SECTION: CAPITOL HILL HEARING TESTIMONY

LENGTH: 4107 words

COMMITTEE: HOUSE JUDICIARY

SUBCOMMITTEE: CRIME

HEADLINE: TESTIMONY IMPACT OF MENTALLY ILL ON JUSTICE SYSTEM

TESTIMONY-BY: STEVEN S. SHARFSTEIN , PRESIDENT AND MEDICAL DIRECTOR

AFFILIATION: SHEPPARD PRATT HEALTH SYSTEM, BALTIMORE, MARYLAND

BODY:
September 21, 2000 SUMMARY OF TESTIMONY STEVEN S. SHARFSTEIN, M.D. CRIMINALIZATION OF THE MENTALLY ILL IS A PUBLIC HEALTH CRISIS AND A NATIONAL DISGRACE SCOPE OF THE CRISIS The mentally ill are being warehoused in jails and prisons. In 1999, the Department of Justice reported that 16 percent of the population of state jails and prisons, more than 260,000 individuals, suffer from severe mental illnesses. Increasingly police are acting as front line mental health workers when a person with mental illness is in crisis. In the 10 years from 1976 to 1986, the number of "emotionally disturbed persons" the New York City police department took to hospitals for psychiatric evaluation increased from 1,000 to 18,500. By 1998 this number increased to 24,787. Police encounters with persons with mental illness are often deadly. In 1999, there were 30 episodes recorded in newspapers in which law enforcement officers killed a person with mental illness. SOURCE OF THE CRISIS Deinstitutionalization. More effective anti-psychotic treatments, legal decisions protecting the civil rights of the mentally ill and especially the economic opportunity to shift costs from state to the federal government have resulted in fewer than 60,000 patients hospitalized today in public settings, down from over 500,000 forty years ago. Closure of state hospitals has not resulted in adequate resources transferred to communities for outpatient care. Untreated patients and changing standards for involuntary hospitalization have led to homelessness and criminalization of the mentally ill. Studies show that individuals who are in treatment are no more violent than the general public but studies also show that individuals with severe mental illnesses who are not being treated have more risk for violent behavior. SOLVING THE CRISIS Ensure that there are sufficient and effective inpatient and community services. Increased community services such as the assertive community treatment program have been shown to be effective in treating serious mentally ill individuals. Structured residential services are also essential. Provide incentives for states to adopt assisted treatment laws that foster treatment adherence. Assisted outpatient treatment fosters treatment compliance in the community through a court ordered treatment plan. Not only does the court commit the patient to this treatment system it also commits the treatment system to the patient. Increase collaboration between the criminal justice and mental health systems through the establishment of mental health courts, jail diversion programs and post release community based treatment. The Impact of the Mentally Ill Offender on the Criminal Justice System Testimony for the US House Subcommittee on Crime STEVEN S. SHARFSTEIN, M.D.President and Medical Director Sheppard Pratt Health System, Baltimore, Maryland Clinical Professor of Psychiatry, University of Maryland Vice Chair, Joint Commission on Government Relations American Psychiatric Association Thank you very much for the opportunity to appear before you today to discuss one of the most important public health crises in our country: the criminalization of the mentally ill. I especially appreciate the initiatives undertaken by Representative Ted Strickland and Senator Mike Dewine and their staff to provide significant new federal leadership to solve this crisis. Their interest and commitment gives a mental health professional such as myself great hope. My name is Dr. Steve Sharfstein and I am a psychiatrist who has practiced for over 25 years in hospital and community settings in both the public and private sectors. Currently, I am the President of one of the oldest nonprofit hospitals and behavioral care systems in the United States. Last year, Sheppard Pratt provided treatment to over 50,000 individuals throughout the state of Maryland in 20 different locations. The Sheppard asylum was originally founded in 1853 by members of the Friend s Meeting to provide an alternative to jails and other unacceptable settings for the treatment of t he "insane." Our mission today differs little from when we were founded 150 years ago. I am here to present to you a clinical perspective on mental illness and the criminal justice system. First, I will describe to you the scope of criminalization of the mentally ill which I believe is a public health tragedy. Second, I will provide some of my own ideas on the source of this crisis of criminalization. Finally, I will try to provide some ideas on clinical solutions which require collaborative criminal justice and mental health system reform. Criminalization of the Mentally Ill: A Public Health Disaster In 1999 the Department of Justice reported that as much as 16 percent of the population of state jails and prisons, that is more than 250,000 individuals, suffer from severe mental illnesses. With 3,500 and 2,800 mentally ill inmates respectively, the Los Angeles County jail and New York Riker s Island jail are currently the two largest psychiatric inpatient treatment facilities in the country. Many if not most of these individuals could and should have been treated in hospitals and community based mental health treatment if these services were available and accessible. The warehousing of the mentally ill in jails and prisons is an unacceptable throwback to the deplorable conditions in the 19th century which prompted Dorothea Dix and the Quakers, who founded Sheppard Pratt in Baltimore, to develop asylum care. Police are often the front line mental health workers when a person with mental illness is in crisis. In New York from 1976 to 1986 the number of "emotionally disturbed persons" the New York City police department took to hospitals for psychiatric evaluation increased from approximately 1,000 to 18,500 and by 1998 that number has increased to 24,787. Too often these encounters with police end up as deadly ones. From 1994 to 1999 Los Angeles police shot 37 emotionally disturbed persons killing 25 of them. In 1999 alone, police in New York, Houston and Tampa shot and killed three individuals with mental illnesses in each city. The Source of the Crisis of Criminalization The massive deinstitutionalization of patients from state hospitals into the community beginning in the 1960s is a prime factor in the criminalization of the mentally ill today. Deinstitutionalization derived from clinical, legal and most importantly economic forces so that now there are fewer then 60,000 individuals in public hospitals compared to well over 500,000 forty years ago. There are today nearly five times more mentally ill people in jails and prisons as there are in state psychiatric hospitals. The clinical reasons for initial discharge include a more effective medication strategy with the discovery of the antipsychotic medications beginning in the 1950s. These medications which have improved over the years enable most patients to be "better but not well." For many individuals with long term mental illness, remaining on these medications for years is essential if their condition is