Decarceration of U.S. jails and prisons: where will persons with serious mental illness go?

Decarceration (decreasing the number of persons incarcerated in U.S. jails and prisons) has begun. It is estimated that more than 350,000 persons with serious mental illness (SMI) are among those incarcerated in the United States and that many thousands of them will probably be among those released. Currently, the prison population in general is being reduced as a consequence of concerns about overcrowding and of policies and programs such as reclassification of drug possession, which would affect many persons with mental illness. Court-ordered diversion and changes in sentencing guidelines are also serving to reduce prison populations. In recent years, the mental health system did not have to manage as large a number of persons with SMI, especially those who were among the most difficult and expensive to treat, because many of them were incarcerated in jails and prisons. Now, with decarceration and the release of many such persons, the mental health system may be expected to assume more responsibility for them and should be prepared and funded to meet their needs. This population of persons with SMI needs structure and treatment that, depending upon their individual needs, may include 24-hour supportive housing, ACT and FACT teams, assisted outpatient treatment, psychiatric medication, and psychiatric hospitalization.

United States Department of Justice findings letters in psychiatric hospital CRIPA cases: an aid or a distraction?

The Civil Rights of Institutionalized Persons Act (CRIPA) of 1980 allows the United States Department of Justice (DOJ) to investigate and file lawsuits against certain institutions, including state and county psychiatric hospitals, where individuals within may face unconstitutional conditions. Subsequent to an investigation and before negotiations or litigation, the state is provided a Findings Letter generated by the DOJ that generally contains recommended remedial measures. It has never been determined to what extent a Findings Letter provides a state with a recommendation specific to the institution for corrective action before the state enters into negotiations with the DOJ. Three study groups were derived from a sample of 15 Findings Letters written to states concerning their psychiatric hospitals between 2003 and 2009. The individual recommended remedial measures, labeled texts of interest (TOI), were identified, and the degree of overlap among the Findings Letters was determined. To a surprising degree, TOIs overlapped to various extents, from exact copies of text to paraphrased versions, in Findings Letters written between 2003 and 2009 to different states and for multiple state hospitals in the same state. The recommended remedial measures provided in the DOJ's Findings Letters are not specific to each state hospital's deficiencies. The Findings Letters offer limited guidance to the state on how to remedy the deficiencies before negotiating with the DOJ. This lack of specificity causes inefficient and delayed remediation of unconstitutional conditions and other deficiencies in care and treatment in psychiatric hospitals. While the current process most often leads to improvements in state hospitals, it is a costly, inefficient remedy, despite the possibility of alternative remedial processes of less expensive and equal or greater effectiveness.

Commentary: Evaluations of DOJ investigations of state psychiatric hospitals.

Geller and Lee use their study of Findings Letters, sent by the United States Department of Justice (DOJ) to the states after investigations of state psychiatric hospitals, as a way to study the investigation process itself. Their article serves as a useful program evaluation for DOJ and suggests important ways in which the investigations could be improved.

Some perspectives on criminalization.

In recently published articles, there has been an underemphasis on the role serious mental illness (SMI) plays in causing persons to be in the criminal justice system. Increasing attention has been paid to other factors, including criminogenic needs. While these needs may be present and contribute to criminal behavior, persons with SMI who are at greatest risk of criminalization are those who are not receiving adequate treatment, structure, social control, and, when necessary, 24-hour care in the mental health system. Cognitive behavioral therapy (CBT) has been used to reduce recidivism for prisoners, including those with SMI, but persons impaired by their untreated psychotic symptoms may not be able to profit from it. The importance of psychiatric treatment must not be underestimated. Moreover, given their current constraints, correctional systems may not be able to continue accepting large numbers of persons with SMI. Many offenders with serious mental illness pose difficult and expensive problems in treatment and management, such as nonadherence to medication, potential for violence, and substance abuse. The mental health system needs to be given more funding and to take more responsibility for these challenging individuals.

Smoking cessation care in state-operated or state-supported psychiatric hospitals: from policy to practice.

