Ann Kasper has been a keen advocate for persons with mental illness and a witness to the justice system as it pertains to persons who are ill. Her past seven-part video series, A Commitment To Dignity, is available via this web site.

In Advocate for Wellness – Mental Health Court, Ann talks with Richard Baldwin, a Multnomah County Circuit Court judge who presides over the County’s mental health court, Sandy Haffey, manager of Safety Net Services for Multnomah County’s mental health division, and Aaron who is a former participant in the County’s mental health court.

READ – Trial Effort, Portland to Get Pilot Mental Health Court, Portland Mercury, May 1, 2008

The idea may seem preposterous. But the authors of a new study weren’t laughing when they announced they had identified signs of schizophrenia in babies only a few weeks old.

Cute baby. What meds is she taking? (Photo: Flickr.com/tiarescott)

A group of researchers led by John H. Gilmore, MD used ultrasound and MRI to look for brain abnormalities in 26 babies born to mothers with a diagnosis of schizophrenia, along with 26 babies in a “healthy” control group.

Gilmore said the high-risk babies had abnormally large brains, with larger ventricles (fluid-filled spaces in the brain). The differences only showed up in male babies, but Gilmore said that was characteristic of schizophrenia as well, explaining that the illness is more frequent and severe in men.

A Twist of Logic

In other words, when the girls in the high-risk group showed no brain differences at all, Gilmore managed to link the non-results to the illness he was looking for.

And the boys? Gilmore’s press releases do not mention how many male babies actually had brain differences, simply saying that enlargement was present “overall.” At this writing, the full article was only available to paid subscribers to the American Journal of Psychiatry, and the abstract omits exact numbers.

Gilmore, however, was confident enough to envision a brave new world of infant psychiatry. The study, he said, “allows us to start thinking about how we can identify kids at risk for schizophrenia very early and whether there are things that we can do very early on to lessen the risk.”

Milk, Cookies, and Prozac

Is Gilmore talking about drugging babies before they’re a month old? Gilmore doesn’t say that – not quite. He edges quite close, however, with his hopeful assertion that this line of research “will help us target interventions.”

In fact, drugging babies is not that far-fetched, considered along with psychiatry’s progression over the last few decades. Investigative journalist Robert Whitaker, in his groundbreaking new book, “Anatomy of an Epidemic,” traces a path that has led to medicating children on a grand scale.

Whitaker notes that drugging children with psychiatric medications is a relatively new phenomenon. “Mental illness” in children and teenagers was almost unheard of until 1980, when attention-deficit disorder appeared in the DSM-III. Psychiatrists acknowledge that diagnosis mostly followed teacher complaints, not medical evaluations, but doctors were happy to offer Ritalin to fidgety kids. Today, says Whitaker, around 3.5 million U.S. children take stimulants for ADHD – at last count, one in every 23 kids aged 4-17 were taking the drugs.

More Diagnoses, More Drugs

As evidence mounted that the drugs did more harm than good, psychiatrists identified more and more childhood mental illnesses requiring more and more medications. When Prozac emerged as the newest “wonder drug,” kids got SSRIs. By 2002, according to Whitaker, one in 40 kids was on an antidepressant. Drug companies spun efficacy gold from studies made of straw, while keeping the risks quiet. Children taking the drugs paid a price in physical and mental side effects.

The march of psychiatric progress did not falter, however, as doctors came up with another diagnosis that was “exploding” among kids: bipolar disorder. For many kids, who were already taking stimulants or SSRIs, symptoms of mania emerged as a result of their previous psychiatric treatment.

This, of course, required more psychiatric treatment. And the treatment, Whitaker says, involved even more powerful medications, with even greater risks and side effects. Soon, kids were taking antipsychotics and anticonvulsants before they entered grade school. Predictably, many of these kids began experiencing the side effects of these powerful drugs, such as sedation, massive weight gain, and permanent movement disorders.

History suggests, then, when Gilmore hints that medicating babies may be in the near future, we may do well not to laugh.

And history gives one of Gilmore’s remarks an ominous note.

“This is just the very beginning,” he said.

See Robert Whitaker live! Join Portland Hearing Voices for a special benefit lecture:

Thursday, August 19, 7:30 p.m.
Powell’s City of Books Downtown
1005 W. Burnside
Portland, Oregon
For more information: Portland Hearing Voices

From the Portland Mental Health Examiner, June 27, 2010

Stuart Weisberg, MD, who ran a solo psychiatry practice in Northwest Portland and planned to open an assisted suicide clinic in Sellwood, had his medical license suspended on June 24 for unrelated violations, including questionable prescribing practices.

Weisberg said his assisted suicide business was inspired by Jack Kevorkian, a pathologist and euthanasia advocate known as “Dr. Death.”

The Oregon Medical Board issued an Order of Emergency Suspension after the 38-year-old doctor violated the terms of a previous disciplinary order. Weisberg was already on probation and had agreed to meet with a practice mentor twice a week for discussion and chart review. However, earlier this month, Weisberg told the board that he would no longer meet with his mentor, who “no longer supported his ideas pertaining to practice.”

