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Dr. Keith Courtney, chief psychiatrist at Clark County Detention Center, talks to an inmate in June 2009. Once out of jail, many former inmates either avoid, or have nowhere to go for, needed treatment.
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
Sun Archives
- 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.”
Treatment for the mentally ill is much less costly than incarceration. This is a proven fact. The Department of Corrections has the second largest budget in the state, the first being education, which is also lacking.
It would make financial sense to spend those dollars treating the mentally ill, and the excess could be used for education.
Legislators take note.
This article states:
"The June issue of Psychiatric Services magazine focused on the issue and concluded, "jailing is failing people with mental illness."
The truth in America and more importantly in Clark County is that "jailing most people fail in helping the inmate or protecting our society from future actions"
Most of these inmates need a chance to make a choice that will help them in the future by preparing them to find an occupation outside of crime. I would like to see the "trade" unions sending in their education teams to train these men and women. I would like to see reduced sentences for those that completed a year of "state approved training program"... they need to see the future that will employ them beyond being a 30 year old busboy in a kitchen or working in a laundry room.
Most people want to succeed, and will if given a chance. But if you were derailed during the standard educational years (K- grade 12) it is almost impossible to get back on track. We need to offer a second chance of education if we really ever hope to stop building more and more prisons or mental health facilities.
We cannot afford special education and treatment programs for each and every (diagnosed) mentally ill offender. Those programs are free and available to everyone - every non-criminal.
davindwayneosedach,
How do these "free" programs help anyone who has become a criminal because they are mentally ill and can't conform to rules of society and therefore become criminals?
Also, we can afford treament programs. They are much less expensive than incarceration. If we can afford to incarcerate them, we can certainly afford to treat their illness and help them to be productive members of society, instead of a drain on our tax dollars.
The interview that 'health insurance companies' don't want you to see.
http://www.pbs.org/moyers/journal/071020...
This interview with a health insurance executive is the evidence Americans need to phone, email & write to our congress and demand our rights to a better health care system. (one that includes a government option- this is what the health insurance companies don't want, because it will drain their profits)
please forward this, it's serious! (in fact it's deadly serious) 18,000 Americans die each year because of no health care insurance or because insurance was canceled.
I would rather have a government health care option that has a goal of preventing me from getting sick, rather than the current system where insurance companies stand between me and my doctor. Believe it or not, EVERYONE in the USA is only a paycheck away from losing their health insurance coverage. That has to stop.
Please watch this interview and it will motivate you to forward to your friends & family.
Treatment, not incarceraton.
Treatment works and is less expensive. Incarceration (warehousing) does not.
Health care for all.
Stop war, guns and bombs overseas.
Then, we'll have the bucks to clean up our own back yard.
The 1995 truth in sentencing mentality of locking them up and throwing away the key has come back and bite the taxpayers in the rear. Treatment is what is needed not prison.
thanks liberals.
hey, tonja...if treatment works...like all you bleeding hearts think it does...would you be willing to let a convicted rapist live in your house?
no stevem......the typical liberal line of thinking is , we will mandate it....the taxes of the working class will be forced to pay for it...when it doesnt work we will throw more money at it....but dont put it in my neighborhood.....it is good for others , but not me
It's about time someone starts to look into the issue of the mentally ill in jails and prisons in this state. In the prisons, the mentally ill are thrown into solitary confinement, beaten and gassed because of behaviors they are not even capable of controlling. I don't know why the ACLU does not file a lawsuit on behalf of the mentally ill in Nevada prisons. They are many and they not only go untreated, but they get worse due to the abuse they suffer. Then they are released to the streets. Great plan, huh?
We already "throw money" at the problem, but we do it in a way that has no rehabilitative effect. Public officials have a responsibility to demonstrate that there is a cost benefit in doing the right thing here.
I'm pleased to view many of the comments today on the mentally ill, the homeless and the forgotten ones in today's society.
Many of these persons have been tax payers, and some have fought our wars, but as a nation--we have forgotten them.
If this country would stop feeding the Prison Industrial Complex, and wake up to the fact we need to help our citizens, maybe this country wouldn't be in the mess we are currently in.
Our Nevada legislators have been in a coma when it comes to being a helping hand to our citizens, and the governor is a fool. They spend millions of dollars on getting elected, but for what end. It isn't for helping the unfortunate of our state. However, it does them much good. I don't know a poor one!
Our jails and prisons are filled with the mentally ill. Yet,we continue to feed the prisons our castoffs. There is no help in the prison system for our mentally ill. There is however a detention cell used 24/7 hours a day to house them. What is the prisons and the state going to do for them? Nothing, when they let prisoners rot to death--human beings who need medical attention--not a prison cell. We pour millions into this obscene department of corrections, and for what? The department of corrections is a sump hole, filled by our dollars to keep favorite persons employed. There is no help in the prisons--for anyone!
Demand better from our foolish governor, and see what happens. I'll guarantee you no response.
It is time the legislature, the governor, and the prison commissioners get it straight. Our money to them for these filthy facilities need to give the citizens their moneys worth.
A man or woman in need of mental health is not going to come out of prison healed as the state believes. They should be given medical treatment so they come come home a whole person.
It is time to make the administrators of this state wake up and do the right thing. You are disgrace to the human race, and complement the Russian Gulags, Abu Ghraibs and all the other third world prison systems. Aren't we proud?
