CO-OCCURRING DISORDERS: DRUG/MENTAL HEALTH COURTS AND OTHER INTERVENTIONS

Stephen S. Goss, Judge Albany , Georgia Tennessee Drug Courts Conference December 5, 2012

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)

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

Transinstitutionalization

They have been here Mr. Mulder

( you deal with the same folks anyway)

Mentally Ill Inmates

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

SERIOUS MENTAL DISORDERS

Fear- cannot see it; no objective tests Fear- what is hard to understand TMI( too much info)-not MH issues Hushed tones/whispers Hes not right

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

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition

DSM-IV

DSM-IV

Axis I- clinical disorders: mental illness ( i.e. schizophrenia; bipolar disorder) and substance related disorders Axis II-Personality Disorders ( ie antisocial; obsessive-compulsive) and mental retardation

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

Challenges with COD Population

Case Scenario

Diverse and complex problems No one clinical approach fits all Expectation, not exception Personality disorders, learning disabilities and health issues impact treatment plans

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 Cut down on the frantic calls from the jail Pay me now or pay me later

Sequential Intercepts-GAINS

Sequential Intercepts
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

Compare Drug Courts/MH Courts

JAILED WITH MENTAL HEALTH ISSUES

Similar- high incidence of cooccurring issues Self-medication judicial reviews/team approach Drug testing

Differences-smoking cocaine is illegal Schizophrenia is not a crime Incentives /sanctions have to be more individualized with mh participant

Homeless Practically homeless-worn out welcome Housing, economic and lifestyle instabilitylack of Rx regimen History of trauma: sexual, domestic violence

JAILED WITH MH ISSUES

Jail: Treatment Disruption

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

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

Screening

GAINS APIC Model

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

Assess- ( clinical and social needs) Plan- (treatment and services) Identify- (community programs) Coordinate-( try to avoid gaps)

Assessments

Factors

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

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

Level of Function

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

Compare where overlap starts/stops between MH and Drug Court candidates What can you deliver? Practical issues such as ability to participate in groups How you as the judge interact in the courtroom depending on their level

Integrated Treatment

FAMILY

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

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

DEVELOP RESOURCES Frustration

Plan vs. grip and rip ( have a Hon meeting)

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

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

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