The board found Weisberg in violation of their Corrective Action Order, and added two additional cases to the evidence against him. In one case, Weisberg’s treatment of a patient with depression included Ketamine, a drug in the same class as PCP that is sometimes called “Special K.” In the second case, Weisberg signed a medical marijuana card for a patient with bipolar disorder and a history of substance abuse.

The Oregon Medical Board found that Weisberg’s continued practice would pose an immediate danger to the public and his patients, and directed him to stop practicing medicine immediately.

Weisberg recently began promoting his assisted suicide venture, “Dignity House,” a location where people with terminal illnesses could end their lives in accordance with Oregon’s Death with Dignity Act, approved in 1997.

Weisberg says he acquired the skills necessary to induce death by treating opiate addicts. His “End of Life Consultants” website details the effects of a fatal overdose, up to and including a “gurgle and a death rattle.” The menu of services includes the following:

Weisberg’s personal presence at the death, along with his therapy dog: $1,200
Camera service for a “tasteful, professionally-edited video”: $600
Catering for breakfast, lunch and dinner: $400
Media relations (8 hours with a personal assistant/beautician): $400
Linens and flowers “lovingly” picked from Weisberg’s garden: $400

Oregon’s assisted suicide law requires two doctors to evaluate the patient for depression or signs of psychological impairment that would affect their decision-making capability. The only other states that allow assisted suicide, Washington and Montana, also exclude people whose decisions may be influenced by mental illness.

In Switzerland, however, assisted suicide has been available to persons with mental illness since 2007. The Swiss law was changed after a man with bipolar disorder petitioned the court for the right to end his life, and the court agreed that a lethal dose of medication was appropriate.

READ – Portland doctor plans house where terminally ill can kill themselves, The Oregonian, June 23,2010
READ – Order of Emergency Suspension for Stuart Gordon Weisberg, MD, from the Oregon Medical Board April 8 2011
READ – Final Order for Stuart Gordon Weisberg, MD, from the Oregon Medical Board April 8 2011

From the Portland Business Journal, June 2010 – not available online

Derald Walker

Under Derald Walker’s leadership, Cascadia Behavioral Healthcare quietly turned itself around.

Two years after a financial meltdown nearly destroyed Multnomah County’s safety net for the mentally ill, the nonprofit at the center of the crisis has rebounded.

Cascadia Behavioral Healthcare Inc. is a shadow of its former self, and will bear the burden of its April 2008 near collapse for many years. Even at half its former size, however, the Portland nonprofit remains a key component of the county’s safety net.

It returned to profitability in March. CEO Derald Walker, appointed in the midst of the crisis to turn Cascadia around, hopes to build a $500,000 cash reserve by early 2011.

Two years ago, these results seemed inconceivable.

Cascadia Behavioral Healthcare runs clinics for people struggling with addiction, offered counseling to people with severe mental illness and housed poor people with mental illnesses.

But in spring 2008, poor bookkeeping put all that at risk.

State Medicaid officials had ordered Cascadia to repay $2.7 million when the nonprofit could not provide documents backing previous years’ claims. Capital Pacific Bank had demanded repayment of a $2 million loan.

Leslie Ford, who had been CEO since Cascadia Behavioral Healthcare was founded through the 2002 merger of several smaller nonprofits, had been forced out. Two consecutive chief financial officers hired to turn Cascadia around had quit, after declaring the company’s books a mess and uncovering still more liabilities.

By summer 2008, it appeared as though Cascadia Behavioral Healthcare’s programs would be dismantled and farmed out to other nonprofits. Instead, the nonprofit is paying down its debt.

“They still have to watch their pennies,” said Kathy Tinkle, business services director for Multnomah County Human Services. “But they’ve made significant progress.”

Under Walker’s leadership, Cascadia obtained a $2.2 million loan from Multnomah County and the state. It negotiated its Medicaid assessment down to $1.2 million, payable over five years.

It also relinquished its role as Multnomah County’s pre-eminent mental health care provider by transferring several of its programs to other area nonprofits in order to cut expenses.

In August 2008, Lifeworks Northwest took over Cascadia’s Gresham clinic and Central City Concern took control of a downtown clinic at Southwest 12th and Stark streets. Luke-Dorf took control of Bridgeview, a residential treatment center.

Surrendering these programs cut Cascadia’s expenses, and the nonprofit cut costs still further by consolidating office space and leaving administrative jobs unfilled.

By drawing down the county-state loan, Cascadia invested in a $250,000 medical billing system aimed at further improving the nonprofit’s finances. The system prohibits Cascadia from submitting incomplete Medicaid claims, so that it can never again be reimbursed without adequate documentation, Walker said.

These cuts are paying off for the organization, but they have also left Cascadia much smaller.

