Psychoactive Drugs

1
Psychoactive DrugsTreatment of the Mentally
IllIn the Criminal Justice System

• Judge Brent A. Carr
• Tarrant County Medical Examiners
• Ninth Annual Conference
• December 18, 2008

2
What is Mental Illness?

• Mental illnesses are medical conditions that
  disrupt a persons 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

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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
  1970s.
• 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

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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.

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

1. Forced Medication
2. Restructuring of State Mental Health Hospital
   System
3. Criminal and Civil Coordination

44

• Thank You,
• Questions?
• Judge Brent A. Carr
• [phone]
• bcarr_at_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/

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• http//www.surgeongeneral.gov/library/mentalhealth
  /toc.htmchapter6
• http//www.pbs.org/wgbh/amex/lobotomist/program/
• http//www.pbs.org/wgbh/aso/databank/entries/dh52d
  r.html
• http//en.wikipedia.org/wiki/Antipsychotic
• Countless discussions with very dedicated people
  who work in this field every day