Submitted by Charlton Stanley (Otteray Scribe) guest blogger

What is wrong with this picture?  According to figures obtained from the Department of Justice, the National Alliance for the Mentally Ill (NAMI) reports that back in 1999, sixteen percent of the prisoners in State and Federal jails and prisons had a diagnosable major mental illness. These diagnoses include schizophrenia, bipolar disorder, major depressive disorder, or some other mental illness that can be classified as “severe.” Based on the number of known prisoners, this means there were roughly 283,000 persons with severe mental illnesses locked up in Federal and State correctional facilities, and that was 13 years ago. It has gotten worse since then. At the end of 2011, 2,266,800 adults and approximately 71,000 juveniles were incarcerated in Federal and State prisons, and jails.  That is 2,337,800 incarcerated inmates. If the sixteen percent figure holds, and there is no reason to believe it hasn’t, there are now about 374,000 mentally ill inmates in correctional facilities. “Correctional facility” is an oxymoron when it comes to providing treatment.  According to both law enforcement and mental health groups, the percentage of mentally ill being locked up is growing, not decreasing.

By way of contrast, public psychiatric hospitals have a patient population of 70,000 with similar severe mental illnesses. Want to know something else scary? Thirty percent of those patients are classified as forensic patients. They are awaiting trial, or so in need of treatment the prison system cannot cope with them. This was something I saw when I worked at the Mississippi State Hospital on the forensic unit. We would get prisoners from the State Department of Corrections that could not be managed adequately on the psychiatric unit at the penitentiary. Almost all State and Federal correctional facilities now have special units for the mentally ill, or with mental or physical handicaps. County jails nationwide do not usually provide mental health care at anything more than the most superficial level.

Furthermore, law enforcement officers are increasingly becoming first responders to people with severe mental illnesses in crisis. That is not working out very well for the police or the public, as we have seen in numerous stories reported on this blog. I talk to many sheriffs who are both angry and frustrated their jails are filling up with the mentally ill. They do not have the trained staff or the facilities needed to care for the mentally ill. At the same time, access to mental hospitals is becoming increasingly difficult.

Starting about 1955, a social movement began to “deinstitutionalize” the mentally ill. This movement was based more on political correctness than sound public policy.  Proponents of the movement, nor the operators of mental hospitals, offered a sound treatment alternative for patients released onto the street. When I went to work at the Mississippi State Hospital in 1972, the total inpatient census was 4,400.  Getting a patient into the hospital was no big deal, and most patients did not stay more than three weeks or so. There were long-term care wards for patients who were too ill and too resistant to treatment to be released, and some of those patients had been there for years. Most of those patients had no place to go upon release.  When I left the hospital ten years later, the total patient census was only 1,600.  At the same time, jails began filling up with former patients. We began seeing many of the same people who had been released recently funneled back through the forensic unit for pre-trial evaluations. The ones who survived, that is. That is another story for another day. Some patients didn’t even live long enough to get into legal trouble.

The Federal government singled out public mental hospitals for denial of Medicaid payments. However, Medicaid would be paid to privately owned and operated nursing homes and other group homes. The hidden agenda behind this was to speed the destruction of state-run mental hospitals. Well, I have news. It worked. According to NAMI:

• Since 1960, more than 90 percent of state psychiatric hospital beds have been eliminated. In 1955, there were 559,000 individuals with serious brain disorders in state psychiatric hospitals. Today, there are less than 70,000. Based on the nation’s population increase between 1955 and 1996 from 166 million to 265 million, if there were the same number of patients per capita in the hospitals today as there were in 1955, their total number today would be 893,000.

• The pace of psychiatric hospital closures has accelerated. In the 1990’s, 44 state psychiatric hospitals closed their doors, more closings than in the previous two decades combined. Nearly half of state psychiatric hospital beds closed between 1990 and 2000.

In Tennessee, Lakeshore Mental Health Institute in Knoxville closed its doors for the last time in 2012. That means inpatient care for all those Lakeshore patients is now dumped on the three East Tennessee acute-care psychiatric hospitals: Peninsula in Knoxville, Ridgeview Psychiatric Hospital in Oak Ridge and Woodridge in Johnson City.  This, despite the fact that all those facilities are for short-term care only.  Mental patients who will not, or cannot, be treated at any of those facilities have to depend on mental health centers. Whose bright idea is this?  State Commissioner of Mental Health Douglas Varney. Doug Varney is the former CEO of Frontier Health, one of the largest mental health centers in the area, with an annual budget in excess of fifty million dollars. They serve, where else? East Tennessee and southwest Virginia.

As all these patients began being dumped into the communities around the country, something new we had not seen before began to emerge. Bag ladies. Homelessness. Increased crime. At the time I left the Mississippi State Hospital at Whitfield, I was consulting with law enforcement agencies all over the state, including the State Attorney General’s Office.  The situation got worse, literally by the day. Then in the early 1990s, something else changed. Remember when Hillary Clinton proposed reforming health care insurance? There was an intensive ad campaign by the insurance industry about patients not being able to choose their own doctors.  Ms. Clinton’s plan was shot down in ignominious defeat. The smoke from that had not even cleared before something called “managed care” was instituted by the insurance industry. It is still with us.

Mental health providers (psychiatrists, psychologists, counselors and clinical social workers) were reimbursed at only 50% the normal rate as other specialists.  Not only that, most managed care plans limit providers to six visits.  Very few psychiatrists or psychologists outside mental health centers accept health insurance these days. Pay at the door, and you can file your own insurance claim.