It lost $2.1 million on revenues of $55.9 million in the year ending June 30, 2008, and lost $514,000 on revenues of $42.5 million the following year. Walker expects to end this fiscal year with a surplus of at least $200,000 from a budget of $38 million.

In 2008, Cascadia provided about 80 percent of Multnomah County’s mental health services. Now it provides only 32 percent of these services.

Meanwhile, county mental health officials have undergone their own transformation aimed at avoiding more surprises like the April 2008 Cascadia meltdown.

“We have realized that we can not be in a situation where we are so dependent on a single agency,” Tinkle said.

County mental health leaders now meet quarterly with their largest nonprofit contractors, and monthly with Cascadia, to track the performance health of the nonprofits that they fund.

Jason Renaud, volunteer and secretary of the board of the Mental Health Association of Portland, applauded Cascadia Behavioral Healthcare’s turnaround, and the county’s renewed oversight.

But he also lamented a mental health system that faces stagnant funding and growing demand.

Cascadia’s front-line workers, in particular, have borne a difficult burden through this transformation.

They have not received pay hikes since 2008. With a recent increase in the portion that many pay for health insurance, a number are now taking home less than they did two years ago. Walker also cut vacation days.

A new program that manages counselor productivity can allow some employees to boost take-home pay if they increase billings as a share of total hours worked. Though many workers have embraced the program, others grumble on the growing emphasis on money in a caring profession.

Since the nonprofit’s fiscal crisis, employees have had to accept paper checks because Cascadia does not have enough of a cash buffer to implement a direct deposit system.

But unlike the crisis of two years ago, these are challenges that observers expect Cascadia Behavioral Healthcare to survive.

“Unfortunately, any nonprofit with the county is in this boat,” Tinkle said. “Our dollars aren’t growing as fast as our personnel and expenses.”

LEARN – Cascadia Behavioral Healthcare
READ – Cascadia Behavioral Healthcare, Independent Auditor’s Report, June 30, 2009 AND 2008

From the Eugene Register-Guard, June 26, 2010

The proposed facility in Junction City faces declining support from lawmakers who are worried about the cost

Opponents of a proposed psychiatric hospital in Junction City are gaining traction in their push to scrap it, because of a flagging state budget outlook that calls into question Oregon’s ability to pay the cost of staffing and running the big facility.

Advocates of community-based mental health services have for years been critical of the state’s planned hospital, the smaller of two such institutions that are part of a master plan to replace the 127-year-old Oregon State Hospital in Salem.

A consulting firm hired by the state recommended the two-hospital plan in 2006 to replace the Oregon State Hospital. A majority of legislators voted in 2007 to authorize the state to borrow money for construction of both the 620-bed Salem facility, which is being built and is to open next year, and a 360-bed hospital in Junction City, which is in the planning stage and is to begin operating in fall 2013. The state has since scaled back the Junction City hospital’s size to 270 beds, with a construction cost of $186 million.

Now, with a decade’s worth of state budget shortfalls on the horizon, some lawmakers are increasingly attuned to the arguments from longtime critics of institutionalized mental health care.

“Everybody acknowledges the fiscal reality has changed since the concept of the proposal was first put forward,” said House Speaker Dave Hunt, D-Gladstone.

The operating costs of the Junction City hospital are estimated at $214 million per biennium.

The proposed hospital, with a staff of 1,000 or more, would be good economic news for a county badly bruised by the recession. Lane County area job seekers have swamped the state with inquiries about positions at the Junction City facility.

But the groups Mental Health America of Oregon, National Alliance on Mental Illness (NAMI) and Disability Rights Oregon, along with community-based providers of mental health services, have been meeting with Hunt and other House members, seeking to convince them to reconsider plans for the hospital.

Chris Bounoff, the NAMI Oregon executive director, said the strategy — raising the issue of tight budgets as a reason to stop a facility his group has long opposed — appears to be paying off.

“People are realizing we can’t afford it, so I suspect we’ll be having more conversations about that,” he said.

Advocates, including the two legislators who represent Junction City, say the increased scrutiny is important. Even so, said Rep. Val Hoyle, D-Eugene, it still makes sense to proceed with the facility.

“If this wasn’t needed, I wouldn’t support it,” said Hoyle, whose district includes the future hospital’s site. “There’s no way around the fact that we need the beds and since we need them, Junction City is the right place to build it.”

For now, the hospital continues to have the support of many powerful officials. Senate President Peter Courtney, D-Salem, has been a champion from the start. Gov. Ted Kulongoski maintains his support for the Junction City hospital as part of the state’s comprehensive approach to mental health care, said spokeswoman Anna Richter Taylor.

But Beckie Child, board president of Mental Health America of Oregon, said Hunt and other House members have been receptive to the push to cancel the Junction City facility.

She said a meeting with Hunt gave her the impression that “he gets it.”

“He said if we had a good plan, he’d be willing to take Courtney on,” Child said. “The Senate has taken the lead on this for so long. It’s time for the House to stand up and do something.”

