Appropriate Treatment for Incarcerated People with Schizophrenia - Episode 13
Peter Salgo, MD: Let’s say that we’ve got a system that works, maybe a system that takes them from that initial encounter and transitions them to a correctional facility, and you get the right drug and the right frequency. Now it’s time to leave and we’ve got another transition here, which is the transition into the community. If they’re on this once-every-2-month Aristada [aripiprazole lauroxil], and it’s doing well, what happens?
Judge Steven Leifman: It depends if they have insurance or benefits. Is there a community provider? What usually happens is there’s no warm hand off when they leave the facility. It’s in all the facilities where they’re leaving—a civil-stay hospital or jail—there’s no collaboration or coordination with the community provider.
Richard Jackson, MD: Early on we usually see the system fail. If they do leave on a long-acting injectable with the medication in their system versus a bottle in their pocket, which usually doesn’t stay with them, you have a much better chance of getting them into treatment during that window of efficacy.
Mauricio Tohen, MD, DPH, MBA: In Albuquerque we work closely with the county. The first thing that we wanted to do was develop the reintegration center, to where the individual is transported after leaving the correctional facility. At that point, the proper follow-up and medication is administered, resulting in a decreased chance of recidivism.
Judge Steven Leifman: With advanced technology, this system shouldn’t be too hard to integrate. We should know who the treatment provider is, where they’re going, and what the follow-up system is going to be. That’s what we’re trying to create in Miami, and we’re getting close to doing it. It’s doable, but there are many working parts that must be functioning properly: there’s not 1 person responsible for the whole system.
Nneka Jones Tapia, PsyD: In Cook County we were able to collaborate with a community mental health provider. Everyone in our facility that has a diagnosed mental illness is released through 1 area of the jail. That community mental health provider then, at the point of release, assesses the patient in order to create an effective release plan and determine what they require of the community. They arrange for an appointment, and if they need more services, we then transfer them to a supportive release center with which the mental health provider collaborates. It’s outside of the jail and they receive a more comprehensive release plan.
Judge Steven Leifman: But that’s the problem: there’s 3200 to 3700 counties in the United States, all of which have individualized and hermetic systems; you have to visit each county and integrate this system. We’re a part of a major initiative called “Stepping Up,” where we’re working with counties around the United States to educate key figures on how to do this. It’s an enormous task.
Mauricio Tohen, MD, DPH, MBA: It is essential that the mental health services visit the correctional facilities before the patient is released.
Peter Salgo, MD: I’m guessing the person who is doing this reintegration is swamped, overworked, underpaid, and crazed. They don’t have a lot of time per discharge.
Nneka Jones Tapia, PsyD: They don’t, which is why it’s important to have a reintegration center or supportive release center so you have the ability to spend more time with the person in order that they receive a comprehensive release plan. In Cook County, we started our supportive release center in July of 2016—and to date, we’ve seen more than 700 people pass through the system, receiving a warm shower, meal, change of clothes, and a release plan. We then follow up with them in the community.
Peter Salgo, MD: What is the delay between injection and full effect of these 2-month injectables?
Richard Jackson, MD: Most patients—especially when they’re leaving—are already on an oral agent. They’re going to transition with what is known as an “overlap,” where they have a few weeks in which they may need to stay on the medicine once they get an injection. No matter what, it’s better to start earlier in the program. The medicine, when it’s injected—lauroxil or others—within a few days it’s in your system, and is typically effective within 2 weeks. When you have a 2- or 3-month injection early on, you have an effective medication for this patient who leaves the incarceration with this injectable exhibiting effectiveness.
Peter Salgo, MD: It can’t start the day of discharge.
Richard Jackson, MD: Correct.
Peter Salgo, MD: You’ve got to ramp it in.
Judge Steven Leifman: There’s no blueprint or protocol for these systems that communities can follow, and so people are having to figure it out one at a time. They’re not necessarily using the correct information, either.
Mauricio Tohen, MD, DPH, MBA: Not all long-lasting antipsychotics are the same. There are some even within aripiprazole where you must give additional PO [per os, or oral] medication; however, there are also injections that have a quick response rate.
Peter Salgo, MD: Who can administer long-acting injections such as aripiprazole to the patients outside of the correctional facility?
Richard Jackson, MD: There are centers that you can visit which administer injections—doctors can do it. Many of them can do it in their private offices; it’s very simple. Nurses, as well, are oftentimes qualified. The delivery of the injectable is not a problem, it’s actually getting it.
Peter Salgo, MD: What happens if you miss an appointment?
Richard Jackson, MD: Well, if you miss an appointment, there’s often leeway with these medicines.
Richard Jackson, MD: Depending on the medicines, you can miss it for a whole month and then just take your next injection, specifically the aripiprazole lauroxil.
Mauricio Tohen, MD, DPH, MBA: With oral medications, if you miss a treatment, the symptoms will come back within a few days, but with injectables, the delay is much longer.
Judge Steven Leifman: Fifty percent of people with mental illnesses in the criminal justice system are homeless. Getting them to their local Walgreens or CVS is not as easy as it sounds. They are not as sophisticated for various reasons: some of them have been psychotic for extended periods of time and suffer cognition issues. They need a warm hand off that begins before they leave the correctional institution and involves a case management system situated in the community that could help them navigate these systems.
Transcript edited for clarity.