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Continuum-of-care programs could help ex-offenders treat their mental illness — and stay out of jail

Continuum-of-care programs could help ex-offenders
REUTERS/Joshua Lott
Tim Stratton, Ph.D.: "A lot of folks with mental illness self medicate with alcohol or heroin or meth or some combination. When they go to jail, they are prescribed psychiatric medications and their symptoms stabilize."

It’s no secret that a large percentage of people living behind bars have been diagnosed with a mental illness. Behaviors caused by those mental illnesses may be partially to blame for their incarceration.

While jail time rarely feels like a positive experience, it is the time when many individuals are first diagnosed with and treated for mental illness. Inmates are often prescribed psychiatric medications that can help reduce symptoms of common mental illnesses like anxiety, depression or even psychosis. During incarceration, individuals may actually see an improvement in their mental health symptoms.

But when inmates are released into the community their mental health supports often vanish. Thanks to lack of funding or botched communication between jails and social service agencies that serve individuals with mental illness, many lose access to the psychiatric mediations that caused a reduction in their mental health symptoms.

Tim Stratton, Ph.D., a professor at the University of Minnesota-College of Pharmacy, Duluth, saw this scenario being played out many times over. He hoped to develop a program that would make it easier for inmates to continue to get access to their psychiatric medications once they were released into the community. Though programs like this sound expensive from the outside, Stratton argues that it could save money over the long term.

“If we make this transition back into the community easier,” he said, “we may be able to keep some folks from reoffending.”

To build a case for his idea, Stratton and his colleague and former student, Brittney Rohrer, Pharm.D, conducted a survey of 78 Minnesota adult jail facilities. Twenty-eight county jails responded to the survey, estimating that greater than 40 percent of their inmates received medication for mental illness during incarceration.

While the majority of inmates diagnosed with mental illness in the responding Minnesota jails were taking psychiatric medications at the time of their release, few correctional facilities reported having continuum-of-care programs designed to ease inmates’ transition back to the community. This means, Stratton argued, that only a small number of offenders have access to the psychiatric medications that eased their symptoms.

Last week, I spoke with Stratton about his idea, and about the results of his and Rohrer’s survey, which were published in the October issue of the Journal of Correctional Health Care.

MinnPost: What inspired you to study continuum-of-care issues for offenders with mental illness?

Tim Stratton: I supervise pharmacy and medical students at our student-run free clinic in Duluth. We’ve had many instances where recently released inmates from the county jail end up at the homeless shelter because that is the only plan for their housing at release. These people then end up at our free clinic seeking refills for psychiatric medications they were prescribed while they were incarcerated. When they are released from the county jail, they are provided with a three-day supply of those medications. They are on their own after that. They are left to their own devices at a time when they could really use support.

My co-author had a similar experience. She was working at a pharmacy in central Minnesota. She saw that recently released inmates would show up at her pharmacy looking for refills for their psychiatric medications. There was little that could be done.

MP: Why is it important that people continue to have access to their psychiatric medications once they are out of jail?

Tim Stratton, Ph.D.
Tim Stratton, Ph.D.

TS: A lot of medications for mental illness are chronic mediations. That means that we realize that we are not likely going to be able cure a person’s mental illness in their lifetime, but we are able to control their symptoms while they are on their mediation. Once a person stops taking their psychiatric medication, in many instances their symptoms will return. 

What we’ve heard anecdotally from our survey respondents is they often see re-incarceration of many offenders with mental illness because when these individuals are released from jail, they often fall off their psychiatric medications because they cannot get easy access to them. Then somehow, they re-offend and end up back in jail where their medications can get restarted. It becomes a vicious cycle for many of these folks.

MP: Does falling off a psychiatric medication cause a person to re-offend? 

TS: There’s some debate about that. When we submitted our article to the journal, one of the reviewers came back to us with the comment, “There’s probably not a connection between mental illness and criminal intent. It may just be coincidental rather than being a cause-and-effect relationship.”

A lot of folks with mental illness self medicate with alcohol or heroin or meth or some combination. When they go to jail, they are prescribed psychiatric medications and their symptoms stabilize. When they get out of jail and off the psychiatric medications that keep their symptoms under control, they often fall back into the abuse patterns that got them into jail in the first place.

MP: Can you tell me more about how this happens?

TS: I’m participating in a release-planning program for inmates at the Carleton County Jail. We interviewed inmates there who went into this program because they have a mental health diagnosis of anxiety or depression and anxiety. What our subjects have told me is that they don’t have access to their medications post-release. Corrections officers say that when they get into a stressful situation, some wind up striking out and eventually coming back to jail on an assault charge. Or they turn back to the substance that they had been using before incarceration. They get caught again in possession of that substance and that’s a violation of their parole agreement, so they end up back in jail. It’s an expensive cycle.