Hunt didn’t dispute Child’s characterization. “There are a large group of House members who have been more interested in getting more engaged in this issue, and they are. Appropriately so.”

Project needed, official says

No one is questioning the need for the new 620-bed hospital in Salem to replace the decrepit Oregon State Hospital. The new facility has roughly the same capacity as the existing one.

But Dr. Bruce Goldberg, head of the Oregon Department of Human Services, said it would be problematic to cancel the Junction City hospital plans. Oregon leases 90 psychiatric care beds in Portland and runs a facility in Pendleton with residential care for 60 mental patients. Both are scheduled to shut down by the time the Junction City hospital opens in the fall of 2013.

The new hospital in Salem won’t be able to accommodate the Portland/Pendleton patients once those 150 beds are eliminated, so the state needs the Junction City hospital, Goldberg said.

He also said the net state cost of operating the Junction City facility will be less than the $214 million projection. The $56 million Oregon currently spends biennially to house and care for those patients in Portland and Pendleton would no longer be spent, so the Junction City facility would only represent a net spending increase to the state of $158 million, he said.

Many of those skeptical about the Junction City hospital say they worry its increased operating dollars will drain money from Oregon’s community-based system of caring for people with mental illnesses.

“I don’t see how, given our budget situation, we can open a new hospital,” said Rep. Sarah Gelser, D-Corvallis. “It does not make any sense to me to fund more institutional settings when we have not adequately funded our community-based system of support.”

Kevin Campbell, CEO of Greater Oregon Behavioral Health, said the state should move away from institutions to more community-based services, such as those his company provides in Eastern Oregon and in Douglas and Clatsop counties.

“Let’s reconsider the Junction City necessity and let’s look at what a right-sized state hospital and care system would look like and ultimately put those dollars into community-based treatment operations, instead of simply sticking them in a state hospital,” he said.

Mental Health America of Oregon’s Child said ongoing problems at the Oregon State Hospital underscore the importance of moving away from the institutional model.

The U.S. Department of Justice is expanding its four-year investigation of patient care at the Oregon State Hospital and the lengthy patient stays there. This month, the state disclosed that five hospital employees were reprimanded for providing inadequate care for a patient who died there last fall.

Forensic patients an issue

Over time, Oregon State Hospital has become the destination primarily for “forensic” patients — those who committed crimes and were either unable to assist in their trial because of mental illness or were found guilty except for insanity.

The movement of these forensic patients from the state hospital into community-based treatment has been slow, limiting the space that is then freed up at the hospital for new civilly committed as well as forensic patients.

The state Psychiatric Safety Review Board holds jurisdiction over these “guilty-but-for-insanity” patients. Because the board’s statutory mission explicitly prohibits it from releasing patients who pose a danger to themselves or others, many of these patients are committed for the full length of their sentences — decades or the remainder of their lives.

That worries both critics of the state’s system and those who run it.

Goldberg said a state panel is examining the possibility of changing the statutory mandate in order to reduce the housing of forensic patients at the Salem and Junction City facilities.

Even if that happens, he said, both hospitals are needed and should not be paid for at the expense of community-based mental health budgets.

Goldberg noted that the master plan drawn up by consultants and being pursued by the state called for both components of Oregon’s system of mental health care to be improved.

“We’ve got to fund both parts of the system,” he said. “We can’t be pitting mental health in one place against the other.”

Goldberg questioned how realistic it would be to create the 16-bed community-based facilities that some hospital critics have called for in place of a large institution. He said neighborhood opposition would be fierce if the state were to site one or two dozen such facilities.

So far, the state has spent or committed about $1.5 million to $2 million for planning, design and other costs related to building the Junction City hospital on a 240-acre state-owned parcel that’s also the planned location for a prison complex.

Junction City’s city administrator, David Clyne, said the state committed to paying $30 million of the city’s $34 million cost for the first phase of adding infrastructure to serve both the hospital/prison site and nearby land the city has for years sought to develop as an industrial park.

When the cost of the wastewater treatment facility is factored in, he expects the state’s overall infrastructure cost to be as much as $50 million, with about $20 million in expenses falling to the city.

Clyne said Junction City was prepared for the possibility that both the hospital and the prison fail to materialize. He cited language in the intergovernmental contract assuring that Junction City’s costs would be shifted to the state if it decides against building its planned institutions.

“We would walk away not happy about losing the two facilities and all those jobs,” Clyne said. “But at least we won’t be responsible for any of the infrastructure development if they don’t come.”

From the Salem Statesman Journal, June 26, 2010

$175,000 contract aims to help improve mental health care

A section recently demolished of the Oregon State Hospital

The state has hired a Pennsylvania-based firm to conduct a $175,000 “quality and compliance” review aimed at improving patient care at Oregon State Hospital.

Liberty Healthcare’s looming review of the Salem psychiatric facility follows a series of investigations that found flaws and failings in patient care.

The outside review is designed to “bring a fresh and expert perspective to this complex operation,” according to the firm’s contract with the state.

