“When psych beds go down, incarceration goes up”

January 4, 2016 by  

Chief Biasotti of the International Association of Chiefs of Police (IACP) got it right. Since the 1950’s the number of psychiatric beds in the U.S. have been reduced by 95% (replaced by “community treatment”).   Now at least 14-16% of Arizona’s incarcerated prisoners suffer with mental illness.

Families are at their wit’s end as they try to secure proper treatment and placement for loved ones suffering with serious mental illness who, instead, cycle in and out of ERs, end up homeless, in our prisons or are outsourced to the police – and the morgue.  Also see DJ Jaffe’s It’s not about money – it’s about misplaced priorities.’

This is just one of the many gaps in Arizona’s mental health system! Here are some of the solutions bridging them:

  1. Fix the Bottlenecks & Increase # of Appropriate Placements.  Sufficient available 24 hour supervised facilities are needed – emphasis on available.  The current system simply is not accommodating the desperate need for long term supervised facilities for the time necessary for recovery.  Emergency rooms, shelters and prisons are wholly inappropriate places to treat the mentally ill, yet these have literally replaced the mental institutions of the past!  There is no commitment to the most seriously ill in our system.  Promoting general mental health has all but displaced treating neurological brain disorders that are progressive and debilitating.  Because of this mistreatment by the system, they are often much worse off, their conditions decompensating to the point where public safety is threatened – just read the headlines!  You’ll likely remember this gruesome story from earlier this year, too.  Unfortunately, these are not fairy tales.

Is Legislation needed?  Probably not at this point but improved Legislative Oversight is (aka accountability):

Accountability The legislature must hold AHCCCS and its providers accountable for building the right metrics into their contracts: focusing on outcomes (reducing hospitalizations, prison recidivism, homelessness, suicide attempts, crisis calls etc.) rather than process (number of treatments/evaluations provided, heart rates, clicks on a website, etc.) before a person is deemed ready to move into a less restrictive environment in the community – if ever.  This also speaks to Improving the Involuntary Treatment Process protocolsArizona’s Assisted Outpatient Treatment laws are sufficient, but rarely implemented efficiently.

Are there other barriers?  Yes – which is why I applaud Congressman Matt Salmon and others diligently working to pass Rep. Tim Murphy’s HR 2646 – removing the Federal Regulations standing in the way.

2.  Stop Warehousing the incarcerated Mentally Ill & start treating them.  Most mentally ill should never end up in  jail     or prison in the first place, but because by some estimates 24% of DOC inmates are mentally ill, about 20,000 will be released to the streets this year.  This number is released every year – untreated, with no place to go and $50 in their pocket.  It’s no wonder most reoffend and are back in custody within weeks or months – only for longer sentences next time!

Is Legislation needed?  YES.  I am sponsoring 2 bills in the 2016 session transitioning two categories of prisoners that should reduce recidivism by 50%:  low-risk offenders and those with mental health and/or co-occurring substance abuse disorders.  The key to both programs is the transition itself – addressing the addiction and/or treatment plan while still incarcerated and assigning navigators to help them upon release.   Governor Doug Ducey’s support to move these policies forward is encouraging, as substance-use disorder is one of his passions – see footage from The Governor’s Office of Youth, Faith and Families’ The Elephant in the Room  substance abuse week (Dir. Debbie Moak) kick-off from October.

The next logical step is Recidivism Reduction goals built-in to our corrections contracts.

3.  Filling the Doctor Shortage.  Over-medicating patients; unqualified Nurse Practitioners acting as Psychiatrists; inappropriate medication dosages; unresponsive case managers that can’t handle caseloads — all speak to the critical shortage of health care professionals in Arizona – especially in high-needs areas like Psychiatry.

Is Legislation needed?  YES.  2016 Legislation will allow the Arizona Medical Board to issue “critical needs” licenses ASAP to physicians currently licensed and in good standing in another state – to meet Arizona’s immediate need in critical shortage areas.   The current licensing process still takes too long.  Longer term, plans are to engage citizens to address proper medication usage and over-prescribing.

