SERIOUS MENTAL ILLNESS COOCCURRING SUBSTANCE ABUSE DISORDERS Stephen

SERIOUS MENTAL ILLNESS & CO-OCCURRING SUBSTANCE ABUSE DISORDERS Stephen S. Goss, Judge Superior Courts of Georgia Albany, Georgia Colorado Drug Court Conference April 26, 2011

Largest mental hospital in U. S. ? Los Angeles County Jail with 3, 000 MI inmates every day Earley, Pete, Crazy: A Father's Search Through America's Mental Health Madness (Putnam, 2006)

Transinstitutionalization

Mentally Ill Inmates n n n Lack of community treatment-ER time police Jails de facto treatment centers(i. e. LA & Rikers) 10 -15% Inmates on Mental Health Rx(APA; DO. Co. Jail) SSI and funding issues Human vs. tax cost: jail, legal, child, ER Homeless shelters

STIGMA n n n Fear- cannot see it; no objective tests Fear- what is hard to understand TMI( too much info)-not MH issues Hushed tones/whispers “He’s not right”

Olmstead 527 U. S. 581 (1999) Under ADA Title II, states are required to provide community based MH treatment when recommended and if placement can be reasonably accommodated

SERIOUS MENTAL DISORDERS n n n Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM-IV), American Psychiatric Association Bipolar Disorder (Manic Depression) Schizophrenia Mood Disorders Developmental Disabilities Organic/Traumatic Brain Injuries

DSM-IV Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I- clinical disorders: mental illness ( i. e. schizophrenia; bipolar disorder) and substance related disorders n Axis II-Personality Disorders ( ie antisocial; obsessive-compulsive) and mental retardation n

DSM-IV Axis III- General Medical Issues (diabetes; HIV; hepatitis) n Axis IV-Psychosocial and Environmental Factors(homeless; death of spouse) n Axis V- Global Assessment of Functioning n

Challenges with COD Population n n Diverse and complex problems No one clinical approach “fits all” Expectation, not exception Personality disorders, learning disabilities and health issues impact treatment plans

“They have been here Mr. Mulder” ( you deal with the same folks anyway)

Case Scenario n n n n Returned to Community Outpatient Treatment and Medicines Life Stressor(i. e. family or job) Decompensates- No Rx or Drugs & Alcohol Public Safety Call Combative or “mercy booking” Importance to Judge- Revolving Door Cases

The Headache Analgesic Symptoms-Cause

WIIFM? “What is in it for me? ” Better docket management n Cut down on the frantic calls from the jail n “Pay me now or pay me later” n

Compare Drug Courts/MH Courts n n Similar- high incidence of cooccurring issues Self-medication judicial reviews/team approach Drug testing n n n Differences-smoking cocaine is illegal Schizophrenia is not a crime Incentives /sanctions have to be more individualized with mh participant

JAILED WITH MENTAL HEALTH ISSUES n n Homeless Practically homeless-worn out welcome Housing, economic and lifestyle instabilitylack of Rx regimen History of trauma: sexual, domestic violence

JAILED WITH MH ISSUES n n n Possible security issues: decompensated, combative with jailers Increased suicide risks Other poorly managed chronic medical issues (HIV, diabetes, hypertension)

Jail: Treatment Disruption n n Decompensated on entry Formulary only: side effects Loss SSI Rx Gap: Leave jail until Dr. appt.

Sequential Intercepts n n n Where /how are you screening? Challenges of large jurisdictions CIT Jail staff/nursing staff GAINS ( handout page)-Brief MH Jail Screen Do not have a separate MH Court

Sequential Intercepts-GAINS

Screening n n Red Flags Jails routinely screen for other purposes - security classifications History of violence, health issues, suicide risks etc. Quick Overview/Non-clinical

GAINS “APIC” Model n n Assess- ( clinical and social needs) Plan- (treatment and services) Identify- (community programs) Coordinate-( try to avoid gaps)

Assessments n n n Clinicians if available- at times, in context of a competency evaluation Look at your program criteria- Axis I; Developmental Disabilities; Traumatic Brain Injuries Criminal Risk assessments; Social Needs Like a jury- who to exclude vs. who to accept You are a judge, not a doctor-DO NOT prescribe from bench

Factors n n Sometimes sobriety “clears the haze” and the mh symptoms rise to the surface History-treatment, special education classes Unusual appearance, thoughts, speech patterns, movements Hearing voices/seeing images

Factors n n n Lethargic/bursts of energy Sleep pattern disruptions History of trauma-vets; abuse victims

Integrated Treatment n n Not parallel or sequential Treat each disorder ( SA and MH)as primary and seek integrated treatment

FAMILY n n Exhausted-end of rope Role reversal with adult mentally ill “child” and elderly parents Can help with case management Can try to manipulate when get the case “out of the ditch”

Frustration n n Mentally ill defendants-sick and tired of being sick and tired Cf. criminal justice motivations Tired of the cyclical pattern of criminal justice system Families- Role reversal for elderly/adult child All tired of gaps in system

DEVELOP RESOURCES Plan vs. “grip and rip” ( have a “Hon” meeting) n n n Forensic Services, State Hospital: ACT Community Services Board Local Medical Community Local Disability Groups, particularly on transportation and housing issues If more limited program, look into nurse with MH/SA treatment background for jail assessments and referrals

DEFINING A “WIN” n n Do not expect perfection-crisis frequency reduction is a win Episodic crisis events It is an illness –manage not cure Do not cherry pick- lawyer settling too many cases

QUESTIONS? Definition of “Insanity”Doing the same thing the same way over and over again expecting a better outcome.