OBJECTIVES: The aims of this study were to identify changes in smoking policies and their implementation and to determine the level of smoking cessation care provided at state-operated or state-supported psychiatric inpatient hospitals. METHODS: Hospitals were surveyed in 2008 (N=219) and 2011 (N=206) about their smoking policies and practices, and changes in specific policies and practices, such as staff specialty training about smoking cessation care, assessment at intake, provision of smoking cessation treatment and education, and aftercare planning, were examined. Smoking cessation care was categorized as best, good, average, or poor. RESULTS: The survey was completed in both 2008 and 2011 by 108 hospitals. The number of hospitals prohibiting smoking rose by 73%, from 48% in 2008 to 83% in 2011. The provision of specialty training to staff did not significantly improve. Nearly all hospitals assessed smoking status at admission, and nicotine replacement therapy was provided by more hospitals than any other treatment in both 2008 and 2011. The number of hospitals providing no follow-up of smoking cessation care after discharge dropped significantly, from 64% to 41%, and significantly more provided good versus average smoking cessation care. CONCLUSIONS: Analysis of smoking policies at state-operated or state-supported psychiatric inpatient hospitals found significant movement in adopting nonsmoking policies and some increase in active treatment, notably wellness counseling. Educational resources have not reached full penetration, and continuum of care activities are also lagging behind. Additional resources and staff training may be needed to continue to address smoking cessation both during and after hospitalization.

CRIPA, Olmstead, and the transformation of the Oregon Psychiatric Security Review Board.

This commentary explores the relationship among the 1999 U.S. Supreme Court Olmstead decision; the Department of Justice, Civil Rights Division, in its application of CRIPA (the Civil Rights of Institutionalized Patients Act); and the application of both CRIPA and Olmstead to the question of individuals hospitalized in state mental institutions following commitment from criminal courts. Using Oregon as an example, the commentary illustrates the interplay between state and federal governments as Olmstead and CRIPA are expanded into the realm of criminal court commitments to state facilities and into the arena of community mental health services for deinstitutionalized persons.

The end of the asylum (town): community responses to the depopulation and closure of the Saskatchewan Hospital, Weyburn.

Never is the fraught relationship between the state-run custodial mental hospital and its host community clearer than during the period of rapid deinstitutionalization, when communities, facing the closure of their mental health facilities, inserted themselves into debates about the proper configuration of the mental health care system. Using the case of Weyburn, Saskatchewan, site in the 1960s of one of Canada's earliest and most radical experiments in rapid institutional depopulation, this article explores the government of Saskatchewan's management of the conflict between the latent functions of the old-line mental hospital as a community institution, an employer, and a generator of economic activity with its manifest function as a site of care made obsolete by the shift to community models of care.

Evaluation of patient rights practices in a developing country: the Edirne model for the implementation of patient rights in Turkey.

OBJECTIVE: The aim of this study was to examine the development of the implementation of patient rights and the practical course of patient rights legislation in Edirne, as well as the verbal and written applications to relevant departments between 2004 and 2008. METHODS: The present study was a descriptive, retrospective and cross-sectional study. The data of the study were obtained by retrospectively reviewing records of written complaints to patient rights units and on-site solutions between 2004, the year of establishment of these units, and 2008. RESULTS: The incidence of written and verbal complaints were calculated to be 23.1 in 100,000 and 137.9 in 100,000, respectively. The increase was 102.2% for on-site solutions, whereas it was calculated as 97.8% for written applications. It was noticed that the rate of violation judgements was high (42.5% (17/40)) in the first year the Edirne State Hospital patient rights committee was established. CONCLUSIONS: Possible problems encountered during the presentation of health services can be solved by the implementation of patient rights under the legislative guarantee. The implementation of patient rights should be considered as reflections of a socialised government on health services.

Providing medical care in state psychiatric hospitals.