As a former Nevada State Corrections officer for almost 16 years I have seen many individuals that everyone would classify as mentally ill. In fact, I had a situation that shots were fired inside the unit that I worked in. The reason was the said inmate was not taking his medication. As an officer we are not trained to deal with people that were and are mentally ill.
It is a tragedy that many people here on the site do not understand what is happening to all of us. What if it was me. People get angry at people that may not have all the paddles going at the same speed. We are all human beings and some people are a little different.
That being said things can be done when it comes to the street cop to the corrections officer working in the prisons and of course to the judge on the bench. It's called training. That is a fist step of many steps.
LasVegas2009,
Where is your compassion? There are many people who cannot take care of themselves, the elderly, the very young and yes people who are mentally ill. Some of these people have served society and are now unable to. So your answer is to take their lives?
I find your words to be nothing but spewing anger and frustration. Have you thought of counseling? You must be suffering from a mental illness. How else could you so callously condemn so many to such a fate?
lasvegas2009 and stevem;
Not only are you morally out of bounds, you simply cannot see the forest for the trees.
It is more COST EFFECTIVE to treat the mentally ill BEFORE they commit crimes and go to jail/prison. And if you don't think it's also the right thing to do, you are missing some essential human ingredient.
Rejeco....your a fool....you prove it weekly......we closed the hospitals becuase they were horrible places now we have the jail and the jails in my view are the best place IF? the intergrate services..this stop gap stuuf we are doing is not good cops are not counselors and nor should they be make the units staffed with trained people...but medicating people into submission is not an solution either
HALF OF THE INMATES ARE MENTALLY ILL! IF THEY AREN'T STARTING OUT, THEY WILL BE AFTER A FEW YEARS OF ISOLATION FROM THE REST OF THE WORLD. SAD THING IS NO ONE CARES, AND IT KEEPS ON GOING LIKE A DIE HARD BATTERY. WHEN YOU ONLY GET ONE TO 2 HOURS OF DEFENSE BY A PUBLIC DEFENDER, AND YOU ARE POOR, THEN YOU WILL GO TO PRISON, WHEITHER YOU ARE INNOCENT, OR NOT. IT HAS BECOME A BUSINESS IN NEVADA. CASINOS, PRISONS, AND WAREHOUSES, IN THAT ORDER, ARE THE NUMBER THREE BUSINESSES IN NEVADA.
Good story. Thanks.
Many of our law enforcement person's interactions with the public are with mentally unstable people. Better care for the mentally ill would reduce the burden on the police and allow them to focus on crime and public service.
Lots of us are sick. Better health care makes us a better society.
My son is mentaly ill, if it wasn't for the CIT officers, who have been trained by metro to deal with people in crisis, my son would have ended up in jail numerous times when what he needed was mental health care.I have to commend the officers who have this training and show the care, compasion and commitment to the mentally ill.
unfortuantely, the powers to be often lack the awareness necessary to understand that mental illness is a disease and not a choice. It is a disease like all others.
85 percent of the mentally ill also have co-occurring issues which cause them to self medicate. They are not worthless drug addicts. They are sick people that need resources to get well to lead productive lives in the community.
Jail teaches those who are not criminals how to be, but the trade off is they get the care that they need. Jails can't say we have no room, you can't stay here, you are a drug addict, you don't get medicine, etc.
Why is it that we don't assist those that are mentally ill get the care that they need rather than criminalizing them.
In the end it would be less expensive and more theraputic than putting them in jail.
Let's allow these individuals the dignity that they deserve!
I too have a family member that is mentally ill. He has been diagnosed with bipolar, aspergers, anxiety disorder,and co-occurring substance abuse. He has attempted suicide on 3 occassions, once hanging himself and almost completing the attempt. He was hospitalized, but due to overcrowding, was not kept in the hospital long enough to truly be stable on his medications. When being released, I said, he has no where to go, I was told that its not a crime to be homeless. It does however create crime. I believe everyone wants shelter and food.
Unfortunately, due to overcrowding and lack of resources, the mentally ill don't get the care they require or deserve. Nevada according to Nami, has a D- rating for mental health care. Would you bring your child who had a heart problem to a state with a rating of D- for that care?
I was also told have him complete the paperwork for social security, it will help him with medical care and housing. Have you ever seen those forms? I don't believe anyone who is mentally ill could complete them without assistance.
There have been a few changes, Metro, thanks to Asistant Sheriff Moody provided CIT training. At one time, it was uncomfortable to call the police, as I knew he was going to jail when what he needed was mental health care. Now, with the trained CIT officers, care and compassion, my son is taken to the hospital to get the care he needs.
Jails are a representation of the community, if 20 percent of the jal population is mentally ill, what is out in the community. Why is it that jails have become the de-facto mental health care facilities? why are we criminalizing someone for being ill? Mental illness is a disease not a choice, they aren't worthless drug addicts. Why can't we get the help for these people that they need and deserve?
Wouldn't it make more sense to provide treatment centers for co-occurring issues, job skills training, it would be less expensive, it would reduce crime, and it would give people the dignity that they deserve to live productive lives in the community.
I find it hard to believe that the people making the decisions aren't aware. What I fear is they don't care.