A Maine judge makes the unprecedented decision to forcibly medicate a murder suspect with antipsychotic drugs. A violent, severely mentally ill patient is shipped to state prison after twice attacking staff members at Riverview Psychiatric Center.
Now Gov. Paul LePage, besieged with troubles at Riverview, has plans to send even more violent patients to prison, and proposes to spend millions to convert the prison facility in Windham to house mentally ill inmates.
These headlines point to a much deeper crisis in Maine. After a well-intentioned move decades ago to shift the care of the mentally ill away from psychiatric institutions, many Mainers can’t find adequate care in their communities. They still end up institutionalized — but now it’s behind bars.
The ranks of inmates taking psychiatric medications in Maine’s jails and prisons today once would have filled the state’s largest hospitals for the mentally ill.
Between 30 and 61 percent of Maine’s 1,774 county jail inmates were prescribed at least one psychiatric medication, according to a survey conducted by the Bangor Daily News in August. About a third of the 2,223 inmates in state prisons were taking drugs to manage their mental illness. At the Intensive Mental Health Unit at the state prison in Warren, all inmates were medicated at the time of the survey.
The figures are even higher at Maine’s now consolidated youth corrections facility. More than half of all juvenile offenders, or 79 of the 127, took medications. Many of them are at high risk of returning to the prison system as adults, still in need of mental health treatment.
As high as those percentages are, they underrepresent the real population of inmates with mental illness, because the figure is nearly impossible to nail down.
County jail and corrections officials broadly agree that the rising volume of mentally ill patients is untenable. But counting prescriptions offers only a point-in-time snapshot of the problem. It also fails to account for offenders who are undiagnosed or have mental illnesses that don’t require medication, or varying, facility-to-facility policies for dispensing medications.
Inmate advocates also contend that budget cuts have spurred jails and prisons to crack down on taxpayer-funded prescription drugs, leaving some prisoners unmedicated.
Penobscot County Sheriff Troy Morton said many of the people walking through his jail’s doors are undoubtedly experiencing a mental health crisis, whether they have an official diagnosis or not. The need burdens everyone it touches — from the sick individual to the law enforcement official apprehending them, from the jail taking custody to the taxpayer picking up the tab.
“There was a day when if a person was on the street yelling and screaming, [police] didn’t know what to do with them, so they were charged with disorderly conduct, end of problem,” Morton said. “But it wasn’t the end of the problem. It was a temporary delay.”
A moving target
After an arrest, inmates typically are asked about their mental health. Most correctional facilities follow National Commission on Correctional Health Care guidelines for initial screenings, which include a questionnaire that asks about current medications and thoughts of suicide.
Jail and prison staff do not make decisions about medical care, including for mental health problems, Morton said. All correctional facilities contract out for those services.
“We are not doctors,” he said.
Screeners review the questionnaire, “triage it, and get them to a provider” if the inmate is on prescription medications when they enter jail, said Geoffrey Archambeau, CEO of Correctional Health Partners, a Denver, Colorado-based company that contracts with the Penobscot County Jail, the Kennebec County Jail and other facilities throughout the country.
If an undiagnosed person is in crisis, they are directed to a medical provider who can prescribe medications, if warranted, according to jail officials from across the state.
“Usually they have committed a crime due to not taking their medication,” Knox County Sheriff Donna Dennison said in an email.
One reason the state has no current count of inmates with mental health diagnoses is because “it’s not a searchable thing” since each jail uses a different computer management system, Archambeau said.
“Here’s the problem: Nobody has real numbers,” Morton said.
While the state has one centralized administrative system for all its facilities, called CORIS, it does not allow prison or Department of Corrections officials to query inmates’ mental health records because of medical privacy laws, according to Deputy Commissioner Jody Breton.
Only the department’s contracted medical provider, Correct Care Solutions, can search those records. John Newby, Correct Care regional vice president, found that in 2015, around 48 percent of juveniles and 34 percent of adult inmates were prescribed psych medications.
“For the State of Maine, we are actually below the national averages on prescribing of psychotropic medication,” Newby said in an email to Breton that she forwarded to the Bangor Daily News.
Many inmates diagnosed with mental illness also have developed drug dependency from “self-medicating,” according to Morton.
That often leaves jails serving as their region’s largest detox and mental illness crisis centers, he said.