BACKGROUND: Dorothea Dix State Psychiatric Hospital (DDH) was cited by regulatory agencies in 1999-2001 for serious deficiencies in providing medical care to psychiatric patients. This resulted in a change in the discipline responsible for providing medical care. We report here how clinical staff and regulatory agencies evaluated the change. In addition, we sought to determine how medical care is currently provided at other state hospital across the nation. METHODS: A transition occurred whereby the responsibility for medical care (direct care and supervision of physician extenders) was changed from psychiatrists to internists. We surveyed psychiatrists and nurses about their impressions of the change and calculated the number of citations from regulators pre-and post-changeover. In addition, a survey was sent to all 212 state psychiatric hospitals. RESULTS: Response rates were: 100% for DDH psychiatrists, 42% for DDH nurses, and 67% for state hospitals. At DDH, clinicians favorably viewed the changeover with 23 (96%) of the 24 psychiatrists reporting a preference for internists having overall responsibility for medical care. There was also a marked reduction in deficiencies cited by regulatory agencies, with 10 prior to the change and only one after the change. Responses to the State Psychiatric Hospital survey revealed that psychiatrists currently provide or are responsible for at least some portion of the medical care at 690% ofall facilities. LIMITATIONS: DDH staffevaluated a change from a system that had not been in place for 3 years. Quality of care measures were not available. How these data generalize to other state hospitals is unknown. CONCLUSIONS: Having internists responsible for medical care was well received by staff and regulatory agencies. Currently, state psychiatric facilities use different approaches to provide medical care. Further research is needed on how quality of care, and ultimately patient safety, may be impacted by these different service delivery models.

Against the grain? A reasoned argument for not closing a state hospital.

In the face of the Massachusetts Governor's attempts to close one of the state's four remaining state hospitals, Massachusetts legislators overrode the Governor's veto of funding for the hospital, but required the state's Mental Health Authority to author a study of the implications of further loss of public sector inpatient beds. The Center for Mental Health Services Research of the University of Massachusetts Medical School conducted its own study concluding that maintaining a longer-term inpatient capacity in the public sector in central Massachusetts was both necessary and accrued a significant number of benefits. This article can serve as a model for the reasoned position that a state hospital in 21st century psychiatry can be looked at as a multiservice center that fulfills a key role in a public sector, integrated system of treatment, care, training and research.

Confirmed, unconfirmed, and false allegations of abuse made by adults with mental retardation who are members of a class action lawsuit.

OBJECTIVE: The purpose is to explore differences in confirmed, unconfirmed, and false allegations of abuse made by consumers with mental retardation in regards to type of abuse and perpetrator. METHOD: Interviews were conducted with 1,220 people with mental retardation who were part of a class action lawsuit in North Carolina. A content analysis of abuse allegations was performed. Frequencies of responses and subgroup differences are reported for type of abuse allegation and perpetrator. RESULTS: Unconfirmed claims are the most frequent. Females made more allegations of abuse than males in general, and more allegations of rape. There are no significant differences among the subgroups (confirmed, unconfirmed, and false allegations) by type of abuse allegation. There are significant differences among the subgroups in regard to the alleged perpetrator. Other consumers with mental retardation are most frequently accused of confirmed assaults. Staff members are most frequently accused in false allegations. CONCLUSION: Ability of the alleged victim to report information and timing of the investigation are important factors in substantiating abuse. Awareness of consumer-to-consumer violence and prevalence of false accusations against staff necessitates increased safeguards for both consumers and staff.

"Titicut follow-up": successful transfer of assaultive patients from a high security facility to a less restrictive setting.

Currently many state mental health agencies are redoubling their efforts to close or downsize state hospitals and place their populations in less restrictive settings. Prior to 1990, certain assaultive non-criminal male patients from public facilities operated by the Massachusetts Department of Mental Health (DMH) could be transferred to prison psychiatric facilities operated by the Department of Corrections (DOC). In 1989 that practice was declared illegal, and clients so placed were ordered returned to DMH facilities. This case study describes the liaison process by which patients remaining in the DOC facility returned to DMH facilities, describes their subsequent hospital course, and reviews the validity of policy assumptions made about these patients' needs in the context of this follow-up data. The results of this analysis indicate that many fewer patients in this group of primarily chronic schizophrenic men required a secure facility upon their return than was previously assumed.