MP: This Carleton County program sounds interesting. How does it work?

TS: It’s a new program. So far we’ve had one or two inmates meet with the team and sign up. In the program, which is voluntary, inmates are assigned to a care team that works with them to prepare for their eventual release into the community. Then the team works to make sure that the inmate has access to their psychiatric medications and medical advice and social services once they are released.

It is too early to tell what impact this will have on former inmates re-entering the community, but we are optimistic. We’ve only been working on this project for a couple of months.

MP: How did you get involved in the Carleton County program?

TS: One of my colleagues, Dr. Laura Palombi, has been active in this issue for some time. Her practice site is the Carleton County Public Health Department. She talked to me about getting involved in the group. And then I also had a student with an interest in preventing recidivism by providing a continuum-of-care infrastructure in county jails.

We set up a demonstration project with Carleton County Jail where an inmate with a diagnosis of mental illness got to consult with a pharmacist and a physician while they were still incarcerated. The pharmacist is based in Brainerd, but she conducts sessions with inmates by video conference.

MP: Why is it important to have a pharmacist available by video conference? Couldn’t the same information be gathered by telephone?

TS: Our pharmacist has many years of experience working with patients with mental health and substance-use issues. She is able to bridge the gap between a patient’s physical medical needs and their psychiatric needs and act as a go-between between the medical physician and the psychiatrist.

Through video conference, we can look for potentially dangerous drug interactions. Antipsychotic medications, for instance, can cause quite a bit of weight gain and can put a patient at greater risk for cardiac events or stroke. Using video conference, the pharmacist can observe the patient and provide insight to the physician. The physician might not be completely comfortable with prescribing psychiatric medications or the psychiatrist might not know as much about interactions between the psychiatric medications and the patient’s physical health. The pharmacist is the go-between, the bridge.

MP: It sounds like the pharmacist plays a central role in your program.

TS: Yes. Ideally the pharmacist is an equal member of the medical team. It is our hope that the release planning team pharmacist will also relay prescription information to the inmate’s local pharmacy of choice before they are released. They can place a call to say, “This has been going on with the person while they were in jail and this is what you need to look out for when they are in the community.” They can also build a relationship with the local pharmacist to make sure that the patient gets their medication on time.

MP: Are there programs like what you’re working on in Carleton County in other parts of Minnesota?

TS: There was one program we are aware of in Crow Wing County. In that situation, inmates could voluntarily sign up for a 90-day release advance planning case management program and then somebody from the jail kept contact with them after their release. That person would help the inmate make advance contact with social service mental health agencies and then, after their release, help insure that they continued to receive their psychiatric medications.

MP: Why do you think that drug and alcohol abuse is so closely tied with mental illness and incarceration?

TS: A lot of the folks that we are working with have substance abuse problems. That’s one of the reasons they end up in jail. When they are in jail, they get sober in and in good shape. Then they are released to the community. Many times they just return back to the environments that got them in trouble in the first place. We try to get all the pieces in place before release, even down to identifying addiction treatment options. Our goal would be to get all of the pieces in place for inmates so that when they are released from jail they have ready access to their psychiatric medications and they know where to turn to keep themselves sober.

But our work doesn’t always stick. A lot of people with mental illness self medicate with alcohol and drugs. Psychiatric medications are not cheap. The truth is it’s easier and cheaper to get access to a bottle or an illegal drug than to get your psychiatric medications refilled. We want to change that, to break down that cycle.

MP: Does it ever feel discouraging?

TS: Sometimes. But I understand that most people don’t decide to become addicts. There are a number of stressors in their lives that have sent them down that path. It may be a combination of genetic predisposition to addiction combined with poverty and hopelessness — when those two things combine, we end up with folks who get back in trouble again and again. 

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Comments (1)

Mental illness & the jails

There are different causes of mental illness. Some individuals are sensitive to foods which set them off mentally, so it's not just medication which needs to be looked at. Some people need the supervision and support which jails simply can't provide. Some individuals do better with natural substances because they are sensitive to medications. All this provides complication in treating mental illness in and out of prison. I worked at a facility with mentally ill adults. People do have side effect from medications. My former roommate was having toxicity problems with his kidney. Fortunately he had a good practitioner who was willing to look at a mix of medication, natural substances, exercise and diet. I had a book on the subject, which the practitioner read and then he contacted the authors. He set up a program where my former roommate was able to reduce the medication where it was not having toxic effects by using natural substances, exercise and herbs along with the reduced doses of medication. So you see, it's not a simple matter.