Prisons Grappling With More Mentally Ill Inmates

About one in five prisoners in Connecticut is receiving mental health treatment – a proportion that has increased in the last decade, contributing to a rise in inmate health care costs that is now attracting lawmakers’ scrutiny.

Adding to those costs is the likelihood that inmates with serious mental health problems will end up back in the prison system after release. In its 2010 annual recidivism report, the state’s Office of Policy and Management Criminal Justice Policy and Planning Division found that inmates with mental health problems had “significantly higher recidivism rates” than other offenders.

The price of prison health care, for both mental and physical ailments, has some lawmakers pushing to look into alternatives to the prison system’s $98 million annual managed-care contract with the University of Connecticut. Connecticut’s budget for the next fiscal year is about $3.5 billion in deficit.

The most recent annual report by UConn’s Correctional Managed Health Care [CMHC] shows that about 3,500 prisoners, or 18 percent of the prison population, are receiving mental health treatment. That percentage has climbed since 2003, when an estimated 13 percent were considered mentally ill.

The prison system’s handling of the mentally ill—a longstanding topic of controversy – is now a focus of Michael Lawlor, Gov. Dannel Malloy’s new chief of criminal justice planning and policy. Lawlor said he wants the state to pursue alternatives to prison for mentally ill inmates who are convicted of lesser offenses and do not pose a danger to society.

“Some people definitely need to be in prison, but not all of them do,” Lawlor said. “If our goal is to get those [non-dangerous] people better, the worst place to do that is in prison.”

Data from CMHC show that mental health costs rose significantly from 2004 through 2007—- from 18.8 percent of total medical expenses, to more than 23 percent. But despite the continued rise in prisoners with mental health problems, CMHC has worked to hold down the costs of caring for them in the last four years, with the percentage dropping to 19.3 percent in 2010, officials said.

The most severely mentally ill male prisoners are housed at Garner Correctional Institution in Newtown, where the corrections department consolidated its mental health services in 2004 as part of a settlement in a lawsuit brought by the state Office for Protection and Advocacy for Persons.

While the overall cost per inmate for medical, mental health and dental services in 2010 was $4,780, the per-inmate health cost for Garner was significantly higher – about $12,000, according to the DOC.

Lawlor said the state needs to shift focus from “solutions that equip our prison system to better handle the mentally ill” to more community treatment options and better training of law enforcement to direct non-dangerous offenders to those options, rather than throw them in jail.  He noted that health care expenses in prisons are not reimbursed by Medicaid, as they would be in hospitals.

“The more mental health beds you put in the prison system, the more mentally ill prisoners you’ll end up with,” Lawlor said.  “Sure, it’s good that we have a big mental health prison with state-of-the-art services, but it’s also become kind of a magnet.”

In the area of training, Connecticut has a program, the “Crisis Intervention Team,” that trains police officers to deal with people who have mental impairments, defusing tensions and reducing the need for arrests.  But program officials said the training program is underutilized, with the exception of a few cities such as New London, which have trained large numbers of officers.

Holding The Line On Costs

The state has contracted with UConn to provide managed care within its prisons since 1997. CMHC performs medical, dental and mental health assessments on every new admission to prisons or jails, with one out of five of those assessments yielding a need for prompt medical or mental health intervention, according to CMHC’s 2010 annual report.

The annual report shows that a full 40 percent of Connecticut’s prison population was on medications as of last June.

“Pharmaceutical costs continue to rise sharply, with increasing demand for costly medications for treating HIV, Hepatitis C and psychiatric conditions,” the report says. “Schizophrenia, bipolar disorder, post traumatic stress disorder (PTSD), depression, severe personality disorders, traumatic brain injury and addictive disorders are overrepresented in this population.”

Garnett said the DOC and CMHC have taken a number of steps to hold the line on health care costs in the last five years, including savings on pharmaceutical purchasing, reducing overtime costs and reviewing the use of specialized treatment. As one example, in 2010, the department sharply reduced its spending on one-on-one observation of inmates at risk for suicide by retraining staff and using alternative methods, a 2011 DOC Program Report Card says.

Other savings have come from a decline in spending on psychotropic medications. About 18 percent of inmates were receiving psychotropic drugs in 2010 – down from 20.3 percent in 2007. The decline “is a result of changes in prescriber practices due to increased education and the introduction of more programming which has resulted in a reduced need for medications,” Garnett said.

While the cost of CMHC’s health services grew by only 5 percent since 2007, it has skyrocketed 67 percent since 2000, while the number of inmates has risen only slightly. In 2000, Connecticut spent just over $59 million to provide health care for 17,459 inmates. The state was incarcerating 17,746 people as of Jan. 1, 2011.

More Mentally Ill

Garnett said the rise in the proportion of mentally ill inmates is due partly to the system’s efforts at better screening and identification of mental health problems.

“I would suggest that the increase is probably a combination of additional people with mental health issues and additional screening procedures we have in place,” he said. “I think that our level of mental health oversight has improved throughout the years.”

But others say moving the mentally ill out of state hospitals, or deinstitutionalization, has fueled the higher percentages of inmates with mental illness. Connecticut closed its state-run psychiatric institutions in the 1980s and ‘90s.

“Ironically, whatever money people thought they would save through deinstitutionalization, we’re now spending it on prisons,” Lawlor said. He said a key challenge now is to “separate the mentally ill and dangerous, from the mentally ill and not dangerous” who do not need, or benefit from, a prison setting.

Despite the increased resources for mental health, the 2010 recidivism report, which tracked inmates after they were released from state correctional facilities in 2005, found that offenders who had mental health problems were more likely to end up re-arrested or returned to prison than other inmates. More than 45 percent of offenders with serious mental disorders were re-incarcerated to serve a new sentence within three years of being released, compared to 36.6 percent overall.

Garnett said that in recent years, the DOC has stepped up collaborations with other state agencies to address the re-entry needs of offenders with mental health issues.

“We work with the Department of Health and Addiction Services and others on discharge planning of inmates with mental health issues to ensure that when they leave, they don’t decompensate and come right back to us,” he said.

CT Costs Not Highest

While Connecticut’s prison health costs are raising concerns, they are lower than those of nearby Massachusetts, which spends an average of $7,240 on health care per inmate, including inmates at Bridgewater State Hospital, which houses the mentally ill.

Mental health has been a particular problem in Massachusetts, where published reports in 2007 highlighted an inordinate number of suicides and suicide attempts among mentally ill prisoners held in isolation cells.

As of Jan. 1, 2010, 21.4 percent of male inmates in Massachusetts were classified as “open mental health cases,” with 18.1 percent taking psychotropic medications, according to state corrections department figures. The numbers are even higher for female prisoners: 60.8 percent are open mental health cases, with more than half on psychotropic medications.

Like Connecticut, Massachusetts contracts with outside agencies to provide medical and mental health treatment in its prisons and has taken steps to contain costs.

In recent years, Massachusetts lawmakers have sponsored bills that would elevate treatment standards for inmates and strengthen training requirements for corrections officers.  But the proposals have languished.

Massachusetts state Rep. Ruth B. Balser, a clinical psychologist who has been active in mental health issues, said concerns about the quality of health care in the state’s prisons are often overshadowed by budgetary concerns – as they are in Connecticut today.

“It’s an issue that tends to fall into the background,” she said.

C-HIT writers Colleen Shaddox and Tom Puleo contributed to this story.

To read related story on Massachusetts prison health care costs published by the New England Center for Investigative Reporting click here.