Peter Salgo, MD: Is it fair to say, based on what I’ve heard, that the correctional facilities in this country have become the de facto psychiatric crisis centers? Centers of last resort in this country—is that fair?
Judge Steven Leifman: One-hundred percent.
Richard Jackson, MD: Unfortunately it’s only getting bigger. What’s happening is, you’re getting increasing mental health programs within the correctional facility rather than having those in the centers where they should be.
Judge Steven Leifman: And we don’t raise taxes in this country—so what do they do? They take the money from the existing community system to pay for this. Over the past 10 years in the United States you’ve seen a leveling off of the number of people going into jail, but not for people with serious mental illnesses.
Mauricio Tohen, MD, DrPH, MBA: You mentioned that we have become the crisis center, but in fact in a number of cities—San Antonio and Albuquerque for example—we have what’s called a “crisis center,” and it is, again, a collaboration with law enforcement and the medical system. That is a place where the officers will bring individuals with a mental illness to be treated promptly.
Judge Steven Leifman: That’s what we should be doing—but it’s only in a minority of communities.
Mauricio Tohen, MD, DrPH, MBA: That is the way to do it.
Judge Steven Leifman: That is the route, absolutely.
Nneka Jones Tapia Psy.D: Not many are doing it, but you’re right—criminal justice institutions have become the de facto mental health institutions, and there is an issue there because, as the criminal justice institutions begin treating those with mental illness better, it’s almost like more individuals with mental illness keep ending up there. Do they not contend with the issue that they’re dealing with and push them back out to a community, which they know doesn’t have adequate resources? Or do they work hand-in-hand with the community to build up those resources?
Peter Salgo, MD: It would seem odd to me that a community, unless we change the perception, would say, “I’m going to work with the prisoners, I’m going to work with the jails.” It seems more palatable to say, “I want to work with the hospital.”
Richard Jackson, MD: It would, but what we’ve seen is that all the community mental health workers are now transitioning to correctional facilities because that’s where mental health treatment is moving toward.
Judge Steven Leifman: It’s ridiculous. A lot of it has to do with the parity laws not being followed and an imbalance of funding between mental health and primary health. You know the insurance industry has done a terrible job of making sure that this population is getting the services they need. The states do not fund these at the same level as primaries.
Peter Salgo, MD: There was an editorial from one of my colleagues—a Presbyterian—who worked at a psychiatric institute and said, “You know, it’s with mental illness not being recognized as a ‘real disease’ with insurance companies.” He didn’t name any names—but many companies limit the number of therapeutic visits to 5, which is ridiculous.
Judge Steven Leifman: It’s arbitrary.
Peter Salgo, MD: It’s arbitrary. We’ve condemned a cohort of our population to do exactly what we’re seeing here today—that was over 10 years ago.
Judge Steven Leifman: That’s exactly what’s happened.
Nneka Jones Tapia Psy.D: And it’s still happening today.
Judge Steven Leifman: It continues and it’s getting worse.
Richard Jackson, MD: We know that mental health—you could speak to this—courts work very well. Give them treatment options versus going to jail or prison. Most of the communities we see don’t offer these mental health courts or substance abuse programs through courts.
Judge Steven Leifman: It’s a perfect storm. It didn’t happen overnight. It got this way through a combination of things. We closed most of the psychiatric hospital beds. We went from about 550,000 to 32,000. We went to the war on drugs and crime. We instituted sentencing guidelines. We really pushed this population from hospitals to the street and into the correctional system.
Transcript edited for clarity.