Peter Salgo, MD: Schizophrenia: Why is it such a problem? Why is it considered such a serious mental disease?
Mauricio Tohen, MD, DPH, MBA: The definition of serious mental illness is actually a matter of function: Individuals with mental illness who have low-functioning cognition would be classified as such.
Judge Steven Leifman: Do you think part of the problem is poor diagnostics? That they don’t always come up with the proper determination for someone who is schizophrenic or bipolar because their behaviors can be all over the place?
Mauricio Tohen, MD, DPH, MBA: Absolutely. Diagnostics in psychiatry are what we observe—it’s phenomenological, not etiological. We don’t diagnose diseases but disorders. Someone who was diagnosed with schizoaffective disorder 10 years ago, with that new criteria, would have had a different diagnosis.
Peter Salgo, MD: OK, the ground is shifting under our feet.
Judge Steven Leifman: Yes, which makes it hard.
Peter Salgo, MD: I’ve seen that big textbook that comes out—it’s the number 5. But let’s make a distinction then between schizophrenia and other serious mental illnesses: How does schizophrenia, per se, differ?
Richard Jackson, MD: Schizophrenia is a pervasive brain disorder—it’s probably the most severe disorder that we treat in psychiatry because it affects almost all areas of the brain. However, people who have it are typically noncompliant toward their treatment.
Peter Salgo, MD: One of the things you said struck me, and I don’t think we would have said this several generations ago: You said, “It’s a brain disorder,” and not because they’re a bad person. You didn’t say it’s something they’ve acquired because of the things they’ve done. There’s something biochemical and physical occurring inside the brain.
Richard Jackson, MD: Absolutely. And we’ve come to learn that it’s actually a degenerative brain disorder—you actually see brain tissue loss, and the level of functioning continues to deteriorate. We know that you lose much of the functioning early in the disease course, which is why it’s critical to get these patients immediate treatment.
Peter Salgo, MD: You’re implying that if you treat them early, they won’t have brain loss?
Richard Jackson, MD: We don’t know per se, but studies looking at, for example, the before and after of a long-acting medication treatment—a “mirrored image study”—typically reveal significant improvement in the maintenance of stability.
Mauricio Tohen, MD, DPH, MBA: You mentioned disorders of the brain. Actually, they’re systemic. It’s not just the brain.
Peter Salgo, MD: How is that?
Mauricio Tohen, MD, DPH, MBA: Individuals with schizophrenia or bipolar disorder are more susceptible to illnesses such as diabetes because of the inflammation that occurs in the brain at the outset, which then progresses to other body systems.
Peter Salgo, MD: We touched on the incidence of schizophrenia in correctional facilities. The question that comes up, which I think everyone is asking, is: Are people with schizophrenia inherently violent? Should they be in correctional facilities in the first place? Or, if they’re just medically ill, if there are inflammatory issues, shouldn’t they just be treated medically and kept out of the correctional system?
Judge Steven Leifman: Jails are the last place for people with mental illnesses—we need to build a better system of care. Last year, we had 1.5 million people [with serious mental illness] in the United States arrested in almost 2 million incidents. On any given day, we have almost 550,000 people in jails and prisons with serious mental illnesses and another 900,000 under some sort of correctional supervision. The costs are enormous: Last year, the United States spent a total of $80 billion in correctional costs and another $71 billion in prison costs. Most of this is because of untreated mental illnesses and substance abuse disorders, when we should be taking those dollars and building community mental health systems so people do end up in our system.
Nneka Jones Tapia, Psy.D: Not only that, people with mental illness—especially serious mental illness—who end up in our criminal justice system are more likely to be victimized. Not only are we putting someone with a serious thought disorder in a setting where they shouldn’t, but we’re setting them up to become victims. Instead of talking about how they may be at risk of violence, which I don’t believe they are, they’re more at risk of being victimized.
Peter Salgo, MD: What do you mean by victimized?
Nneka Jones Tapia, Psy.D: There’s a low frustration tolerance in correctional facilities for individuals with a serious mental illness, from the other inmates as well as the staff. They are likely to become a victim of fights and sexual abuse—things of that nature—because they have a difficult time contending with rules and speaking up for themselves.
Judge Steven Leifman: And retraumatization while they’re inside.
Peter Salgo, MD: It’s physically dangerous.
Judge Steven Leifman: Yes. It is also consistent out in the community. But on treatment, people with serious mental illnesses are much less likely to be violent than the general population.
Peter Salgo, MD: The common view is, “These are [people with schizophrenia]—they’re violent, put them in jail!” But what you’re saying is they’re not. Do prosecutors and defense attorneys know this?
Judge Steven Leifman: They don’t.
Peter Salgo, MD: Why not?
Judge Steven Leifman: That’s part of the problem: There’s a big lack of education across the physician and legal populations. In fact, we just rewrote the American Bar Association standards regarding this and added a new section on the education of judges, prosecutors, and defense attorneys on dealing with these issues. The stigma is pervasive in this arena.
Peter Salgo, MD: Is that why [people with schizophrenia], so many of them, are incarcerated—people just don’t know the numbers?
Judge Steven Leifman: It’s not that they don’t know the numbers. Appropriate treatments are not available in the community. You need a structured setting. Our laws are antiquated—they’re fragmented. Getting access to care in America for people with mental illness is very difficult.
Nneka Jones Tapia, Psy.D: It’s difficult for law enforcement as well. When they are called to a scene involving an individual with serious mental illness, particularly a psychotic disorder, they can either take them to a hospital and spend hours of their day, while the “real” crime is taking place in the city. Or they can drop them off at jail. You know it’s a balance of the 2, and we really needed crisis centers where officers can drop people off and know that they’re going to be assessed and administered the appropriate treatment.
Mauricio Tohen, MD, DPH, MBA: The majority of individuals who suffered from mental illness and were incarcerated were typically victimized and provoked to commit a crime, or they broke a minor law like trespassing or urinating in public.
Transcript edited for clarity.