Treating Patients With Schizophrenia in the Prison System

Peter Salgo, MD: Thank you for joining us for this unique MD Magazine® Peer Exchange entitled “Appropriate Treatment for Incarcerated People With Schizophrenia”. Although statistics in the criminal justice system are notoriously poor, a conservative estimate suggests that nearly half of America’s incarcerated population is mentally ill. Correctional officers find themselves at the front lines of mental health treatment, even though they often lack clinical training. Living with any mental illness, including schizophrenia, is daunting enough for an individual—but being incarcerated can only make things worse. In this Peer Exchange panel discussion, I’m joined by a group of highly esteemed colleagues to talk about the unique and costly problem of keeping the mentally ill in correctional facilities rather than in medical treatment centers.

I’m Dr. Peter Salgo, a professor of medicine and anesthesiology at Columbia University College of Physicians and Surgeons in New York and an associate director of surgical intensive care at NewYork-Presbyterian Hospital. Now joining me for this panel discussion are Dr. Richard Jackson, a founder and an owner of the NeuroBehavioral Medicine Group in Bloomfield Hills, Michigan; Judge Steven Leifman, chair of the Florida Supreme Court Task Force on Substance Abuse and Mental Health Issues in the Court and associate administrative judge for the Eleventh Judicial Circuit Court of Florida, in Miami; Dr. Nneka Jones Tapia, former executive director of Cook County Department of Corrections in Chicago, Illinois, and now a leader in residence and licensed clinical psychologist at Chicago Beyond; and Dr. Mauricio Tohen, professor and chairman of the Department of Psychiatry and Behavioral Sciences at the University of New Mexico Health Sciences Center in Albuquerque, New Mexico.

I want to thank all of you for joining us. Let’s get started with mental health problems that we see in America’s correctional institutions. There’s a difference, right, between prisons and jails?

Judge Steven Leifman: Jails are for people usually waiting for trial. You go to prison after you’ve been sentenced to usually more than a year. The state pays for the prison; the local county pays for the jail.

You’re going to find most of the prevalent serious mental illness in jails and prisons—not so much in the federal system.

Peter Salgo, MD: What’s the difference between schizophrenia and schizoaffective disorder?

Richard Jackson, MD: Schizophrenia is a disorder of thought where patients experience hallucinations and delusions—the classic presentation of schizophrenia. Schizoaffective disorder, on the other hand, includes these cognitive inhibitions in addition to a mood disorder, either depressive or bipolar. [Patients] have a significant elevated mood or period of depression, with psychotic symptoms.

Peter Salgo, MD: A lot of medical folks et al are buying into the old “popular view” that people with schizophrenia have multiple personalities. That’s nowhere near true, is it?

Nneka Jones Tapia, Psy.D: No, the prevalence of schizophrenia in the population is somewhere around 1%, and the occurrence of multiple personality disorder is far less. It’s a personality disorder as opposed to a psychotic disorder.

Peter Salgo, MD: Schizophrenia certainly is an important problem, but let’s pull everything in if we can: What percentage of the incarcerated population is mentally ill? Do we have a number? Is it reliable?

Judge Steven Leifman: There was a study done by Dr. Stedman and the Ochsner Health System, who found that about 17% of the population in jail have a serious mental illness. Furthermore, 33% of the overall population of incarcerated women have a mental illness, whereas 14% of men do. We know this because trauma has a significant etiologic role. One of the worse statistics you’ll hear is that 92% of women in jails and prisons in the United States with serious mental illnesses were sexually abused as children. This is a major contributor primarily because we do not identify the early signs of mental illness when they arise in children and therefore are unable to administer timely, preventive treatments.

Nneka Jones Tapia, Psy.D: In larger cities, we’re seeing increased rates of trauma-related patients who are mentally ill. Like in Chicago, we conducted a study with the Illinois Criminal Justice Information Authority and found that almost 90% of people entering the criminal justice system had a history of trauma—that’s something we don’t often talk about in the correctional world.

Peter Salgo, MD: Is that men and women?

Nneka Jones Tapia, Psy.D: Correct.

Judge Steven Leifman: It’s about 75% of men and 92% of women.

Peter Salgo, MD: I’m flabbergasted that it hasn’t really been made public. Is it because we don’t want to talk about it?

Judge Steven Leifman: And why aren’t pediatricians and schools screening for these issues at an early stage to prevent these folks from growing up in our criminal system?

Peter Salgo, MD: All right, Your Honor, let me pose that question to the panel: Why aren’t pediatricians and other clinicians who have a responsibility to protect our children screening for early signs of mental illness?

Richard Jackson, MD: Unfortunately, it’s not easy to screen for severe mental illness. For the most part, mental illness presents later in adolescents and early teens.

Peter Salgo, MD: I think his point was not so much mental illness but trauma.

Judge Steven Leifman: Right.

Nneka Jones Tapia, Psy.D: And we can’t screen for ACEs [adverse childhood experiences] in schools.

Judge Steven Leifman: Exactly.

Nneka Jones Tapia, Psy.D: Especially if we’re talking about real mental health parity. Schools and pediatricians should be looking at screening for trauma because we know the high rates of people with trauma ending up in the correctional institutions—it’s the mismanagement of funds.

Peter Salgo, MD: Well, why don’t we?

Mauricio Tohen, MD, DPH, MBA: I think it’s important to point out that we’re talking about serious mental illness, and although schizophrenia naturally comes to mind, in fact, the majority of individuals with serious mental illness do not suffer from schizophrenia but bipolar disorder, depression, or trauma.

Peter Salgo, MD: Nonetheless, schizophrenia is still a big problem.

Judge Steven Leifman: They tend to be the highest utilizers of the criminal justice system. We conducted a study where we wanted to define the highest utilizers of the criminal justice system in mental health services in the Miami Dade County correctional facility. The University of South Florida has this incredible capacity to identify this population because they possess a significant amount of data on the criminal justice system.

We sent them the names of thousands of people who have been through the system because we wanted to see whether we could wrap our hands around a smaller subpopulation. They narrowed it down to 97 people: primarily men, people with schizoaffective and schizophrenic disorders, the homeless, co-occurrents, and people who, over a 5-year period, were arrested 2200 times. They spent 27,000 days in the Dade County Jail and 13,000 days at some type of psychiatric facility. It cost taxpayers $13.7 million, and we got nothing for it. It was mostly people with schizophrenia because the treatments in the community are not effective enough.

Transcript edited for clarity.