National % Forensic Spending

1

Courtesy of Ted Lutterman, NRI

NASMHPD Forensic Survey

• 75% demand for forensic services has increased (a lot 54%, moderately 21%)

• 78% of states responding report that increased demand for forensic services has required that they maintain waiting lists for admission

• Half of states responding report that they have been threatened with or found in contempt of court for failing to admit court ordered patients in a timely manner

2Forensic Mental Health Services in the United States: 2014

All Forensic Commitments

3

FL, NY, TX, & GA32%

All Other31%

CA37%

California’s Forensic Population

Source: 2013 NASMHPD State Profiles

IST Problem

• Colorado to hire consultant to ensure speedy competency ...Colorado Springs Gazette-Aug 2, 2016

• With state hospitals packed, mentally ill inmates wait in county jails ...Dallas Morning News (blog)-Apr 21, 2016

• Jail wait times are inhumane for the mentally ill The Delaware County Daily Times-Jul 18, 2016

• Federal trial to tackle Washington’s mental competency wait lists. The Seattle Times. March 14, 2015.

• Jails are becoming 'new psych hospitals‘ Jackson Hole (Wyoming) News & Guide-Aug 10, 2016

• ACLU revives lawsuit against Pa. over 'off the charts' delays to treat mentally ill defendants. Pennlive.com May 11, 2017

• Lawsuit alleges Utah agencies 'unconstitutionally delay' mentally ill inmates' treatment. Deseret News Utah September 9, 2015

• Long, Dangerous Wait for Hospital Beds for Those Incompetent to Stand Trial KQED California October

20,2015

• New York plan aims to divert mentally ill people from jail’s revolving door. The New York Times.

December 2, 2014.

Trueblood v. Washington (2015)

Trueblood v. Washington (2015)

• Over $80,000,000

• Now new settlement structure

Forensic Patients in State Hospitals

• 74% in the number of forensic patients in state hospitals from 1999 to 2014

• 72% the number of IST patients from 1999 to 2014

DSH-NAPA TRIAGE

• Designed to evaluate types of IST admissions

• Needed assessments of:• Malingering

• Symptoms

• Competence

• Cognitive deficits

• Assessments must be valid, reliable and brief

PROCEDURE IMPLEMENTED

• M-FAST

• GCCT

• BPRS

• Unstructured interview

• Clinician judgment

OTHER DATA RECORDED

• Estimation of understanding of courtroom procedures

• Estimation of ability to assist defense

• Overall estimation of competence

• Is patient malingering?

• Cognitively impaired?

Malingering?

Already Competent?

More (or less) Ill?

More Substance Abuse?

More Criminal History?

Age Differences?

STATEWIDE - ADMISSIONS

• IST admissions between 10/24/2016 and 1/15/2017

• N=396 interviewed/records reviewed

• Used same assessments as DSH-Napa

STATEWIDE - ADMISSIONS

19

STATEWIDE - ADMISSIONS

• Department of Health Care Services (Medi-CAL) linkage

• Services measured by billing tickets

• Multiple services per visit all billed separately

• Example: patient overdoses, at ED, multiple labs

• Billed for ambulance ride, ED visit and each lab

• More than 48,000 services in calendar years 2014-2017

20

STATEWIDE - ADMISSIONS

37%

12%27%

24%

No MH services in 6 months No MH ED services in 6 months

1-2 MH ED services in 6 months 3 or more MH ED services

21

State Survey for IST

Who Completed Survey50/51 Jurisdictions Responding

Central Office48%

State Hospital30%

Other22%

Evaluations

Referrals for Competency Evaluations Increasing

70.8 70

2.1 00

10

20

30

40

50

60

70

80

Misdemeanors Felonies

Increasing Decreasing

Referrals for CompetencyEvaluations Increasing

• Of the 50 jurisdictions responding (including DC)- 41 (82%) said referrals for competency evaluations were

increasing either for misdemeanors or felonies

Restoration

Referrals for Competency Restoration Increasing

68.8 65.3

2.1 00

10

20

30

40

50

60

70

80

Misdemeanors Felonies

Increasing Decreasing

Referrals for CompetencyRestoration Increasing

• Of the 50 jurisdictions responding (including DC)- 39 (78%) said referrals for competency restoration were

increasing either for misdemeanors or felonies

Waitlist/Litigation for Admitting IST Patients?

70.8

38.8

0

10

20

30

40

50

60

70

80

Waitlist Litigation

Why?

Reason for Increase?

• Homelessness?

• More awareness of MI by courts?

• Bar for involuntary meds too high?

• Inadequate ACT services in community?

• Inadequate crisis services in community?

• Bar for involuntary hospitalization too high?