I knew traditional mental health treatment was nearing an end when I got a frantic phone call from the psychiatrist in charge of the Dual Diagnosis Unit at one of the private psychiatric hospitals where I was on the staff. Dual Diagnosis is for treatment of patients who have an addiction problem in addition to an overlying mental illness. I had just walked in my office at 8:00 AM when the phone rang. The conversation went like this:

Dr. Bill the Psychiatrist: “Chuck, I need you to see a new patient for an evaluation right away.  I need some psychological testing to get a better handle on just how sick this patient is.”

Me: “Be glad to, Bill, when was he admitted?”

Bill: “Last night at 7:00.” 

Me: “OK, but I’d like to wait a day to let him settle in. He hasn’t had time to find the bathroom yet. We both know it is stressful to be admitted to the hospital, and I would like to give him a little time to get used to being there.”

Bill: “No, no. I need him seen this morning. He came in with a provisional diagnosis of cocaine addiction and a major depression. He is seriously suicidal.”

Me: “OK, in that case I will come over and see him this morning.”

Bill: “I need your written report by 1:00.”

Me: “What? How come you need the final report by one o’clock?

Bill: “We are going to staff his case at one o’clock, and I will need you here then. His insurance only allowed a 23-hour admission, and I have to let him go by six this afternoon.”

Me: “Say what!?! They gave you one day to cure a coke addiction and suicidal depression?”

Bill: “Yup. It’s getting worse. They didn’t want him admitted at all; they wanted me to see him for six outpatient visits, but I did manage to get him admitted for one day.”

As an example, I had a worker’s compensation case in the mid-1990s. The patient was a Vietnam veteran, who had sustained a significant back injury at work, causing chronic pain. In addition to preexisting PTSD from combat, he was both depressed and angry over his present situation. He was not able to work, and was about to lose his home. Needless to say, with the insurance balking on paying any of his doctors, that added to his frustration, which was reaching the boiling point.  I continued to see him, because as fragile as he was, the risk of abandoning him as a patient trumped not being paid by a wide margin.  His insurance adjuster was refusing to pay our office for my time, saying I was trying to gouge his company for fees and the vet was just trying to get something for nothing.  The fellow came in one day with a high-capacity magazine for an AK-47 in his pocket. I asked him about it, because it is rather hard to miss a 30-round magazine sticking out of a man’s pocket.  He pulled it out, turning it over in his hands several times, saying he just bought it for his AK-47 rifle. He had one magazine already, and this was an extra. In a soft voice, he said if the adjuster did not stop giving him such a hard time over his benefits, he was going to go to Florida, find his office, and shoot the SOB.

I told him I was going to push the case harder, and in the meantime, don’t do something stupid without coming and talking to me anytime day or night. I gave him my home phone number, after he reassured me he was not going to go down to Florida right away, that he would give the insurance adjuster some time, but not much time. My business partner at the time was a psychiatrist as well as an attorney. He moonlighted part time as a deputy sheriff. To say that he can be blunt when he wants to is an understatement. He said he would call the adjuster and light a fire under him.  I found out later he called the adjuster and explained to him in very simple terms, that, “Don’t you understand that Dr. Stanley is the only thing standing between you and death?  The adjuster must have gotten the message because suddenly he could not do enough for me, and the vet did not lose his house.

This is a long and convoluted story, involving intrigue, deception, greed, misguided people on all sides, and where idealism clashes with harsh reality.  We are not done yet.  I have a story in the works for next week about the new DSM-5 diagnostic handbook, which will replace the present DSM-IV-TR.

The criminal justice system has no mechanism for mental illness other than, “not guilty by reason of insanity,” for dealing with the mentally ill.  For non-lawyers reading this, insanity is a legal term, not one found in the diagnostic manual.  Insanity has very specific legal meaning. Many mental health professionals do not understand that legal insanity does not equate to any specific mental, psychological or neurological condition.

There are judges who don’t really believe there is such a thing as mental illness.  It is really hard to get an N.G.R.I. verdict. When I was at the State Hospital seeing hundreds of pre-trial defendants, very few were truly schizophrenic. Of those schizophrenics, only about seven percent of them met the M’Naughten criteria for legal insanity. M’Naughten is the rule for insanity in Mississippi. When those cases went to trial, almost all were convicted anyway. Juries are skeptical of insanity defenses.

Prison or jail is the worst place a mentally ill person can be. They do not get treatment.  Many are locked up in solitary confinement or protective custody, usually because of acting out due to the illness.

At the same time, public mental hospitals across the country are closing to, “save money.”  I have news for those folks.  If we use the state of Michigan as an example, a Bazelon Center report shows the stark reality of the cost of keeping a mentally ill person locked up in prison, versus case management in the free world. The annual case management of a mentally ill person in Michigan is $2,165. A more intensive program, The Assertive Community Treatment Program is even more intensive for the more severely ill, with a per-patient cost of $9,029 per person per year. By contrast, the average Michigan prison inmate costs the state over $34,000 annually.

The cost is more than just money. In 2010, 530 inmates with mental issues committed suicide while locked up.  All suicides are a tragedy for everyone concerned, but some seem to be more poignant than others. The gifted blues guitarist, Roy Buchanan, committed suicide in the Fairfax County, Virginia Jail in August 1988 at the age of 48. He was arrested for public drunkenness, but had a history of depression. Roy should have been in a hospital rather than a jail. Far too many people with mental issues self-medicate with alcohol or recreational drugs. What could possibly go wrong?

I will leave the reader with one of Roy Buchanan’s tunes. No wonder he was so good at the blues. He lived the blues, and died an inmate in a jail with a homemade noose around his neck. The title of this is, When a Guitar Plays the Blues, recorded at Carnegie Hall. The Blues indeed.