Psychoactive Drugs & Treatment of the Mentally Ill In the Criminal Justice System

1. Psychoactive Drugs&Treatment of the Mentally IllIn the Criminal Justice System Judge Brent A. Carr Tarrant County Medical Examiner’s Ninth Annual Conference December 18, 2008

2. What is Mental Illness? Mental illnesses are medical conditions that disrupt a person’s thinking, feeling, mood, ability to relate to others, and daily functioning.

3. What is Mental Illness? Mental illnesses are biologically based brain disorders.  They cannot be overcome through "will power" and are not related to a person's "character" or intelligence.

4. How Many Are Mentally Ill? • Estimated: more than one-fourth of adult Americans (26.2%) suffer a diagnosable mental health disorder in a given year • The main burden of mental illness is concentrated in approximately 6% of the general adult population

5. Population U. S. Adult Population (18yo +): 229,500,000 Tarrant County Adult Population: 1,350,000

6. How Many Are Mentally Ill? Adult Population (18yo +) Diagnosable Mental Illness Given Year: United States: 60,129,000 (26.2%) Tarrant County: 353,700

7. How Many Are Mentally Ill? Adult Population Serious Mental Illness United States: 13,740,000 Tarrant County: 81,000

8. General Population vs.Confined Population 2005

9. Confinement Population With Mental Health Disorder 2005

10. Co-occurring Disorders About 74% of state prisoners and 76% of local jail inmates who had a mental health problem also met criteria for substance dependence or abuse.

11. A Short History of MH Treatment Bethlam Royal Hospital England, aka Bedlam

12. A Short History of MH Treatment Prior to 1800 a mentally ill person was often thought to be: • possessed by evil spirits, • under the spell of witchcraft, or • influenced by the moon, (origin of the term "lunacy").

13. A Short History of MH Treatment The insane were seen as incurable, subhuman creatures doomed to a life in shackles and chains at an almshouse (poorhouse) or in jail cells for the mad.

14. A Short History of MH Treatment Beginning around 1800 institutions called “Asylums” were created with the aim of restoring lunatics to health in a therapeutic environment. The numbers were overwhelming and the noble goal was forgotten.

15. A Short History of MH Treatment Common asylum practices included: • The use of drugs to sedate agitated patients • Wrist and leg restraints • Straitjackets • Sterilization of patients deemed incurable

16. A Short History of MH Treatment The Rise of the Mental Health Hospital • 1890 State Care Act, New York • Mental Hygiene (prevention) • Mental illness viewed as a nervous system disorder requiring medical solutions • 1920 American Psychiatric Assn • Psychotherapy

17. A Short History of MH Treatment Early Treatments • Electroconvulsive Therapy • Metrazol (drug induced seizure) • Insulin Shock Therapy • Hydrotherapy • Lobotomy

18. A Short History of MH Treatment Electroconvulsive Therapy

19. A Short History of MH Treatment Dr. Walter Freeman performs a lobotomy

20. A Short History of MH Treatment The Frontal Lobotomy

21. A Short History of MH Treatment Rise of Psychoactive Medications 1952 First Generation 1989 Second Generation 1963 Community Mental Health Centers Act Massive deinstitutionalization

22. A Short History of MH Treatment Deinstitutionalization Inpatient population exceeded 500,000 in 1960. Inpatient population approximately 57,000 by late 1970’s. Today inpatient population is approximately 70,000.

23. Rise of the Drugs Typical or First Generation Antipsychotics 1952 Thorazine (Chlorpromazine) introduced by a French surgeon who was looking for a better anesthetic. Hailed as the single biggest advance in psychiatric treatment. Typical Antipsychotic drugs developed and introduced during this time.

24. Rise of the Drugs Typical Antipsychotics Haloperidol Levomepromazine Chlorpromazine Promethazine Fluphenazine Chlorprothixene Perphenazine Flupenthixol Prochlorperazine Thiothixene Thioridazine Zuclopenthixol Trifluoperazine

25. Rise of the Drugs Side Effects Involuntary muscle movements (tardive dyskinesia) Reduction in white blood cells (leukophenia or agranulocytosis) Sedation, slurred speech, dry mouth, constipation, glucose tolerance, weight gain, light sensitivity, sexual dysfunction

26. Rise of the Drugs Cost range per dose Haloperidol $ 0.05 - 2.01 tablet / ml (Haldol) Perphenazine $ 0.18 - 0.43 tablet / ml (Trilafon)