• Inadequate number of inpatient psych beds?

• Inadequate general mental health services in community?

• Or, other?

California Hospital Association Report

33

34

Organisation for Economic Co-operation and Development (OECD)

• Average of 71 beds per 100,000 in 35 OECD countries

• Expert Recommendation is 50 beds per 100,000

• United states is 22 beds per 100,000

• California…17 beds per 100,000

• 25 of 58 California counties do not have inpatient psychiatric services

35

Bastiampillai, et al. JAMA. 2016

• Decline from 34 to 22 beds per 100,000 population

• 35% Reduction

36

Relationship between psychiatric beds and suicide.Bastiampillai, et al. JAMA. 2016;316(24):2591-2592. doi:10.1001/jama.2016.16989

37

National Forensic Spending

38

Link Between Beds and Arrest

Study of police discretion indicates that when confronted with the choice between arresting a person with mental illness or bringing that person to an emergency room, the most important factor was whether the officer thought that person would be admitted to a hospital bed.

• Green, TM International Journal of Law and Psychiatry, 1997

39

Our Current Hypothesis

• Prevalence of Schizophrenia Spectrum Disorders is not increasing to our knowledge.

• Population growth does not account for massive surge.

• Half of ISTs are homeless at time of arrest.

• Major increase in prior arrests, often arrests related to conditions of homelessness and untreated psychosis.

• Half of ISTs did not access reimbursable mental health services in six months prior to arrest.

40

Our Current Hypothesis

• Individuals with Schizophrenia Spectrum Disorders are drifting into an untreated, unsheltered condition.

• These conditions are leading to increased contact with police and criminal charges.

• This increased contact is leading to a surge in IST referrals to state hospitals.

• Building more beds will only exacerbate the problem long term.

• IST restoration is not adequate long term treatment plan.

• So, what can we do?

41

35-year-old male transient male. Police called, arrived as patient was on roof, pulling the roofing tiles off the residence and throwing roofing tiles off the roof. He took off his clothing. Officers stated patient then threw roofing tiles at them. One tile landed a foot from officers. Broke skylight, doused himself with water from spout. No response to taser. Ran away and was apprehended. Agitated and talking to himself. Charged with felony aggravated assault on a police officer (AWDW roof tile), and felony vandalism.

45-year-old transient male entered a sandwich shop. Believed he owned the

establishment. Locked the back door and put crates in front of it, per his

comments to secure it because it “was busted”, and asked for a sharpie and

paper to put an out of order sign on the back door. Proceeded to bathroom,

cleaned it, and expressed concern about someone slipping due to excess

water on the floor. Asked the clerk for the money in the register stating,

“Don’t worry I’m the owner.” Was denied without incident. Then asked for a

sandwich. Clerk ran out and into the storefront adjacent for help. At the time

of arrest was delusion about owning stores and talking about “Tony the Tiger”.

Pt charged with false imprisonment and attempted robbery.

37-year-old. Police called when patient refused to leave Jack in the

Box. Police asked him to step outside and he complied. During a

search, the police informed patient he was not welcome at the Jack

in the Box. He became upset and tried to get out of the grasp of the

officer. He then tried to call the police on an imaginary phone. He

was talking to himself about the devil. He was missing his left eye

and informed police he took out his eye because the devil told him

to. The police attempted to handcuff patient and the patient

struggled, was tasered multiple times. Charged with battery with

Injury on a police officer and resisting executive officer.

45

• 1923 Penrose

• 1972 Abramson, MF• 100% increase in mental health arrests from 1968 to 1970

• 1978 Sosowsky, L. • 301 former state hospital patients

• “Markedly higher” incidence of arrest

• 1988 Arvantites, TM• “An examination of the nature and operation of an IST commitment reveals its potential to emerge as an

alternative to civil hospitalization.”

• 2010 Torrey et al• More mentally ill persons are in jails and prisons than hospitals : a survey of the states.

Capacity Increases

FY 2012-13 to 2019-20

• 436 State Hospital Beds

• 227 Jail-Based Competency Tx Beds

• 60 Admission Evaluation Stabilization Beds

• 150 LA CBR Beds

• 236 SH Beds – Metropolitan State Hospital*

• 78-Bed CONREP Step Down*

*In Progress

46

Capacity & Systems Impact

IST Referrals Outpaced Capacity Growth

(data through

17/18)…

• Increase in Felony IST Referrals• 60% increase in referrals

• 232 to 372 per month

• Increase in Pending Placements• 139% increase

• 343 to 819 per month

47

Does an IST commitment help?