The Statesman Journal obtained a copy of the contract through a public records request with the state Addictions and Mental Health Division.

READ – Liberty Health Care Corporation contract to review Oregon State Hospital

Confirmed neglect of a patient who died at the hospital last autumn prompted officials to seek the external review, said Richard Harris, director of the Addictions and Mental Health Division.

“Patient care issues are really looming (as) the largest of all the challenges we have in the hospital,” he said. “The sort of question is: How would you make sure that people were doing their jobs the way they needed to do them?”

In an e-mail sent to members of the OSH advisory board, interim hospital superintendent Nena Strickland said Liberty Healthcare has more than 20 years of experience in providing an array of quality improvement programming, specialty consultations and training.

“While these are difficult economic times, we firmly believe this one time investment will improve the future of patient and staff safety,” she said.

Liberty’s corporate headquarters are in suburban Philadelphia, according to the company Web site. The firm also has offices in California and Indiana.

Harris said the consulting firm will send a team of specialists to visit the state hospital July 12-15. A second visit is yet to be scheduled.

“The expert team shall advise OSH as to what works and what does not, and focus on where patient care is delivered on a day-to-day basis,” states the contract. “The review shall focus more on what actually happens on the units versus how the reports and minutes look.”

The consultants are scheduled to issue a draft report by mid-August and a final report by the end of September.

Though the state hospital has a quality-improvement unit, Harris said that an outside review was deemed essential by Human Services Director Bruce Goldberg and himself.

“My belief is we’re not at the proper level with that (internal) quality-improvement program, and I want an outside entity to tell us what we need to do to change it and make it more effective,” Harris said.

Liberty Healthcare’s specialists will meet with a large number of hospital employees, according to the contract.

“It is estimated that there are over 100 key management and line staff members that Contractor will want to interact with directly, either individually or in groups,” it says.

After completing their review, the consultants will “create a blueprint for action,” the contract says.

The new consulting contract comes at a time when state agency budgets are being cut by 9 percent to plug a $577 million shortfall caused by a drop in tax receipts amid the recession.

“It is difficult to find $175,000 in the hospital budget, but to me if we don’t do this we are jeopardizing the primary mission of the hospital and certainly my concern about improving patient care,” Harris said. “So I think it is an investment that will pay off in the future.”

Money for the consulting work will come out of “administrative costs and savings,” he said.

Harris and Strickland emphasized that funds used for the consulting work will not cut into the hospital’s ability to hire more front-line staffers this summer.

The quality of patient care at Oregon’s main mental hospital has been called into question by multiple investigations.

State officials recently capped the latest investigation by revealing that five hospital employees had been reprimanded for lapses in care provided to Moises Perez, the patient who died last fall.

Perez, 42, was found dead in his hospital bed Oct. 17. An autopsy determined he died of coronary artery disease.

In February, the U.S. Department of Justice sent a letter to the state saying that its review of Perez’s treatment found “alarming” failures.

Breakdowns in the patient’s care mirrored problems federal investigators reported to the state two years ago, wrote Shanetta Cutlar, chief of the Special Litigation Section of the U.S. DOJ’s Civil Rights Division.

Cutlar’s letter called for the state to take immediate action to improve patient care and protect their safety.

A separate state investigation into Perez’s care, conducted by the State Office of Investigations and Training, determined the hospital neglected Perez by failing to provide adequate medical care.

The OIT investigation triggered a shakeup in hospital leadership. Superintendent Roy Orr was forced to resign on April 2, the same day the state released results of the OIT investigation.

The state is moving forward with a search to hire a new superintendent. Last week, the field of candidates was narrowed to six from a pool of more than 30 applicants.

Harris said he hopes to fill the job by the end of July.

“I’m quite optimistic that from this pool we should be able to find somebody that should do a good job,” he said.

State officials are not releasing the names of the six candidates.

“I think that’s probably pretty much normal in a job search for a high-profile position like this,” Harris said.

By Stephen Lendman, published with permission from the SteveLendmanBlog

In July 2008, the Southern California ACLU released a “Report on Mental Health Issues at Los Angeles County” Jail by Dr. Terry Kupers, a practicing psychiatrist, an expert on long-term isolated prison confinement and correctional mental health issues. He’s also written numerous articles on these topics, and been an expert witness on the mental health crisis behind bars, what he wrote about in his book “Prison Madness.”

In May, he toured the LA County Jail system where most inmates aren’t convicted and are awaiting trial – Men’s Central Jail (MCJ), Twin Towers 1 & 2 (TT 1 & 2), and the Inmate Reception Center (IRC). He interviewed 18 prisoners in private, confidential settings; others in more casual, cell-front ones; and discussed issues with mental health and custody staff.

As in all prisons nationwide, many LA County inmates suffer “serious mental illness.” Incarceration exacerbates it. They need treatment, but aren’t getting it.

