Why Are Inmates Dying?

In yesterday's New York Times there was a story by Erin Banco called Suicides Worry Experts at Big Jail in Capital. The story talks about four deaths at the DC jail this year and the general worrying trend of increasing correctional suicides nationally. The article speculates that the deaths may be attributed to lack of adequate mental health staffing or deficiencies in the jails' observation practices. Some of the people interviewed for the story linked the deaths to cutbacks in state mental health budgets.

Correctional suicide is an area that, as Dinah would put it, is a "Clink" thing---a topic I've been interested in for a number of years. I wrote about this three years ago in an article called Correctional Suicide: Has Progress Ended? In my article I pointed out that nationally we seemed to have hit a "floor" with regard to suicide prevention---rates had been declining consistently over the years until a recent plateau. I wrote about what I thought might be the cause of that plateau: the Prison Litigation Reform Act which limited prisoner access to the courts and circumscribed how far courts could intervene to improve prison and jail conditions,  as well as changes in the profile of the typical correctional suicide, and the increasing problem of gang violence and intimidation in corrections.

What was most striking for me then was the fact that correctional suicide studies are starting to show increasing numbers of inmates who die from suicide without any previous mental health history or history of suicide attempts. I coined the term for this phenomenon a "clean" suicide---one that could not have been picked up or prevented through currently accepted screening methods and referral protocols. The New York Times article didn't address this, but I couldn't help wondering if the deaths in the DC jail might fall into this category.

What I didn't mention in my earlier paper---because the numbers weren't out yet---was that the increase in jail and prison deaths may reflect a larger trend in rising national suicides. According to the CDC, the age-adjusted death rate for suicide has increased by 8.7 percent since 2000. The other new data comes from the recent Department of Justice report on inmate sexual victimization and abuse. According to this national survey, being a sex offender increases the by other inmates. The Washington Post has reported that three of the four DC jail deaths were by detainees who were charged with sex offenses.

The Times may be correct that cutbacks in state mental health budgets have had an effect, but this does not address the fact that for many states the funding for correctional health care comes out of the public safety budget rather than the health and mental hygiene budget. State cutbacks could still play a role, just not through the route the article suggests. States with privitized correctional health budgets would also have to be examined separately to look for contractual budget changes.

So those are my thoughts about the NYT correctional suicide story. I figured I'd better get this post up fast before Dinah nudges me to write about it. (Yeah I know, I'm supposed to be re-reading the book proposal but Dinah you know I had to blog about this.)

What This Shrink Rapper Would Tell Congress

Recently one of our readers posted this comment:

“If any Shrink Rapper ever has the time and inclination it would be interesting to read about what you would do to fix the mental health system, particularly the issue of involuntary hospitalization, if you had unlimited funds and political resources. You've been in the trenches, it would be great to hear your thoughts.”

Simultaneously, over on Peter Earley’s blog I see that he is planning to testify next week before a U.S. house subcommittee regarding issues related to violence and severe mental illness. He is asking for people to contribute responses to six specific questions he expects to be asked. Please go over there and contribute your ideas---this is your chance to make a difference.

Meanwhile, I have my own thoughts about this which may or may not be directly relevant to the six questions, but I want to bring this to the attention of the subcommittee if Mr. Earley would be kind enough to include it. For those of you who want the "bottom line," I've underlined my main ideas.

First, a bit about why I think my experience and ideas are relevant.

As a forensic psychiatrist, I evaluate and treat severely mentally ill people who are or have been violent. I see the rare exceptions, the people who as a result of their disease commit acts that seriously injure or kill others. As a correctional psychiatrist I have also evaluated and treated thousands of prisoners, many of whom also have serious psychiatric disorders.

I will emphasize, as you've already heard from others, that violent offenses due to psychosis are the exception to the rule. Almost all crimes of violence are not committed by people with schizophrenia or other psychotic disorders. Drug and alcohol abuse is the culprit in most violent crimes and we must vigorously address this and do more to provide treatment to people with substance abuse problems at the time that they are willing to accept treatment.

From evaluating insanity acquittees, people who are found not criminally responsible for  their crimes due to mental illness, I’ve learned that one significant systemic problem is the lack of public awareness about psychosis and how to recognize prodromal symptoms. Often the early symptoms get written off as attributable to some other life stressor: the breakup of a relationship, the stress of a young adult's transition to college or some other understandable life event. Sadness, withdrawal from family, loss of interest in hobbies or friendships can be explained in this context. However, as the illness gets worse and the patient's personality changes, there is more recognition that something serious is going on. Friends, neighbors and teachers recognize psychosis only when there is increasing disorganization, inability to complete tasks, or eventual bizarre behavior and unusual statements.

Therefore, my first suggestion to address violence due to mental illness would be to provide better public education to recognize emerging psychosis.

Once the psychotic episode is recognized for what it is, the challenge for families then becomes figuring out what to do. Finding a psychiatrist and getting prompt evaluation and treatment is a tremendous challenge particularly in rural or underserved areas. In southwestern Minnesota where I was raised, there is only one fulltime psychiatrist serving a seven county area of 70,000 people. Our local Baltimore City Detention Center has a higher per capita number of psychiatrists than my hometown. That has to change.

My second recommendation is this: the government needs to provide increased funding for medical education, particularly the training of psychiatrists. There should be additional incentives, beyond Federal public health service commitments, to work in underserved regions or state facilities.

All of my patients are institutionalized but most will return to the community eventually. Insanity acquittees typically are hospitalized for substantially longer than they would have been incarcerated if convicted. The majority of my mentally ill offenders are convicted of misdemeanor property offenses that are drug or alcohol-related, and return to the community within months to a few years. Regardless of the length of confinement, we need better programs to transition patients from a public institution to the community. Insanity acquittees and mentally ill offenders need housing, transportation, educational and vocational programs in addition to addressing their medical and mental health needs. Lack of adequate community services and transition plans are a key factor in unnecessarily prolonged hospitalizations.

Many recent high profile crimes have lead the public to demand looser civil commitment standards and easing of laws for involuntary treatment. In my opinion, this creates an adversarial atmosphere and unnecessarily sets families in opposition to their mentally ill loved ones. People with psychiatric illnesses have legitimate reasons to oppose confinement, and we should examine these reasons thoroughly and address them.

Some public psychiatric hospitals, of the few that remain, are antiquated and dilapidated. We need to improve environmental conditions of these facilities and address the poor ventilation, bad plumbing and faulty infrastructure. The inpatient unit should emphasize treatment plans that respect a patient's educational level, skills and interests rather than focussing solely on disability. Inpatient safety and security are increasing concerns, leading some patients to be strip-searched arbitrarily. We must improve hospital security to protect both patients and staff from physical assault. As a recent story in our local newspaper indicates, concern about violence is not limited to free society and must be addressed within facilities as well.

Finally, we need to reinvigorate collaborative treatment planning through the use of psychiatric advance directives. Make them meaningful and useful. Currently patients don't trust them because they know doctors can override them. Ironically, doctors don't trust advance directives for exactly the same reason---because they can be revoked by patients. We need to update psychiatric advance directive laws to make them binding, effective and safe, then make sure treatment providers are educated about their use.

Thank you for reading this far. We can’t make the system perfect, but I’m sure we can make it better.