Transcript Psychoactive Drugs - Tarrant County, Texas

Psychoactive Drugs
&
Treatment of the Mentally Ill
In the Criminal Justice System
Judge Brent A. Carr
Tarrant County Medical Examiner’s
Ninth Annual Conference
December 18, 2008
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.
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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.
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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
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Population
U. S. Adult Population (18yo +):
229,500,000
Tarrant County Adult Population:
1,350,000
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How Many Are Mentally Ill?
Adult Population (18yo +) Diagnosable
Mental Illness Given Year:
United States: 60,129,000 (26.2%)
Tarrant County: 353,700
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How Many Are Mentally Ill?
Adult Population Serious Mental Illness
United States: 13,740,000
Tarrant County: 81,000
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General Population vs.
Confined Population 2005
60
50
40
30
20
10
0
Conf Pop MH
Disorder 55%
Gen Pop MH
Disorder 26%
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Confinement Population With
Mental Health Disorder 2005
70
60
50
40
30
20
10
0
Local Jail
64%
State Prison
Federal
55%
Prison 45%
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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.
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A Short History of MH Treatment
Bethlam Royal Hospital England,
aka Bedlam
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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").
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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.
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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.
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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
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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
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A Short History of MH Treatment
Early Treatments
• Electroconvulsive Therapy
• Metrazol (drug induced seizure)
• Insulin Shock Therapy
• Hydrotherapy
• Lobotomy
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A Short History of MH Treatment
Electroconvulsive Therapy
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A Short History of MH Treatment
Dr. Walter Freeman performs a lobotomy
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A Short History of MH Treatment
The Frontal Lobotomy
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A Short History of MH Treatment
Rise of Psychoactive Medications
1952 First Generation
1989 Second Generation
1963 Community Mental Health Centers Act
Massive deinstitutionalization
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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.
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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.
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Rise of the Drugs
Typical Antipsychotics
Haloperidol
Chlorpromazine
Fluphenazine
Perphenazine
Prochlorperazine
Thioridazine
Trifluoperazine
Levomepromazine
Promethazine
Chlorprothixene
Flupenthixol
Thiothixene
Zuclopenthixol
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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
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Rise of the Drugs
Cost range per dose
Haloperidol
(Haldol)
$ 0.05 - 2.01 tablet / ml
Perphenazine $ 0.18 - 0.43 tablet / ml
(Trilafon)
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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
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Rise of the Drugs
Atypical Antipsychotics
Abilify
Clozaril
Geodon
Invega
Risperdal
Seroquel
Solian
Zyprexa
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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
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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.
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Criminal Justice MH System
Priority Populations
Bipolar Disorder
Major Depression
Schizophrenia
Schizoaffective Disorder
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Criminal Justice MH System
Why These?
Sickest
Most expensive
normal inmate:
seriously mentally ill
Respond to medication
$50 / day
$150 / day
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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
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TARRANT
COUNTY
RESPONSE
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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
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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
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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
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Jail Diversion Coalition
MHMR & 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.
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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%
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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
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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
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Coming Attractions
1. Residential Facility, 32 total beds
•
•
16 beds for acute crisis stabilization
16 beds for residential treatment unit
2. 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
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Hot Issues
1. Forced Medication
2. Restructuring of State Mental Health
Hospital System
3. Criminal and Civil Coordination
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Thank You,
Questions?
Judge Brent A. Carr
(817) 884-3410
[email protected]
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References
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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/
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• http://www.surgeongeneral.gov/library/men
talhealth/toc.htm#chapter6
• http://www.pbs.org/wgbh/amex/lobotomist/
program/
• http://www.pbs.org/wgbh/aso/databank/ent
ries/dh52dr.html
• http://en.wikipedia.org/wiki/Antipsychotic
• Countless discussions with very dedicated
people who work in this field every day
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