Besides prison confinement harm, state mental hospital deinstitutionalization took hold in the 1980s, part of Reagan Revolution policies that whatever government can do, business does better, so let it. As a result, large numbers of seriously ill patients were discharged, based on studies indicating community care was superior to state facilities. The consequences were predictable.

The promise was never realized because of budget cuts, unaffordable housing, and other priorities.

In 1955, state and VA psychiatric hospitals had about 550,000 patients. In 2008, there were less than 60,000, but given constraints today on budget strapped states and communities, the numbers are likely lower and dropping.

Yet according to a study by the Federal Bureau of Justice Statistics, over a million individuals suffer from significant mental illness in jails and prisons. With 20,000 detainees, some call the LA County Jail system the largest psychiatric hospital in the country (the Men’s Central Jail has 5,000), but, like elsewhere, treatment there’s not forthcoming.

Correctional setting mental illness factors:

“are complex, including shortcomings in our public mental health systems, the tendency for post-Hinckley criminal courts to give relatively less weight to psychiatric testimony, the incarceration of large numbers of drug offenders including those with dual diagnoses (substance abuse and mental illness), and the growing tendency for local governments to incarcerate homeless people for a variety of minor crimes.”

As a result, the prevalence of prison mental illness is high and rising – about 15 – 30% according to national epidemiological studies. The 2006 Special Report from the Federal Bureau of Prison Statistics titled, “Mental Health Problems of Prison and Jail Inmates,” confirms a high, unprecedented mental illness population behind bars, concluding that 64% of jail inmates suffer significantly – based on structured interviews, “not necessarily clinical diagnoses.”

A comparable 1999 study estimated 19%. The 2006 one concludes that previously homeless inmates are twice as likely to be ill, the result of living on streets or in unfavorable environments, unconducive to good mental health.

Other epidemiological studies concur with the Bureau of Justice Statistics, and despite the prevalence of inmate illness, few prisoners get help, what’s provided is inadequate, and medications only for many are stressed. Even then, they’re only given to symptomatic inmates, then withdrawn when they abate, when it’s essential they be continued. Otherwise, those in need aren’t helped.

Overcrowding and Few Inmate Programs – A Serious Problem

When the 1970s prison population was much smaller, studies showed overcrowding caused violence, mental illness, and suicides. Today it’s much worse. “One ha(s) only to tour a jail or prison to understand how violence and madness were bred by the crowding.”

Imagine a small dormitory expanded to house 150 prisoners – the situation in LA County Men’s Central Jail with bunk beds lined up in rows. “A prisoner cannot move more than a few feet away from a neighbor, and lines form at the pay telephones and the urinals.”

It’s the same with four men crammed into small cells with barely enough room to get off bunks for any reason. The cells have no chairs, desks or any space but bunks to sit or lie on. It’s enough to fray anyones nerves, but with “tough men” in small spaces, altercations follow, then disciplinary action, greater anger, and inevitable mental illness for many.

“In general, as an individual prone to psychosis becomes angrier, his thinking becomes more regressed and irrational, and therefore subjecting (these inmates) to conditions that exacerbate irritability and anger (worsens) their mental illness, often precipitating a state of acute de-compensation or ‘breakdown.’ ”

For those depression prone, self-imposed isolation to escape violence or unbearable conditions deepens their problem and “leads to thoughts of self-harm.” Open rage and violence pushes some over the edge, especially with no remedial treatment. Also, mentally ill prisoners are prime targets for violence because they’re vulnerable. “The more violence, the more madness, and the crowding exacerbates both.”

Over the past 30 years, few constructive changes were made in jail architecture. Most cells are windowless. Recreation for most is once a month. For many, none at all, even though they’re supposed to have three times a week minimum. Even the Medical Disability/Stepdown area (6050) is deplorable.

“Men in wheelchairs, on crutches, and otherwise disabled were stuffed like sardines into long interconnecting, dark rooms with far too many bunk beds for them to be able to walk around.” Absent are desks and chairs, and moving between bunks requires others to make way.

Under conditions of overcrowding and little rehabilitation, prisoners are idle – the result being worse traumas and abuse for many. Loners are especially vulnerable, an easy target for rapists or others to vent anger without retaliation.

Imagine a jail complex where 13,000 prisoners enter monthly in overcrowded quarters, others, of course, being released. But with inadequate assessments of mental illness and no treatment, inmates are on their own to survive in a very harsh environment. If they don’t follow rules, they’re in trouble, are punished, are abused by other prisoners, and their condition deteriorates.

“I was stunned by the degree of overcrowding I witnessed (on) May 8 & 9, 2008.” Inmates stay in windowless cells nearly 24 hours a day, with no furnishings except their bunk. They have poor round-the-clock lighting. It disturbs sleep and hampers reading. They’re noisy, fraying nerves. They eat there with no programs or mental health treatment possibilities. A combustible environment is inevitable, and it erupts daily.

In one Administrative Segregation Unit (2904), cells are also small (about 5 x 6 feet) with no windows and solid doors always closed. Isolation produces claustrophobia, suffering, and serious psychiatric harm.