“My question is: Is that what corrections is supposed to be about?” said Morton, who started as a corrections officer in 1988. “Is that really how we should be treating people with mental illness and substance abuse? To me, this is really an expensive way to do it.”
Jails and prisons often fail to identify inmates with mental illness, according to an April 2014 report by two Texas doctors. Published in the American Journal of Public Health, the study examined a nationally representative sample of U.S. prisoners, finding that more than half who were taking medications for mental health conditions upon arrival failed to receive the drugs after incarceration.
“This lack of treatment continuity is partially attributable to screening procedures that do not result in treatment by a medical professional in prison,” the report states. “This treatment discontinuity has the potential to affect both recidivism and health care costs on release from prison.”
Joseph Jackson, who formed the Maine Prisoner Advocacy Coalition upon his release from prison two years ago, says many inmates go without drugs they need or receive “cheaper” substitutes.
When he was arrested for shooting another man in 1995 and locked up in county jail, Jackson was taking medication for depression.
“I was on one treatment going in and they got rid of that,” said Jackson, who was the triggerman in a drug-related slaying in Lewiston on Easter morning 20 years ago that left one man dead. “It doesn’t matter if you’ve been on one [prescription] for 20 years and it’s been working well. They say it’s because doctors on the outside are manipulated.”
When he was eventually convicted of manslaughter later that year, Jackson entered the state prison system. Again, his prescription for depression changed.
“They gave me amitriptyline,” Jackson said. “That is how, mostly, they dealt with us. They gave it away back then.”
But today, the cost of medications has changed how correctional facilities dispense them.
“It depends on what those pills cost,” said Jackson, who started a chapter of the NAACP and earned a college degree while behind bars. “They‘re going to give you the cheapest pills.”
Providing substitute medications may help county and state pocketbooks, but Jackson describes that approach as an injustice against inmates.
At the Cumberland County Jail in Portland, inmates formerly received psychiatric medications upon request. But in 2011, the jail changed its policy “to only giving the medications when the inmate comes into the jail taking the medications and after being verified,” Cumberland County Sheriff Kevin Joyce said in a recent email. “Or, when the doctors and/or psychologist believes that the medication is necessary.”
That change saved the jail thousands of dollars per year on medication costs, he said. Other jails have instituted the same policy.
For his part, Archambeau, the medical contractor for the Penobscot County Jail, disputes the contention that cost drives decisions on which drugs are dispensed. PCJ spends about $40,000 a year — close to 8 percent of its $525,000 annual medical budget — on psychotropic medications.
Yet costs can vary by facility. What jail and prison leaders say they have in common is that they’re doing all they can to accommodate inmates with mental illness.
Capt. Jeff Chute, Androscoggin County Jail administrator, said he has witnessed the transformation of county jails over the years. He started in law enforcement in 1984, joining the jail in 1995.
“We are de facto mental health facilities,” Chute said. “Sometimes we’re there to stabilize them. In order to prevent recidivism, we try to get them back on their meds.”
The costs go beyond prescription drugs, according to Dennison, the Knox County sheriff. When hospitals are full, jail officials pull double duty.
“We have to have a guard sit one-on-one with this person,” Dennison said. “Sad situation all around, not only for mental health folks but also for jails and officers.”
The housing of Maine’s mentally ill in correctional facilities may be making headlines today, but the problem dates back decades, according to Sharon Sprague, superintendent of Dorothea Dix Psychiatric Center in Bangor.
Many of the country’s psychiatric institutions downsized or closed starting in the 1950s, under a process known as deinstitutionalization. States intended to care for psychiatric patients in their local communities, but often failed to set up adequate services.
“When you consider we had 1,200 patients in 1970 and are down to 40 patients today, it says a lot,” Sprague said of Dorothea Dix, which opened in 1901 as the Eastern Maine Insane Hospital. “Our capacity, if we were to fill all the units, is 51. That has been a huge change.”
Riverview opened in 2004, replacing the Augusta Mental Health Institute, which began in 1840 as the Maine Insane Hospital. Riverview has dual roles: to treat violent offenders and to assess those charged with crimes to determine whether they understand the charges and are competent to stand trial.
Among the patients housed there today is Leroy Smith, who made headlines earlier this month after Kennebec County Superior Court Justice Donald Marden issued an order authorizing the state to medicate him for six months against his will in an attempt to restore his competency to stand trial.
