released.
Ghertner’s other group winds up in the same unit as the inmate who attacked a member of his family, or in one of the isolation rooms. They suffer more severe mental illnesses and commit more severe crimes. Of course, the notion is a moving target, and the same person can belong to each group at different times.
But the point is the same, Ghertner says: The Las Vegas Valley doesn’t have enough hospital beds for the mentally ill, and the outpatient system is imperfect at best. Of the 8,000 outpatient clients the state sees at its four clinics, about 15 percent are homeless, he says.
“They lose contact with what care and services are available. These folks don’t always make appointments.” Then they “get in trouble on the streets” and wind up back in jail.
The more severely mentally ill with histories of violence also lack options. Many of them are also addicted to drugs or alcohol, “co-occurring disorders.” The state recently contracted with a private firm to open the first facility for treating the two problems together, but it has only 10 slots.
Rosanna Esposito, interim executive director of the Treatment Advocacy Center, an Arlington, Va.-based nonprofit organization, said one key way Nevada lags most of the nation is that it has yet to pass a law that would allow family or doctors to petition a special court to mandate outpatient treatment for mentally ill people with a history of avoiding treatment. The idea is to have a way to force people into treatment before they commit crimes or hurt themselves or others. Variations on this have become law in 43 states, and those laws have helped get people off the justice system treadmill and into clinics.
Many states passed their laws at least a decade ago, so Nevada “is far behind the curve,” Esposito says.
Lesley R. Dickson, past president and current treasurer of the Nevada Psychiatric Association, points to another ignominy: Nevada has 6.2 psychiatrists per 100,000 people, a rate that places the state 46th in the nation, the governor’s task force on health noted earlier this year.
So the state starts at a disadvantage because “we have nowhere near enough care,” Dickson says.
Whether it is through funding more hospitals, clinics or psychiatrists, making better use of existing services, or passing laws that mandate care, a consensus is building that communities must seek alternatives to incarcerating the mentally ill. The June issue of Psychiatric Services magazine focused on the issue and concluded, “jailing is failing people with mental illness.”
Ghertner belongs to the same local coalition as Reagan, but he is skeptical about the group having enough clout to effect the necessary budgetary or legislative change in Nevada.
“The movers and shakers need to get organized ... and sit down and do some long-range planning,” he says.
Esposito is sharper-edged. “We know that treatment works,” she says. “It’s only because of a lack of will and due to bad policy that the treatment isn’t available.”