“Throughout the Men’s Central Jail (MCJ), the cells and dormitories violate minimum standards in terms of both social and spacial density (including) compensatory out-of-cell time for jail prisoners confined in substandard cells or dormitories. (It’s) intolerable to leave prisoners in harsh, crowded conditions that we know cause psychiatric breakdown.”

Conditions also affect staff. They get impatient, angry, and take it out on inmates for minor infractions. They, in turn react, and the longer they’re incarcerated awaiting trial (at times years), the worse their condition becomes.

Like the MCJ, conditions in the Twin Towers are poor. Yet some positive mental health programs are in place, including inpatient beds in the Forensic Inpatient Program (FIP), crisis intervention/observation capabilities in TT 1, a step-down or subacute mental health unit, mental health housing, pre-release linking with community mental health services, and Jail Mental Evaluation Teams (JMET). The latter are “excellent in concept,” but inadequate in implementation, prisoners outside mental health housing units saying they’re not helped.

For the most part, little besides psychotropic medications are provided. Yet prisoners complain about not getting them or having them discontinued, their charts corroborating their accounts. Most inmates needing help wait weeks or months to be seen, that at best lasts a few minutes. Others are never seen because of too few staff to handle large numbers in need.

“I was told repeatedly by prisoners that there is nothing available in the way of mental health treatment except the prescription of psychiatric medications. This is far from adequate mental health treatment….There is a Pattern of Failure to Diagnose and Inappropriately Down-grad(e) the Diagnoses of Prisoners who Cannot be Accommodated in Mental Health Housing.”

Some inmates are never diagnosed despite complaining of “significant psychiatric history.” Others, seriously ill, are “un-diagnosed;” for example, Schizophrenia to a personality disorder, an “adjustment disorder,” or “malingering.” Without treatment, symptoms inevitably worsen, often jeopardizing inmate safety.

“It is important to note that serious mental illnesses are, mostly, lifetime conditions that pursue a waxing and waning course. An individual suffering from Schizophrenia might go into remission,” especially if properly medicated, but it doesn’t mean he’s cured. Future eruptions can happen anytime and do. Under LA County Jail conditions, a complete breakdown or suicide can result.

“It is striking how indifferent mental health staff are to evidence of serious mental illness by history – past hospitalizations, Social Security Disability benefits, or even competency evaluations.” Instead, they focus only on current symptoms, and do it poorly by misdiagnosing.

Disciplinary Housing Exacerbates Mental Illness and the Potential for Suicide

A “disproportionate number of prisoners with serious mental illness predictably wind up in punitive segregation.” Besides harming them further, it contributes to a greater pandemonium level throughout the prison population because of their screaming and irrational actions like throwing feces at guards.

“Human beings require some degree of social interaction and productive activity to establish and sustain a sense of identity and to maintain a grasp on reality.” Absent these, paranoia and an inability to control rage increases.

Segregated inmates do what they can. Some pace relentlessly. Others read and write letters, but many are illiterate. They fare worst in isolation. Anxiety, hallucinations, anger, obsessions, and/or despair result.

In isolation, previously healthy inmates develop psychiatric symptoms, including anxiety; rage; claustrophobia; panic attacks; headaches; lethargy; heart palpitations; violent fantasies; depression; and/or trouble focusing, remembering or sleeping.

Conditions “that cause emotional distress in relatively healthy prisoners cause psychotic breakdowns, severe affective disorders and suicide crises in prisoners who have histories of serious mental illness, as well as in (some) who never suffered a (previous) breakdown….”

Enough stress can break anyone, and “once an individual crosses a line into psychosis or depressive despair, it is very possible that (removing harsh isolation won’t be able) to bring him back to a normal mental state.”

Staff abuse is also a major problem. Based on widespread inmate reports, they’re excessive, including severe beatings, compounded by the stress of overcrowding and inmate-on-inmate violence.

Recommended Remedies

They’re often made but ignored, including:

Reduce overcrowding;

Increase mental health treatment by competent staff;

Provide diversion for seriously ill prisoners;

Institute early release programs for outside treatment;

Address forced idleness, lack of recreation, and the need for more time out of cells – in day rooms, cafeterias, anywhere for needed relief;

Improve lighting and provide desks and chairs;

Remove mentally ill prisoners from overcrowded, toxic environments;

Create more housing for treatment and improved safety for the mentally ill;

Keep them out of segregation and disciplinary housing; they need mental health treatment in a proper setting;

Greatly expand mental health housing;

Halt harmful diagnosis down-gradings;

Properly evaluate psychiatric histories;

Improve JMET interventions and provide better outpatient services in the general prison population and other jail areas;

Provide a range of mental health services;

Have enough competent staff to serve needs;

Increase substance abuse treatment;

Provide more comprehensive post-release planning, including housing, medication, and other social services;

Increase staff training;

Take steps to reduce custodial abuse; and other remedial measures.