4.  Just what the Doctor Ordered – Let Them Practice.   This speaks to removing threats of disciplinary action by Arizona’s regulatory boards for applying non-traditional or complementary off-label uses of approved treatments to benefit patients.  What and who determines the definition of an ‘evidence-based’ treatment is sometimes in the eye of the beholder – and can harm patients and threaten physicians’ livlihoods.  The combination of Obamacare and over-zealous regulatory health boards can become increasingly harmful to patients if their doctors are not free to treat them as individuals or even speak to them about therapies because the employing hospital’s ‘corporate practice of medicine’ might affect their bottom line.  Depression, PTSD and traumatic brain injury are examples where alternative therapies can be instrumental to patient care (see video on Hyperbaric Oxygen Therapy) since non-adherence to medications is so high and psych meds can actually be ineffectual for a large percentage of people, as well – explaining high co-occurring substance use by mentally ill persons.

Is Legislation needed?  YES.  There are 2 bills in the works to help protect the doctor-patient relationship and bar unwarranted board and hospital disciplinary action or retribution.  Just because an approved drug or therapy may not be in the lexicon of a group of regulators doesn’t mean its off-label use is inappropriate standard of care.

5.  Treat the Families as Partners: with Respect.  It’s difficult enough having a family member with a serious mental illness, but being ignored or worse yet – treated as an intruder by physicians and case managers is not only disrespectful to a caregiver, but can be detrimental to the patient.   Yes, there are HIPPA considerations – but confidentiality laws provide for broad communication with families – to receive information from them – and to provide the same information paid providers receive if it is needed to protect health, safety and welfare.

Is Legislation needed?  YES.  There will be two bills – A Caregivers Bill of Rights Resolution will delineate the appropriate expectations of physicians and case managers when interacting with the families who are very often providing housing, care and case management for their grown mentally ill son or daughter.  The second bill should help enable more meaningful family communication by correctly interpreting the leeway physicians and social workers have communicating with family members – within the HIPPA framework.  Importantly, the hospitals and behavioral health entities have agreed to retrain their physicians and others accordingly.  Bravo for cooperation!

6.   Coordinated Care – including Hospital Discharge Plans.   A loved one experiencing psychosis in the emergency room can be heartrending and scary for everyone.  It often happens often because a person has gone off their medication and as a result – cannot control their behavior, becomes suicidal and/or a danger to someone – but when it happens, the treatment protocol isn’t always helpful.  It can be a disjointed affair with new doctors – new social workers – and little or no contact with former treatment providers.

Is Legislation needed?  Not yet…This is an oversight issue in which contract overseers must spell out the expectations of the behavioral health provider – and pay them for producing good outcomes.  What is needed is a dedicated caseworker assigned to help the Seriously Mentally Ill person ‘over the crack’ between hospitalization and the community; Hospitals are often between a rock and hard place with nowhere to send a person with SMI, but as more appropriate facilities become available, the system needs to do a better job validating a person’s discharge plans so one is not released to a homeless shelter –or where treatment continuity is unlikely.

These efforts won’t fix things all at once – but they are a start.  The good news is, unlike in past years, all parties involved are admitting there are problems – which is always one of the first steps in solving them.



7 Responses to ““When psych beds go down, incarceration goes up””
  1. Dr. Phil Barry says:

    Hi, Nancy:

    I have spread the word about your event at Susie Stevens’ house this evening. Unfortunately, I have another commitment so I won’t be there myself. I look forward to working with you on mental health issues this upcoming session. Please let me know if there is a way for me to help. These are important challenges you are taking on and I would appreciate the opportunity to “weigh in.”

    Phil Barry
    17626 N. 57th St
    Scottsdale AZ 85254-6422

  2. DJ Jaffe says:

    Thank you roal all you do and for quoting our work. If there is anything we can do to help your efforts, let us know. There are also some amazing advocates in AZ.

  3. Carol Olson M.D. says:

    Thank you for focusing on issues surrounding the care and treatment of the seriously mentally ill. This is an issue that should not be neglected any longer. I have great hopes for positive changes and am committed to working with patients, families, the treatment community, law enforcement and legislators to improve care for our Arizona citizens with serious mental illness. Please let me know if there is any way I can help in your efforts.
    Carol Olson
    Chair of Psychiatry, MIHS

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