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Stopping the revolving prison door for the mentally ill

A pilot project examines ethics and policy issues involving mental health care in correctional settings.

A young man is released from prison after serving 10 years for assault. But he has only a few days' supply of a prescription for his mental illness, and his family has no idea what kind of treatment he has been receiving inside—or even what his diagnosis is.

Within less than a week, he is staying up all night, pacing and yelling. He hurls glasses at the refrigerator before charging outside with a knife and bumping into someone who thinks she's being attacked.

So she calls 911 and presses charges, sending the man back inside, illustrating the "revolving door" of the mentally ill who endlessly cycle in and out of incarceration, according to Dr. Michelle Joy, chief psychiatry resident at the Hospital of the University of Pennsylvania.

Finding a way to close this revolving door is one of the many goals of a pilot project that Joy and a team of other health care providers, bioethicists, sociologists, advocates—including former Philadelphia police commissioner Charles Ramsey—are collaborating on at Penn.

"Jails should not be the place where people receive mental health treatment on the scale that it occurs now," Ramsey said at an April meeting of the Ethics of Correctional Psychiatry Working Group.

The goal of the team, which I am working with as a freelance writer, is to develop a new line of research to study ethics and policy questions involving mental health care in correctional settings, starting at the "front door" when mentally ill people are arrested.

Funded by Penn's Leonard Davis Institute of Health Economics and part of the Scattergood Ethics Program at the Perelman School of Medicine, the group will also draft policy proposals about how to improve correctional mental health care and divert more individuals to outside treatment.

"We have a shadow behavioral health care system inside jails and prisons," said Dominic Sisti, assistant professor of medical ethics and health policy at Penn and director of the Scattergood program. "The field of bioethics has an obligation to attend to unique issues in correctional settings."

Sisti's department estimates that of the more than 2.5 million people in U.S. prisons and jails, 50 percent suffer from some form of mental illness—with 15 to 20 percent of them experiencing a serious mental illness.

"Through conceptual and empirical work, we hope to bring a renewed and necessary focus on the ethics of treating mentally ill individuals in correctional settings," said Sisti, who is spearheading the ethics in correctional psychiatry team.

The group recently invited Ramsey, who retired in January after eight years at the helm of the Philadelphia Police Department, to participate in the project because of his experience with officers encountering mentally ill people on city streets.

Ramsey also served as chief of the Washington, D.C. police force after a long tenure on the Chicago force. He is now a distinguished visiting fellow at Drexel's Lindy Institute for Urban Innovation.

"If the person doesn't have to go to jail, then I'm all for it," Ramsey said. "The question is, 'What's the alternative?'"

He suggested that crisis intervention teams were a key resource for police when dealing with the mentally ill who are involved in crimes.

The group discussed the idea of having community based triage centers where police could take individuals for evaluation by mental health professionals. They  would need to be open 24 hours a day.

"Then we can get that person the help and treatment they need and hopefully avoid jail," Ramsey said.

Chris Feudtner, a medical ethicist and pediatrician with the Children's Hospital of Philadelphia, suggested the possibility of telepsychiatry for real-time evaluations of people on the street.

But the unfortunate reality right now is that many people with serious mental illness who commit even minor infractions are locked up, making over-crowded prisons and jails responsible for mental health services they are ill equipped to deal with.

"The police are called on to do too much, and the health care system is not doing enough," Sisti said. "The whole idea that the police are now front-line mental health workers shows that we've abdicated our responsibilities as health care professionals."

"The police in their best efforts aren't equipped with the tools"—psychiatric medications, for example, that only physicians and nurses can administer­—"to de-escalate some of these situations," added Cyndi Rickards, an assistant professor in the Department of Criminology and Justice Studies at Drexel.

Dr. Philip Candilis, director of the forensic psychiatry fellowship at St. Elizabeth's Hospital in Washington, described a jail diversion program in Arlington, Va., where courts work with social service agencies to aid people struggling with mental illness who find themselves in trouble with the law. Mental health courts in Philadelphia and Washington function in a similar way.

"Our department of behavioral health makes a serious effort to work with police officers so that our vulnerable patients receive treatment rather than punishment," Candilis said via email.

To further study the revolving door dilemma, Sisti and his team plan to conduct focus groups with everyone from police and correctional officers to incarcerated individuals and psychiatrists. Then they will draft policy proposals and submit scholarly literature on their findings.

The correctional psychiatry team also  expects to  hold an interdisciplinary conference in the fall to examine the need for more inpatient and community based psychiatric treatment opportunities for individuals who might otherwise be incarcerated.

Courtenay Harris Bond is a freelance writer and serves as an editorial consultant for Penn's Department of Medical Ethics and Health Policy.

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