2014-15 IST Recidivism Rate…

…69%

48

IST Diversion

• $100M one-time investment over 3 years

• Increase diversion opportunities for individuals likely to be or found IST on felony charges

• Support counties through contracts to:• Expand existing diversion programs

• Establish new diversion programs

• Focus on post-booking

• Flexible funding source

WIC § 4361(c)(1) Describes eligibility criteria

• “who have the potential to be found incompetent to stand trial for felony charges. . . Or who have been found [IST] for felony charges” [(c)(1)(A)]

• “diagnosed with schizophrenia, schizoaffective disorder, or bipolar disorder” [(c)(1)(A)]

• “significant relationship between the individual’s serious mental disorder and the charged offense OR between the individual’s conditions of homelessness and the charged offense” [(c)(1)(B)]

• “does not pose an unreasonable danger to public safety” [(c)(1)(C)]

50

DSH Diversion - Target Population

Diversion Target Population – Our Population

• Majority have a diagnosis of Schizophrenia, Schizoaffective Disorder, Bipolar Disorder

• 49%- Unsheltered homeless status at time of arrest

• 49% - Did not access Medi-Cal reimbursable services in six months prior to arrest

• Many arrests appear to be correlated with conditions of untreated mental illness and/or homelessness

• Challenges for DSH facilities and patients• Large congregate living facilities

• Shared bathrooms, common areas, bedrooms

• Patients have higher rates of morbidity than general population

• Patients have mental health conditions that make behaviors like cough covering, hand washing, social distancing more difficult

• Admissions from high risk institutions

52

COVID-19 Impacts and Implications

COVID-19 Impacts and Implications

• https://www.ncbi.nlm.nih.gov/pubmed/32226293

• https://www.nbcnews.com/health/mental-health/coronavirus-psychiatric-hospital-it-s-worst-all-worlds-n1184266

• https://www.newyorker.com/news/news-desk/why-psychiatric-wards-are-uniquely-vulnerable-to-the-coronavirus

• https://www.medscape.com/viewarticle/926834src=soc_fb_200317_mscpedt_news_mdscp_coronavirus&faf=1

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https://www.ncbi.nlm.nih.gov/pubmed/32226293https://mcas-proxyweb.us2.cas.ms/certificate-checker?login=false&originalUrl=https%3A%2F%2Fwww.nbcnews.com.us2.cas.ms%2Fhealth%2Fmental-health%2Fcoronavirus-psychiatric-hospital-it-s-worst-all-worlds-n1184266https://mcas-proxyweb.us2.cas.ms/certificate-checker?login=false&originalUrl=https%3A%2F%2Furldefense.com.us2.cas.ms%2Fv3%2F__https%3A%2Fwww.newyorker.com%2Fnews%2Fnews-desk%2Fwhy-psychiatric-wards-are-uniquely-vulnerable-to-the-coronavirus__%3B!!FvgdfVIOElI3!kNKV2hBbmnwx2j9TsZcGeAuxgtCqgRn5fWlfG9Au4eJW1MD1KdvfYjXgvR564izGuL3mCnhgYXo%24https://mcas-proxyweb.us2.cas.ms/certificate-checker?login=false&originalUrl=https%3A%2F%2Fgcc02.safelinks.protection.outlook.com.us2.cas.ms%2F%3Furl%3Dhttps%253A%252F%252Fwww.medscape.com%252Fviewarticle%252F926834%253Fsrc%253Dsoc_fb_200317_mscpedt_news_mdscp_coronavirus%2526faf%253D1%26data%3D02%257C01%257Ckatherine.warburton%2540dsh.ca.gov%257C4e95b657257f4a24b17e08d7ee25ac43%257C807536a6a6b14893a01370509c59ebbb%257C0%257C0%257C637239717877318100%26sdata%3DdoYz6vDAtFXZTtkyXl1rNbEDeHmf%252F7OFO8u%252B8ukWcTU%253D%26reserved%3D0

• Immediate implementation of staff screening

• Early implementation of universal staff masking• 60-day suspension of admissions and discharges

• Suspension of visitation – video visiting implemented

• Immediate implementation of daily meetings of Statewide Executive Team and Medical Directors

• Outreach to other state hospital systems• Development of website, outreach, hotline

• Access to testing/development of testing protocols

• Development of quarantine and isolation spaces and protocols

• Development and refinement of medical protocolso Admission, surveillance, exposure response

o Close collaboration with CDPH

54

COVID-19 Impacts and Implications

Virtual Hospital Proposal

• State Hospitals admissions are not the best answer for the people on the waitlist due to COVID-19 risks.

• We can evaluate and make recommendations for treatment, including psychopharmacology consultation and diversion recommendations.

• In all cases, the number one treatment need appears to be anti-psychotic medication.

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THANK YOU