Smith was charged on May 6, 2014, with killing and dismembering his father, 56-year-old Leroy Smith II, and initially was found not competent to stand trial. He is now receiving psychotropic medication and will return to court in April.
Meanwhile, Riverview is fighting a 2013 decertification for poor patient care, which resulted in $20 million in forfeited federal Medicaid funding.
LePage has said his plan to modify the Windham prison for mental health patients will help get Riverview recertified.
At its peak, Riverview had a capacity of 1,500.
Today, Maine has just a fraction of that number, with about 270 psychiatric beds statewide. Riverview accounts for 92 and Dorothea Dix has 51. The other 127 beds are split between Acadia Hospital in Bangor, Spring Harbor Hospital in Westbrook, and eight community hospitals that all limit patient stays to 30 days.
That’s rarely enough to accommodate the need, experts say, even with Spring Harbor planning to reopen a dozen psychiatric beds after the recent award of $420,000 in state money. Such shortages are a problem in Maine and throughout the country, said Jenna Mehnert, executive director of National Alliance on Mental Illness in Maine, who came to Maine after working in Pennsylvania and New York.
“There aren’t enough psychiatric beds. And sometimes when officers need to divert a person to the hospital there is no room, and they end up back on the streets … in jail or the emergency room,” she said.
Just compare the number of people in mental health institutions back in the 1970s to the populations in homeless shelters today, said Shawn Yardley, Bangor’s former director of health and community services.
“It’s an incredible correlation — it’s the same number of people. What we’ve done is move the need for that comprehensive service … from mental institutions to homeless shelters, not very successfully and not in the best interest of anybody,” he said.
In the past, the philosophy in prisons was to keep inmates with mental illness quiet until they completed their sentence, according to Dr. Dan Bannish, a psychologist at the state prison’s Intensive Mental Health Unit. Now prisons are treating the illness, he said at the unit’s opening in February 2014.
“It’s not a hospital. It’s an intensive mental health unit,” Corrections Commissioner Joe Fitzpatrick said in December. “We really did want this for treatment purposes, not for management purposes. It’s a critical piece and it’s probably the most challenging piece.”
A total of 70 inmates — 39 from the Department of Corrections, 29 referred by county jails from across the state, and two from Riverview — had been treated in the unit as of the end of January.
The number of suicidal behaviors has dropped considerably and self-abusive incidents among inmates in the program have fallen dramatically, he said.
Maine’s county jails also have made changes.
Aroostook County has a mental health nurse practitioner to screen every inmate’s case, said Sheriff Darrell Crandall.
Penobscot County Jail works with Acadia Hospital, which provides clinical services, including two hours of psychiatric services, each week.
Cumberland County Jail has two social workers and Androscoggin County Jail added a full-time social worker who helps inmates transition back into society in an effort to prevent recidivism, Chute said.
“We had to give up some positions for that,” he said. “It was extremely necessary.”
Chute, Crandall and Morton said law enforcement officers also have learned new ways to deal with people suffering from mental health problems.
The Portland Police Department has developed a specialized behavioral health response program, employing a special liaison who goes out on calls whenever mental illness is identified. The liaison also follows up with patients, conducts referrals and serves as a conduit between the department and behavioral health providers.
Mehnert said other departments should follow Portland’s lead.
“We expect [law enforcement] to be social workers, and it’s really not fair, and when they fail we demonize them,” Mehnert said.
The National Alliance on Mental Illness Maine has spent years offering crisis intervention training to law enforcement and emergency responders from all over the state. Every police academy cadet in Maine also goes through that training, along with mental health first aid.
“A lot of this is educating the officers on the street … trying to make sure [they can] identify if somebody is in mental health crisis or needs to be incarcerated for a crime,” Mehnert said. “I think that is a crucial thing.”
A smooth transition back into society is key to preventing criminals from reoffending, experts said. But those who are prescribed medication often struggle to pay for their drugs without a job or insurance coverage.
Most jails have transition programs in place, but funding for them often falls short of addressing the multiple factors that affect inmates’ success on the outside, Morton said.
“It’s crucial because if we only set up the mental health part of it, yet they don’t have housing, or they don’t have food or transportation, we’re setting them up for failure,” the Penobscot sheriff said.
“This is not a county jail issue,” Morton said. “It’s a societal issue.”