Thursday, January 11, 2007

My Big Fat Hissy-Fit

[Note: I sat on this post for a day to cool down and think about it. The title has been changed three times and I also removed a few triple exclamation marks. I've downgraded my rant from a Category IV to a Category II.]

I am about to have a screaming banchee hissy-fit. Consider yourself warned. I've been blogging for almost nine months now and so far have never gone on a full-fledged, died-in-the-wool rant. I am about to make up for lost time.

The topic is an article on CNN that was just posted an hour ago. It's a story about a New England Journal of Medicine paper regarding mortality rates of prisoners who have just been released. I haven't seen the full article yet, but as reported it involved "26,270 men and 3,967 women released from Washington state prisons from mid-1999 through 2003". It doesn't say how the causes of death were confirmed, but the study found that newly released offenders were 3.5 times more likely to die within two weeks of release than an age, race and sex-based comparison group. The most common cause of death was overdose followed by cardiac disease, homicide and suicide.

To all of this I say: "No kidding! How much money did you spend figuring this out?" We knew twenty years ago that incarceration had some protective effect. In 1987 the Johns Hopkins School of Public Health looked at mortality rates among Maryland prisoners and found that age-matched prisoners actually lived longer than men out in free society. The CNN article also noted that the increase in post-release death rates were replicated in studies done in Europe and Australia.

What am I ranting about? It's this except here:
Other experts said the results don't surprise them, because inmates have far more physical and mental health problems than other citizens, (and) often get inadequate treatment behind bars...
There ya go. It's obvious, isn't it? If they're locked up then by definition they are getting inadequate care. It's axiomatic. It's also a knee-jerk stereotype.

Excuse me? Didn't you just say that they die after they get out? Who do you think has been keeping them alive all those months? Are you about to suggest that every patient who dies after discharge from a hospital was obviously neglected while they were inpatient? What planet are you on?

The thing they aren't mentioning is that they have no way of knowing how long the offenders would have lived had they not been incarcerated. These people live dangerous, high risk lifestyles. They annoy other criminals and get murdered. They kill themselves. While they are incarcerated we generally manage to keep all of that from happening. I don't like reading about my patients in the newspaper when they turn up dead after release, but it happens. I really don't like it when people suggest it's because I didn't do a good enough job while they were inside.

The only useful thing about this article that I liked was the conclusion:

Rather than saddling emergency rooms (and taxpayers) with the cost of providing post-release health care, we need to find a model of continuing care for ex-offenders.

Amen. And when we get that accomplished we will have a model for the rest of free society. Ya gotta start somewhere.

Thanks. I feel better.

Addendum: The print version of this story that came out later that day did not include that aggravating phrase. Instead, it concluded this:
Cause (of death) often is overdose of narcotics after forced clean years, study finds
In other words, they lose their tolerance for drugs when they're locked up and so they are more likely to die of accidental overdose when they relapse after release.


Dr. A said...

Thanks so much for saying this. I was getting ready to write a rant of my own on this topic. I'm glad I read yours first. Better than the pathetic post I would have written. Well done!

Steve & Barb said...

What I hear from them after being released is that they were not set up with aftercare, ran out of meds, and decompensated (or relapsed, or both). Clink, do you guys routinely set up aftercare before release?

Dinah said...

What did we do before the blog? It's good the inmates have Clink to love them and keep them alive...

ClinkShrink said...

The medical provider typically isn't notified about a release until the day of release. The mental health provider is never notified about release dates.

The way I handle these situations is find out from the inmate when he is getting out then time my appointments so that he will have a fresh medication order that will be filled just prior to release. Then all the inmate has to do is notify the pharmacy of his release date and they will package up his meds. (By law you can't release them with pill cards. Any release meds have to be packaged in bottles with proper labels.) The inmates can't carry the bottles with them during the release process, but if they wait at the door after release the med nurse can come down and hand off the bottles. If they get released from court then the inmate has to come back to the facility to pick up the meds. Meds are usually held for a couple days after release before being returned to the pharmacy. Most inmates don't want to wait or return. Thus, no meds. I've also occasionally given out my office number to call in prescriptions if needed, but only a handful of inmates have ever taken me up on that.

Regarding aftercare, I usually provide information about whatever treatment resources I know about---which is pretty much limited to Charm City. If it's a jurisdiction I don't know I usually tell them to call the local health department or the First Call For Help number. I don't make their appointments for them.

Dinah said...

So, no.
Somehow I can't imagine that any released prisoner, ever, has called their local health department to ask how to obtain ongoing mental health care. I'd be more shocked if the person at the other end of the line was able to help the former inmate negotiate such care, though I'm sure that's just a function of who you get on the line and what mood they're in; my cynacism of the moment ranting. "Go to the ER" might actually be better advice (I cringe at saying this, and Flea would die, and the ER psych folks would kill me, but from the ER one might actually get a few days of refills and even an appointment made for them-- which this impulsive crew may or may not keep.

Maybe you could make up a sheet to be given to every prisoner upon release: How to Get Mental Health Care, with a zip-code "If you live here, call this number". Maybe even a listing of These Are Your Medical Conditions and These are the Medications (with dosages) that you received. Amazing how many inmates get that little white pill.

ClinkShrink said...

Dinah, they get that already. And I'm not sure how you can take my two paragraphs explaining release mechanisms and summarize it into "so, they don't get any aftercare planning."

Yes, it's up to the inmate to make their own appointments. That's ALL they have to do.

Steve & Barb said...

Clink, I have to agree with Dinah. I concluded that the answer to my question ("do you guys routinely set up aftercare before release?") is no.

For pts in hospital, we attempt to arrange an appointment before discharge. We have both a social worker and discharge coordinator, whose function is to ensure aftercare is arranged. If we leave it solely to our pts, it usually won't get done.

