Tuesday, February 14, 2012

Send Them Away

I saw this story on my twitter feed, about a jail sheriff in Ohio who has instituted a policy to refuse to accept any detainees who are violent due to a mental illness. Some people are saying this is a great policy because it will keep people with psychiatric disorders from getting locked up. The sheriff was quick to add though that diverting people out to an emergency room was not an alternative to incarceration. Rather, it was a means of providing immediate care and stabilization to people who might need it.

What lead to this new policy? The article mentioned that budget cutbacks at the jail lead to a decrease in psychiatric coverage, from full time to less than part time. There was also an incident at the jail in which an inmate on the psychiatric infirmary died while struggling with correctional officers. (No details were mentioned about this incident, although some officers were criminally charged.)

I read this story with mixed emotions. On the one hand, I appreciated the need for emergency medical care for some newly arrested prisoners. On the other hand, I had a visceral response to the sheriff's statement: "We're not going to be a dumping ground for these people," said the sheriff. Apparently, he equates seriously mentally ill people with trash. That's the issue I have with this policy. It's not really about getting people the help they need, it's about NIMBY-ism (Not In My Back Yard), a way to turf the treatment of the seriously ill off on someone else. So the jail doesn't want to accept violent mentally ill people, and hospitals don't want to admit psychiatric patients with histories of violence. It seems that the most ill folks are destined to sift down through the institutional bureaucracies until they pool into some environmental equivalent of a Thunderdome.

While the sheriff may be reacting to a budget cut, remember that legislatures don't dictate line-item cost cutting. That's up to the facility administration. So when the sheriff sat down with his new reduced budget, what made him cut the psychiatric hours? Do you think there may be some problem with priorities here?

In my experience people spend too much time arguing over who belongs where. People with mental illness require the right treatment, at the right time, regardless of their physical location. The real solution is to have adequate mental health staff in place and to have custody staff trained to work with them. The facility needs to have policies in place to give emergency medication, adequate safe and humane housing and staff skilled in verbal de-escalation, not to mention adequate mental health coverage.  This particular jail has hired an outside consultant who will undoubtedly consider and review all these things. The main point of my post being: The solution to a health care problem should never be to get rid of the patient.

But let's assume for the moment he's acting with good intentions and walk this policy through it's logical outcomes. The biggest challenge---and this is not a small barrier---is that custody will not know when violence is due to mental illness. Even clinicians can have trouble telling if someone is drunk or high on crack or psychotic or just really really pissed.

I'd like to invite our readers to participate in a little practical exercise. Read these scenarios and tell me what you think. Although these are clinical questions you don't have to be a clinician to answer. I'd like to give the general public a chance to think like a forensic doctor.

Clinical Scenario:

You are a forensic psychiatrist working full time in a medium-sized local detention center (a jail). Each of the following patients are brought to you on the same day, and you have to make the call to send the patient out to an emergency room for further evaluation and treatment or keep them in the facility. Remember that none of them have been booked or formally charged yet (they are so 'out of it' that they are brought directly to you rather than getting charged first). If you send them to an emergency room you will get a basic set of lab work done but no further workup is guaranteed. There is also the chance that the arresting officer may decide not to press charges after all, so that he can drop the patient off in the emergency room and get back to the streets. On the other hand, if you keep the patient in the detention center you run the risk of missing a serious physical condition that could leave the patient dead in his cell overnight. Here we go:

Hypothetical Patients:

Patient A: Patient A is brought to the jail by the police covered in blood. He is thought disordered, incoherent and talking about angels and demons. He believes he is in heaven and thinks that satellites have been tracking his movements throughout the city. He is homeless and has no known family or friends. This is his tenth incarceration in five years and his presentation today is consistent with all the other times that he has been locked up. From previous jail treatment records you know that he responds quickly to low doses of medication and will require only a week or ten days of admission to the jail infirmary. When well he has a good relationship with you and always reminds staff when his medication order is about to expire. Even now, he knows who you are and appears significantly relieved to know you are there to start his treatment promptly. The arresting officers, who don't know any of this, warn you as you escort him into your office (in a waist chain and handcuffs), "Careful doc, you don't want to know what he just did to his mother." All of Patient A's previous incarcerations were for non-violent offenses like drug possession and minor thefts.

Patient B: Patient B is brought to the jail by the police covered in blood. He smells of alcohol and has an open bleeding gash on the back of his head. The arresting officer tells you that this is the third time in two months he has arrested Patient B for public intoxication and misdemeanor assault. You have never met Patient B before and have no old records. Patient B is disoriented, hallucinating and talking about angels and demons. As the arresting officer escorts him into your office (in a waist chain and handcuffs), he warns you, "Careful doc, you don't want to know what he just did to the other guy."

Patient C: Patient C is brought to the jail by the police covered in blood. He is angry, swearing and wrestling with both the police and the correctional officers in the booking area. You are unable to get close enough to him to ask questions and when asked questions by the booking officer he responds only with profanity. He has no obvious open wounds or signs of trauma. The arresting officers don't need to warn you about anything. You know enough to stand waaaay back. The only thing you know about him is his reported name, which may or may not be an alias. The officers know him only by his street name, "Woo Woo." He isn't cooperative enough to verify his identity through fingerprints so you can find no old records.


Which of these patients would you send out to an emergency room from the jail, and which would you keep and treat in house? Why? Discuss.

(This topic is a classic problem in forensic work. It was the subject of one of my earliest blog posts entitled Hot Potatoes.)