1	Criminalization of Persons with Serious Mental Illness: (The Use of Jails &Prisons as Psychiatric Hospitals) Gregory Sokolov MD Medical Director Sacramento County Jail Psychiatric Services & Assistant Clinical Professor of Psychiatry UC Davis School of Medicine
2	"How did we get here" How did we get here?
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4	Reform Movement in US (1800’s)
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6	Community Mental Health Act (1963)
7	President’s New Freedom Commission on Mental Health (2003) “Mental health delivery system is fragmented and in disarray…leading to unnecessary and costly disability, homelessness, school failure, and incarceration…In many communities, access to quality care is poor, resulting in wasted resources and lost opportunities for recovery.”
8	“Trans-Institutionalization” (Criminalization of the Mentally Ill)
9	Bureau of Justice Statistics (1999)-Mentally Ill Offenders 16% of state prison inmates 16% of local jails (2003 statistics): 230,505 in prison+ 106,476 in local jails=336,981 *(350,000+ pts in state hospitals in 1969!)
10	Types of offenses by mentally ill jail inmates
11	Severe Mental Illness & Jails Cook County Jail (Chicago)-1990: 10% of the inmates had “severe” mental illness (Schizophrenia, Bipolar Disorder, Major Depression) Rate of Schizophrenia (6%) was 4x greater than in community
12	Bipolar Disorder: Legal Correlates Ottawa County Jail (Ohio) 7% of 319 inmates screened positive for bipolar disorder using the MDQ (Mood Disorder Questionnaire) Substance use comorbidity in 94% Alcohol and multiple substances abused
13	Bipolar Disorder: Legal Correlates LA County Jail inmates (7/99-1/00, n=66) with clear history of bipolar I disorder: 75% were manic at arrest 60% were psychotic at arrest Most were recently released from psychiatric inpatient unit prior to arrest and did not follow up with outpatient treatment
14	"What are we doing now" What are we doing now?
15	Sacramento County Jail Psychiatric Services: An Overview
16	Program Overview Jail Psychiatric Services (JPS) is the forensic component of the University of California, Davis (UCD) Department of Psychiatry Department of Psychiatry is one branch of the School of Medicine One of few University-based Jail Psychiatric Service in the United States
17	Sacramento County Main Jail- Downtown Sacramento
18	Rio Cosumnes Correctional Center (Branch Jail)-Elk Grove
19	Program Structure Administration Medical Director Clinical Director (RN) Acute Inpatient Unit (LPS licensed) Located at the Main Jail Outpatient Services Provides services at both Main Jail and Rio Cosumnes Correctional Center (RCCC)
20	Budgetary Issues Sacramento County Sheriffs Department Contracts with U.C.Davis Department of Psychiatry for JPS services Funding for the program comes out of the Sacramento County Division of Mental Health Pharmacy Budget runs at or over 100% (i.e. costs of newer psychotropic medications)
21	Jail “Outpatient” Services Provides psychiatric service to the General inmate population Staff (LCSW, MSW, RN, clerical) Services Provided (Crisis intervention, case management, brief supportive contacts) Services not provided in present structure (long-term individual psychotherapy)
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23	Inpatient Services 17 Bed Acute Psychiatric Unit Located at the Main Jail 24 Hour Licensed Staff (RN, LVN, PT) Emergency Medication Treatment Reise and Certification Hearings Daily Physician Evaluations
24	Types of Patients on Inpatient Unit Patient status will vary 5150 (72 hour) holds 5250 (14 day) holds 5270 (30 day) hold 180 day holds also occur but are rare Temporary conservatorship Conservatorship Placement voluntary by conservator Voluntary status rare due to lack of beds
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26	Treatment Goals Inpatient treatment is focused upon stabilization of the patients mental status and an accompanying return to the general population Two primary Outpatient (general population) treatment goals: Crisis intervention Routine follow-up care & group therapy (SacPort)
27	Emergent Contacts 95% of Acute (urgent/emergency) contacts fall into one of four major areas of concern Suicide potential Violent behaviors Psychotic Decompensation Mood Disturbance
28	Chronic Care 95% of Chronic Services designated for: Schizophrenia Bipolar Disorders Delusional Disorder Major Depressive Disorder (recurrent) Borderline Personality Disorder Paranoid Personality Disorder Schizoaffective Disorder
29	Flow of Care Process Referred patients (by booking nurse, custody, attorneys, family, etc.) evaluated by a clinician to ascertain level of mental health treatment needed Once level of care determined, patients either treated immediately if emergent or scheduled to see a psychiatrist if chronic care is indicated >800 inmates currently are “opened cases” for JPS (>600 patients on medications)
30	Problematic Inmate-Patients Several Types: Non compliant with medications Antisocial Personality Disorder & Malingering Chronic self-injurious (Borderline Personality Disorder)
31	Jail Specific Problems and Issues Incarceration will frequently exacerbate mental health illness Increased stress of the environment leads to a high level of stress in all inmates but especially upon the mentally ill individual Risk of suicide is significantly higher in this environment One on one contact is restricted by the environment
32	What to do if loved one with mental illness is Jail? Be calm, patient, and supportive! Don’t show high “emotional expression” or shame (may be risk for suicide) Share important information with jail staff (custody, medical, psychiatric)
33	"Where do we go from..." Where do we go from here?
34	What Does the Future Hold for JPS? JPS currently in the process of reviewing and streamlining services Sudden increase in inmate population has mandated a change in the manner in which JPS clinicians conduct business Sub-acute “psych pod” JPS is striving to increase community involvement (release planning)
35	Community Mental Health Affiliates-Sacramento County Sacramento Mental Health Treatment Center Adult Access Sacramento County Conservator’s Office “RSTs”: Regional Support Teams (Community Mental Health Treatment Centers) Transitional Living and Community Support (TLCS)
36	“Cycle” of Mentally Ill Offenders Arrest >>>>Treatment>>>Stabilization Release from custody>>Noncompliance >>>Re-arrest………………………….
37	Potential for Diversion Community and Superior Court involvement critical if cycle of re-arrest and noncompliance of treatment is to be broken Funding sources may include grants: Mental Health Legislation & Initiatives: (CA-Prop 63: Mental Health Services Act) (HR 2387: Mentally Ill Offender Treatment & Crime Reduction Act; passed by US Congress in 2004)
38	“Mental Health Courts” Are adult criminal courts Separate docket dedicated to persons with mental illness Divert criminal defendants from jail into treatment programs Monitor the defendants during treatment and have the ability to impose criminal sanctions for failure to comply
39	Comparison of select California “Mental Health Courts” (current) Santa Clara (1999): Misdemeanors or felonies; average 18 months of probation/treatment; savings of >$4 million in jail costs since 1999; 650+clients San Bernardino (1999): Misdemeanors or nonviolent felonies; 1 year on probation/treatment; 30 clients San Francisco (2003): Misdemeanors or low-level felonies; at least one year on probation/treatment; 80 clients
40	FUTURE DIRECTIONS: “ Study the past if you would define the future” -Confucius
41	"QUESTIONS ?" QUESTIONS ?