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Chapter 11: Public Safety and Corrections
Improve the Treatment
Received by Mentally Ill
Persons Held in
Custody
Summary
The growing population of mentally ill offenders in the Texas Department of
Criminal Justice (TDCJ) is not receiving new, more effective medications for the
treatment of schizophrenia and other psychoses. The Texas Department of Mental
Health and Mental Retardation (MHMR) has developed a nationally recognized
“medical algorithm” system that provides consistent treatment using
the most effective medications. TDCJ and the Texas Youth Commission should
review the cost benefits of MHMR’s system to determine its potential for
long-term savings from reduced prison hospitalization, better patient
functioning, and fewer repeat offenses by mentally ill offenders.
Background
At present, more mentally ill Texans can be found in prisons and county jails
than in state mental hospitals.[1] From 1988 to
1998, the number of mentally ill offenders housed in the TDCJ facilities
increased at a higher rate than the total prison population. In 1998, 15,716
mentally ill offenders were being treated in the prison system, about 11 percent
of the total prison population of 143,803.[2]
(This does not include the number of prisoners who refuse treatment, fail to be
assessed correctly, or have a prior history of mental illness but no current
symptoms.)
In 1999, the Texas Youth Commission (TYC) assessed 42 percent of its
population as emotionally disturbed (2,309 of 5,524 youths). TYC had only 341
beds available for their treatment.[3]
Upon release, mentally ill inmates commit new offenses at a higher rate than
other inmates. Compared to the general population, they are more likely to have
three or more prior convictions.[4] Improved
treatment of the mentally ill while incarcerated and following release,
therefore, may be one answer to lowering the state’s recidivism rate.
TDCJ’s services for the mentally ill include both inpatient treatment,
which requires confinement in a mental hospital, and outpatient treatment, which
provides medication and/or counseling to offenders capable of functioning in the
general prison population. At present, TDCJ does not use some state-of-the-art
medications and treatment options because of their higher cost.
Texas Medication Algorithm Project
MHMR has developed the Texas Medication Algorithm Project (TMAP) to provide
consistent treatment options for three major types of mental illness:
depression, bipolar disorder (manic depression), and schizophrenia. Medical
algorithms are processes designed to integrate available research information
with clinical experience to develop user-friendly, step-by-step decisions for
treatment.
Under TMAP, a patient is treated with the most effective medications first,
because the longer a psychotic episode goes untreated, the longer it will last
and the worse it is likely to become. The newer medications used in TMAP cost
more than older drugs but have fewer negative side
effects.[5] A preliminary MHMR evaluation of TMAP
demonstrated improvements in patients’ conditions. TMAP has been
nationally recognized, and has received a grant for more than $300,000 from the
Robert Wood Johnson Foundation for the education of other states’ mental
health agencies.[6]
MHMR will report on TMAP’s clinical outcomes by the end of 2000, and it
will report on its cost outcomes in Spring 2001. This study is one of the most
extensive of its kind with more than 1,400 participants. Dr. Steve Shon,
MHMR’s medical director, believes TMAP could be used to treat mentally ill
offenders upon release and reduce their recidivism rate. Correctional systems in
other states, including California, Ohio, and Missouri, recognize TMAP’s
value and are working toward constructing similar
systems.[7]
Children’s Medication Algorithm Project (CMAP)
MHMR has also created the Children’s Medication Algorithm Project
(CMAP) for the treatment of childhood depression and attention
deficit/hyperactivity disorder (ADHD). CMAP emphasizes proper assessment and
diagnosis, the exploration of all treatment options, the use of the most
effective medications with the fewest side effects as first-line treatments, and
appropriate psychiatric follow-up.
At this writing, MHMR is testing CMAP at four community mental health
centers. A study summarizing the results of this pilot project should be
completed in Spring 2001. The next phase of CMAP will evaluate the algorithm
treatment for benefits and cost.