to remain stable. The most common cause for relapse for severe mental illness is non- adherence to treatment and, as I will discuss later, individuals who are not in treatment or who have dropped out of treatment are the ones that we must worry about in terms of the potential for violence. In addition to the increased clinical efficacy, legal decisions in the 1960s and 1970s guaranteed a right to treatment in the least restrictive setting, the right to refuse treatment under certain circumstances, judicial oversight of involuntary commitment and other protections that established the civil and constitutional rights of the mentally ill. The most significant cause of deinstitutionalization was economics. Federal financing policy established in 1965 led to the discharge of many thousands of patients from state supported facilities who were ineligible for Medicaid and Medicare funding. Such discharge within community based settings made them eligible for Medicaid reimbursement with at least a 50 percent federal payment. State hospitals have closed and continue to close without adequate resources to care for these patients in community based settings. Despite promises to redirect hospital resources after sizing down or closure to the community, states failed to fulfill these promises. For example, when New Jersey closed its largest psychiatric hospital it promised to create 324 new community placements and to study the success of these placements. The study revealed that the state failed to create 47 of the promised new placements and at the end of the study only 167 individual placements, that is half of the promised 324, could be evaluated. In Oklahoma seven months after downsizing Eastern State Hospital 10 percent of its patients spent an average of 32 days in jail. So with deinstitutionalization, there are many patients untreated or inadequately treated in community settings and predictably many of these individuals became intimately involved with the criminally justice system. In the 1960s and 1970s, the standard for state psychiatric hospitalization changed to require that an individual be an imminent danger to self or others. When Pennsylvania changed its law, Philadelphia s police chief issued a directive that non-dangerous people who could no longer be taken into custody under the Mental Health Act could be arrested for disorderly conduct. Pennsylvania s prisons experienced a sharp increase in admission of inmates with severe mental illnesses a few months after the change of the law. In many if not most areas across the country, mentally ill individuals who have committed non-violent property crimes or are arrested for vagrancy have found their way inappropriately into jails or prisons. I would like to make one comment on violence from a public health and clinical perspective. The vast majority of people with mentally illness who are incarcerated are arrested for non- violent crimes, and mentally ill individuals generally who are being treated are no more violent than the general public. Individuals who are not being treated or have dropped out of treatment have the greater potential for violent episodes. One study revealed that individuals who were not taking their medications were 63 percent more likely to be violent than individuals who complied with medication regiments. The New York Times recently studied 100 "rampage killers." More than half of these had histories of serious "mental health problems." The violence of a few individuals with mental illness unfortunately stigmatizes the majority of the mentally ill who are non-violent and are much more often the victims of violence. Clinical Options for Solving the Crisis of Criminalization Treatment works. Medications are increasingly effective with fewer side effects and the combination of psycho-social and psycho-pharmacologic treatment allow the great majority of people with schizophrenia, major depression and bipolar illness and other serious and persistent mental disorders to reside in the community, to work and to live with their families or in non- hospital settings. Unfortunately, there is a great lack of such treatment opportunities in community systems of care such as newer approaches like Assertive Community Treatment which has been shown to be effective for early intervention for people at risk for relapse. Adequate housing and other social welfare supports are other important components of a community-based system. These are also lacking in many communities. Homelessness leads to criminalization. Adequate hospital capacity is necessary in the era of managed care when such hospital stays are very short with the potential for premature discharge. Another option for solving the criminalization of the mentally ill is court ordered treatment. Need for treatment, grave disability, chronic course, lack of insight into illness and previous noncompliance with treatment are all criteria that should be used in court ordered treatment. Court ordered treatment will only work as long as there is treatment available in the appropriate settings. Some patients may benefit from assisted outpatient treatment that ensures treatment compliance in the community to a court ordered treatment plan. Not only does the court commit the patient to the treatment system but also commits the treatment system to the patient. More study and evaluation of assisted outpatient treatment should be undertaken to assess its impact on the criminalization of the mentally ill. Mental Health Courts are another promising opportunity for providing alternative community based services to the non-violent mentally ill offender. Inevitably, some individuals will end up in jail and they should be provided with treatment while incarcerated which is up to date and safe. At release such individuals should be referred to community based treatment. Too often, release from prison leaves the mentally ill individuals with no alternative for appropriate intensive community treatment that is essential in making a success of their lives in the community and preventing reincarceration. One area the Committee could help with now, is to support innovative programs within corrections departments to help people with reentry linkages once released from jail. For instance, SSI and SSDI benefits are currently "suspended" for individuals who are incarcerated under one year. When released, they are expected to go to a local Social Security office to fill out a reinstatement application. There is no review of the individual s medial condition as the SSA assumes they remain disabled but there is the need to document financial status. There is at least a 10-day wait before reinstatement occurs. In some states, the medical application must be made separately at the local welfare office requiring a second visit. I am very heartened by today s hearing as it may lead to a new era of collaboration and cooperation between the criminal justice and mental health treatment systems. Individuals who experience the tragedy of mental illness must be treated and not punished. Communities should be safe from unpredictable violence committed by a few individuals with serious mental health problems. The criminal justice system should not be over burdened with inappropriate numbers of mentally ill inmates. We can do better and we will.

LOAD-DATE: September 25, 2000, Monday