27. Rise of the Drugs Atypical or Second Generation Antipsychotics 1989 Clozapine, first atypical antipsychotic introduced Atypical antipsychotics are believed to have fewer side effects as they are more targeted in their effect Although some recent studies question this belief

28. Rise of the Drugs Atypical Antipsychotics Abilify Risperdal Clozaril Seroquel Geodon Solian Invega Zyprexa

29. Rise of the Drugs Cost range per dose Abilify $ 14.59 – 20.63 Clozapine $ 0.51 – 6.32 Geodon $ 6.57 – 7.98 Invega $ 13.04 – 19.56 Risperdal $ 4.34 – 13.33 Seroquel $ 2.58 – 12.87 Zyprexa $ 7.67 – 28.48

30. Criminal Justice MH System Today millions are spent on resources to deal with the mentally ill in the criminal justice system. A 30 day supply of some medicines may cost $700 - $800. This is a specialty area that requires highly trained personnel.

31. Criminal Justice MH System Priority Populations Bipolar Disorder Major Depression Schizophrenia Schizoaffective Disorder

32. Criminal Justice MH System Why These? Sickest Most expensive normal inmate: $50 / day seriously mentally ill $150 / day Respond to medication

33. Criminal Justice MH System No single strategy alone can effectively manage the mentally ill in the justice system A mix of all available assets is required Funding is a perpetual issue and requires constant vigilance

34. TARRANT COUNTY RESPONSE

35. MHMR Jail Forensic Unit • Screens all incoming inmates for mental impairment • Checks state MH data base • Performs mental health triage • Schedules doctor visits • Medication appointments • Case management • Suicide assessment • Discharge planning

36. MHMR Project Rapp • Project Rapp: Rehabilitative Alternatives to Probation and Parole • Notified of inmates being paroled to Tarrant County with mental health issues • Provides mental health services to parolees and discharged probationers • Provides access and referral to support services from A to Z

37. MHMR Law Liaison Project • The law liaison project offers technical assistance by mental health professionals to police officers in the field who need advice or guidance when dealing with a mentally ill person. • Available 24/7, 365 • Follow-up contact for any mentally impaired person referred to law liaison

38. Jail Diversion CoalitionMHMR & Mental Health Assoc. • Task force is composed of a variety of people and agencies with an interest in the humane treatment of the mentally impaired who enter the criminal justice system. • Police, prosecutors, judges, mental health agencies, community interest groups, government administration, service providers, etc. • The task force recently compiled a list of all local resources available to deal with mentally ill defendants as well as those we should seek.

39. Mental Health Diversion Court • Identifies low risk offenders, felony or misdemeanor, that may be diverted from the justice system after successful program completion • Upon successful completion of the program the criminal charges are dismissed and in most cases the defendant is eligible for an expunction • Capacity: 50 at a time • Approx 225 graduates • Recidivism rate to date approx 15%

40. MHMR T-CAT Program • T-Cat: Tarrant County Assertive Treatment • Provides RAPP type services to pretrial priority population felony defendants • The goal is to better case outcomes for mentally ill defendants by stabilizing their life circumstances • The program is at capacity of approx 70

41. MHMR Mobile Crisis Unit • A unit of mental health professionals that may be dispatched to respond to mental health crisis • May include a medical doctor • Dispatched through the mental health crisis hotline to cases that do not indicate a medical emergency • This unit is also available to assist the police

42. Coming Attractions • Residential Facility, 32 total beds • 16 beds for acute crisis stabilization • 16 beds for residential treatment unit • Criminal Justice Mental Health Coordinator • In house judicial system person responsible for monitoring and facilitating resolution of all mental health issues affecting the local justice system

43. Hot Issues • Forced Medication • Restructuring of State Mental Health Hospital System • Criminal and Civil Coordination

44. Thank You, Questions? Judge Brent A. Carr (817) 884-3410 bcarr@tarrantcounty.com

45. References • http://quickfacts.census.gov • www.census.gov • www.tarrantcounty.com • www.nami.org • http://www.ojp.usdoj.gov • http://www.nimh.nih.gov/ • http://www.nmha.org/

46. http://www.surgeongeneral.gov/library/mentalhealth/toc.htm#chapter6http://www.surgeongeneral.gov/library/mentalhealth/toc.htm#chapter6 • http://www.pbs.org/wgbh/amex/lobotomist/program/ • http://www.pbs.org/wgbh/aso/databank/entries/dh52dr.html • http://en.wikipedia.org/wiki/Antipsychotic • Countless discussions with very dedicated people who work in this field every day