Drug Costs
Older drugs used to treat mental illness cost, on average, $250 a year per
patient, while newer, more effective drugs cost on average of $3,000 a
year.[8] Even so, the newer medications represent major innovations in
the treatment of schizophrenia and other psychoses. A national study has shown
that the use of these newer drugs reduces the use of expensive mental health
services such as hospitalization, thus offsetting the medications’ higher
costs.[9]
The TMAP and CMAP studies are expected to show additional economic benefits,
such as reductions in the number of inmates and juvenile offenders in TDCJ and
TYC psychiatric hospitals and reduced recidivism. Furthermore, reducing side
effects and increasing the ability of the mentally ill to function should reduce
the number of aggressive outbursts and increase safety within the prison
system.
Recommendations
- The Texas Department of Criminal Justice (TDCJ)
should review the costs and benefits of the Texas Department of Mental Health
and Mental Retardation’s (MHMR’s) Texas Medication Algorithm Project
to determine how it could be applied to mentally ill inmates in
TDCJ.
The cost benefit results from MHMR’s TMAP study should be completed in
fiscal 2001, giving TDCJ enough time over the next biennium to review the data
and determine its benefits and costs for the prison population.
- The Texas Youth Commission (TYC) should review the
benefits of MHMR’s Children’s Medication Algorithm Project (CMAP) to
determine how it can be applied to children in TYC
facilities.
TYC should review MHMR’s CMAP and determine its potential benefits for
juvenile offenders with major depressive disorder and attention deficit
hyperactivity disorder. Early treatment can have a long-lasting effect on
children with these conditions.
- The Texas Council on Offenders with Mental
Impairments (TCOMI), in conjunction with the Texas Criminal Justice Policy
Council (TCJPC), should oversee the review conducted by TDCJ and TYC and report
on its results to the Legislature.
TCOMI’s oversight of TDCJ’s review will help safeguard the best
interests of mentally ill offenders. TCJP’s experience with cost analyses
will be beneficial to TDCJ and TYC.
Fiscal Impact
These recommendations would have no fiscal impact. TMAP is an innovative,
nationally recognized program that should be reviewed by TDCJ and TYC to
determine its implications for their populations.
If the cost-benefit analysis of TMAP and CMAP shows favorable results and
the TMAP and CMAP models are implemented, the cost of treating the mentally ill
populations in TDCJ and TYC would increase, and these costs could be paid from
funds appropriated to the Correctional Managed Health Care Program. Long-term
savings from reduced prison hospitalization, better patient functioning, and
reduced criminal justice costs should outweigh higher medical costs. Reducing
the number of high-cost mentally ill offenders in state prisons would allow the
state to redirect funding to support better treatment.
[1] Interview with Dee
Kifowit, executive director of the Texas Council on Offenders with Mental
Impairments, July 18, 2000.
[2] Texas Criminal Justice
Policy Council, The Public Mental Health System in Texas and Its Relation to
Criminal Justice (Austin, Texas, February 2000), p. 18.
[3] Texas Criminal Justice
Policy Council, The Public Mental Health System in Texas and Its Relation to
Criminal Justice, p. 20.
[4] US Department of Justice,
Bureau of Justice Statistics, Mental Health and Treatment of Inmates and
Probationers: Special Report (Washington, DC, July 1999), p. 5.
[5] Interview with Dr. Steve
Shon, medical director, Texas Department of Mental Health and Mental
Retardation, Austin, Texas, March 23, 2000.
[6] Telephone interview with
Dr. Steve Shon, medical director, Texas Department of Mental Health and Mental
Retardation, Austin, Texas, July 14, 2000.
[7] Telephone interviews with
Dr. Lynn Crismon, co-director of the Texas Medication Algorithm Project,
University of Texas Southwestern Medical Center, Dallas, Texas, July 19 and
October 9, 2000.
[8] Telephone interview with
Dr. Steve Shon, November 2, 2000.
[9] Christopher G. Fichtner,
Patricia Hanrahan, and Daniel J. Luchins, "Pharmacoeconomic Studies of Atypical
Antipsychotics: Review and Perspective," Psychiatric Annals 28:7 (July
1998), p. 381.
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