Dinah, time for my rant (guys don't have hissy-fits, but might eat quiche). You correctly predicted that us ER-types would not appreciate your referral of these pts to the ED for refills. Unless pts have aftercare already arranged, and the provider can be contacted in the ED, we generally do NOT give scripts. Why? These pts need follow-up, and it is risky to give a one-week rx for Prozac without any plan for follow-up. We do give them a list of people to call, the same list they'd get calling a warmline.

Here's a more typical scenario of what happens:

Patient: "Dr Dinah told me to come here for prescriptions. I just got out of jail, and I couldn't wait for Dr Clink to get my prescriptions. I ran out 3 days ago."

ER: "You'll have to call your doctor. We don't do that here."

P (knowing how to get their attention): "If you don't help me, I'll kill myself."

ER: "This is Mr. Jones. He'll escort you to our psych area."

P: "Never mind. Just let me leave!"

ER: "You have to stay to be evaluated to see if you're safe."

P: [starts to storm off]

ER: [in walkie-talkie] "Security to Triage. Stat!"

... and so on. ER's are for Emergencies. If you've ever tried to get something routine done in an ER, you'd know what I mean.

Dinah said...

The Ravens are losing at half-time. I may need to bring husband to ER.

At the ER in MajorHospitalCenter (a Fat Doctorism), there are emergency slots held in Outpatient CMHC for ER patients, so that ER can dispose of such patients. Possible that said patient could be given an appointment within a day or two at clinic. I don't know if this persists, lots of changes lately in what insurance clinic can take, if pts need to be in or out of catchment areas, or even if clinic continues to hold slots for ER pts, but given that we're talking about a life-or-death situation for these immediate ex-inmates, really, I think an emergent hospitalization and hook-in to care is a better outcome then death. I'm really against premature death, especially from preventable behavioral/psychiatric issues in young people, just so you know.

Another issue, people often lose their insurance/disability while they are in jail and then they Can't fill those scripts for the super expensive meds we give them.

ClinkShrink said...

OK, so in an ER you do the same release planning that I do with the exception that you don't release them with meds.

Medications are available from the facility at the time of release---they just have to pick them up or call me for a script if they run out. You also give a list of referral resources but don't make appointments for them. Correctional facilities are not hospitals and should not be held to the same standard. An ex-offender in free society has more resources for arranging aftercare than I do. In two of my three work sites I don't even have a telephone much less a social worker or discharge planner.

I don't see that your ER scenario for release planning is that much different from mine.

Remember too that these guys are responsible for (and do) many other required things in free society that aren't set up by the facility: report for court dates, report for urine screens, report for substance abuse treatment (if available) and report for parole hearings. It would be a bit odd to suggest that a clinic appointment should be any different than these other things that they are expected do on their own.

Dinah said...

Oh, and my ideas are just random shrink theory, I don't think you ever have to worry that I'll be in the clinker sending patients to Your ER.. Go see Dr. Roy, he fixes everyone!

Dinah said...

so all 3 of us are blogging during the football game; warms my shrinky heart.

Actually, I'm against making appointments for anyone anywhere unless you're the person who's going to carry them to the appointment. Made appointments don't get kept and stretch the resouces of stretched staff at facilities. As a clinic medical director, I used to have a requirement that folks come in for an intake interview to screen out those who wouldn't show up. The intake times (anyone who called was given a list of the times, twice a week, first-come first serve, so no one waited more than 2 days) was staffed by a psychiatrist who just triaged. Quick screen and an appointment for a full-eval, but the shrink could choose to provide an emergency refill, to EP someone, or if only one person showed up, to simply do a full psych eval. I wish I could say it decreased our subsequent no-show rate, but I don't think it did.

ClinkShrink said...

This blog is really cutting into my Ravens time. Can't say the game is going well but I've loved the commercials.

I like the triage system you set up in your clinic Dinah.

I think the heart of the ex-offender ER visits is the problem getting scheduled aftercare in general. The thinking of the inmates appears to be (from what they tell me): "I don't have insurance. I'm not on disability and I can't afford a doctor. Why bother going out with medications that I know I won't be able to keep taking?" So they don't take their meds with them and eventually realize they need them. I've had guys refuse treatment right up front with the explanation: "I can't afford this when I get out, why start treatment now?" I have no answer to that.

We really need some type of forensic outpatient component. California has mental health parole but I'm not sure I like that idea because it involves coercion with patients who don't necessarily need to be coerced. There's also the privacy & dual agency issues for those providing care. But that's the closest model we have right now I think.

And thank both of you for bringing this up on the blog instead of on a podcast. It's such a hot topic that I really would need to talk.

Dinah said...

You, however, have health insurance and can afford private care. Yell if you need a referral. Talking is good.

Sarebear said...

Clink! Don't feel like you can't talk on the podcasts! On any subject, but especially your expertise!

I like hearing all of you guys anyway.

ClinkShrink said...

Bless you Sarebear.

I may need that referral & health insurance Dinah---running a 101.8 temp here.

Sarebear said...

Oh no. Don't tell me you have that nasty flu that's going around. I'm just over that (with a horrid lingering chest cough!!!).

I had a fever for 7 days, ugh.

I sure hope you don't have that!

a new kind of transference through the blog - flu viruses. hee hee! (to the tttb, not to the flu.

sophizo said...

OMG!!! This is hilarious! You three know each other and see each other, but you decide to debate this issue on the blog. I can't help but get a chuckle out of that. Ha! This is such a podcast topic, I'm surprised you guys are still debating it rather than putting the topic on hold until you are all together and recording.

(person formally known as Jennifer) Ok...I'm still known as Jennifer. I just decided to finally come clean with one of my alter egos. ;-)