Whatever the cost, it’s small compared to readmissions, a larger inmate population, and the toll on society when ill or abused prisoners return to communities.

Stephen Lendman lives in Chicago and can be reached at lendmanstephen@sbcglobal.net. Also visit his blog site at sjlendman.blogspot.com and listen to cutting-edge discussions with distinguished guests on the Progressive Radio News Hour on the Progressive Radio Network Thursdays at 10AM US Central time and Saturdays and Sundays at noon. All programs are archived for easy listening.

From the Salem Statesman Journal, June 25, 2010

How long patients stay and where they go afterward is focus of concern in letter

Federal investigators are expanding a four-year investigation into the Oregon State Hospital, newly released correspondence shows.

The U.S. Department of Justice, in a recent letter to the state, signaled the agency’s intent to examine how long patients stay at the crowded mental institution in Salem, hospital discharge planning and the availability of community mental health facilities for patients deemed ready to leave OSH.

Hospital critics long have maintained that patients stay cooped up for excessive stints of hospitalization, partly because of stringent release practices by the state Psychiatric Security Review Board and partly because of a shortage of community facilities for patients deemed ready to leave OSH.

The Statesman Journal obtained the DOJ’s letter this week through a public-records request with the Oregon Attorney General’s Office.

Mental health advocates said Thursday that they were encouraged by the new development in the prolonged federal investigation of the state hospital.

“They’re asking the right questions,” said Chris Bouneff, executive director of NAMI Oregon, a chapter of the National Alliance on Mental Illness. “The truth is, you can make the nicest facility in the world but if you’re there year upon year upon year and not getting out, conditions will remain abhorrent.”

It’s crucial to examine how and why some patients move into community homes and facilities while others languish at the state hospital, Bouneff said.

“The mistake the state has made throughout this whole thing is to focus on the state hospital as if it exists in isolation and what happens within its walls is the only thing that needs to be tweaked,” he said. “I think the U.S. DOJ is clearly on the right path here. My hope is that a letter like this will shake people awake, but it remains to be seen.”

Tony Green, spokesman for Attorney General John Kroger, said the state plans to respond next week to the U.S. DOJ letter. He declined to elaborate.

The scope of the new line of federal inquiry was outlined in a June 9 letter from David Deutsch, senior trial attorney for the Special Litigation Section of the U.S. DOJ’s Civil Rights Division, to Micky Logan.

Itemized in the federal lawyer’s letter are 12 requests for state documents and data, including a statistical breakdown of the number of patients whose hospitalization falls within specific time periods.

About half of Deutsch’s requests centered on gathering information about community mental health programs, services and providers. He asked the state to provide:

-The names and capacity of community providers/facilities that have been used in the past two years for patients being discharged from OSH.

A list and description of all available alternative community services and supports for patients being discharged from OSH, including locations, capacities, eligibility requirements and waiting lists.

A list and description of mobile mental health services available in the community for patients being discharged from OSH.

All current policies, procedures and guidelines related to participation of community mental health providers in hospital patients treatment and discharge planning.

A list of any current OSH patients or guardians who have objected to patient placements in the community, and copies of the treatment plans for those patients.

A description of all efforts undertaken by the hospital in the last year in accordance with the facility’s program for discharge planning and community integration.

Bouneff said the feds appear determined to dig into sluggish discharge practices that cause some patients to lose hope.

“I don’t necessarily see it entirely as how (the patients) fare outside, but I do see (the U.S. DOJ) asking about getting people outside,” he said. “Are they discharge planning? Are people who are deemed ready to be discharged getting out? Where do they go? What is the planning like? These are all important questions that have to be asked to figure out whether or not the hospital is actually doing its job.”

Wednesday is the U.S. DOJ-imposed deadline for the state to provide the requested documents.

Richard Harris, director of the state Addictions and Mental Health Division, said Thursday that the hospital has been gathering information to respond to all of the federal agency’s requests.

“They asked a lot of questions in there and both my office and the hospital right now are working to answer those questions,” he said. “When we send them an answer back that information will be available to everybody.”

The U.S. Department of Justice began investigating OSH in June 2006. The feds threatened legal action two years ago if Oregon did not fix numerous defects in patient care and hospital conditions. The state responded by launching new treatment programs, hiring hundreds of new hospital employees and moving forward with construction of a new 620-bed, $280 million replacement hospital in central Salem.

But mental health advocates have continued to criticize patient care. They think federal court oversight of the state hospital is necessary to hasten reforms and stop what they describe as a pattern of patient abuse and neglect at the 127-year-old mental institution.

Beckie Child, board president of Mental Health America of Oregon, said Thursday that the U.S. DOJ’s new line of inquiry is in keeping with the Obama administration’s aggressive handling of civil rights investigations.

“They have stepped up their civil rights enforcement,” she said, referring to the U.S. DOJ. “I think that they see the way to get people better is to get them the hell out of the hospital.”

READ – U.S. Dept. of Justice letter to Oregon Attorney General