Mental Health Reform - Patients turn to ER for aid
By Matthew Whittle
Published in News on August 20, 2007 1:46 PM
The face of mental illness can be seen throughout Wayne County -- in churches, in schools and at work.
But it's perhaps most recognizable on the streets, at the hospital and in the cells of the county jail.
Those places, officials said, are where many of the people falling through the cracks in the system can be found.
With state psychiatric hospitals cutting beds and making a concerted effort to reduce the amount of in-patient treatment time, many people are looking toward an increasingly complicated network of private providers -- managed locally by Eastpointe, the local management entity for Wayne, Sampson, Lenoir and Duplin counties -- for help.
For some, though, the increased number of steps toward treatment isn't working, and too often, they end up in jail.
"It's been a major problem for a while," Wayne County Sheriff Carey Winders said. "We do the best we can, but the jail is not a mental health facility. Our staff is not trained to deal with mental patients. Sheriffs across North Carolina are all faced with this same issue."
Dr. Lee McCaskill, the attending physician for the Wayne County Detention Center, estimated that at least 20 percent of the overcrowded 200 to 250 inmate population have some sort of mental health problem.
He explained that the increase in inmates with mental health problems is related to several issues -- the growing jail population that slows down the entire system, the growing recognition of mental health issues and the growing difficulty in finding treatment for the inmates, whose illnesses often run the gamut from bipolar disorder, to depression, to anxiety, to schizophrenia, to alcohol and drug abuse.
"We've always had (this problem), but before we were able to do something about it. You could get them into facilities before, but now, our hands are tied," said Maj. Ray Smith of the Wayne County Sheriff's Office.
In the past, inmates with significant psychotic illnesses that were related to their crimes could be taken to either Cherry or Dorothea Dix hospitals for evaluation and treatment prior to their court dates. Now they often must wait months for an appointment, and in most cases, the hospitals will no longer hold them, not even overnight.
"It's not like you can take them tomorrow," McCaskill said. "They wait in the jail until they can get an appointment. It takes time, and it's a little more difficult now."
Now, Smith added, it might take "as much as three months to get an appointment."
And when they finally do, a deputy has to drive the inmate to the hospital, sit and wait, and then drive him back. It's a process, he said, that often consumes the entire day and can happen once or twice a week.
Most of the time, though, because the majority of the inmates with mental illnesses are there because of petty misdemeanor crimes, they are never ordered to have a mental evaluation and can remain in jail anywhere from three months to a year awaiting trial.
In those cases, McCaskill and his staff are forced to treat the patients -- many of whom also have traditional medical problems -- in the jail.
But because his focus is on the traditional medical care, they are able to offer only medication or sedation. They are not able to offer any counseling or therapy.
"We're not mental health professionals. We don't initiate treatment in jail. We just try to make sure we continue what's already begun and stabilize them while they're here," McCaskill said.
Such efforts, though, still cost money.
Smith estimated that of the $177,000 budgeted for prescriptions and inmate "safekeeping," about 15 to 20 percent goes to mental health medication and services -- about the same percentage as they estimated there are inmates with mental health problems.
And more often than not, McCaskill and other jail officials find themselves treating the same people for the same problems.
"Most of these people aren't first-time offenders," Smith said. "Most of the time the staff at the jail know the people with mental illnesses. A lot of them are street people.
"My opinion is when they're out of jail they're not seeking medical attention. Then when it gets worse, they get in jail and scream and yell that they want their medication, and then we have to contend with it. But when they're out, they don't take it."
And that is a large part of the problem.
Once the inmate is released there is little in place to ensure the cycle won't repeat itself again and again, McCaskill said.
He explained that while he and the nurse practitioner will help inmates set up appointments with their regular psychiatrists or physicians -- if they have one -- they have no authority beyond that to monitor the inmates or make sure those plans are followed.
"They're not getting proper follow-up to ensure they're on the right programs," McCaskill said. "I think reform is making access to care more difficult. There's a lot less in-patient care for mental illnesses and I guess when you don't have enough follow-up, things tend to get out of control."
Fortunately, he said -- although it's only a small measure of solace -- most of the inmates with mental health issues are not violent criminals.
They usually are repeat offenders, but they're arrested for misdemeanors -- petty cash crimes, breaking and entering, communicating threats, trespassing, injury to property, drug charges and probation violations.
"Mental health issues are a little different in that a lot of those are not violent crimes, but are related to trespassing and other misdemeanors -- wrong place, wrong time. Frequently, the inmates are just off their meds and end up in jail," McCaskill said. "I'm more concerned with them going out and hurting themselves."
But that doesn't make it any easier for detention facility officials to watch them come and go.
"We're always concerned with the safety of the public," Smith said. "It's a two-sided sword for us. Do we keep them in here and pay the outrageous cost of medical expenses, or do we turn them out?"