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In jails, steep costs for caring for those with mental illnesses

Funding cuts limit treatment options

In unit 4C of the Pueblo County jail, any human presence draws inmates to the narrow windows of their solitary cells.

They bark requests and complaints, or just grin and make small talk. One man’s ceiling is leaking; another wants to know how many more days he has left in segregation.

“Ma’am, do you work here?” asks a tall African-American man with a steady, serious gaze, who wants to know when his glasses will be delivered.

“I’m the warden, Darlene Alcala,” she replies. Alcala is small and elegant in black and wears a friendly smile at odds with the cinder-block bleakness of the jail. “You can call me Chief.”

Though they live on opposite sides of the jail’s heavy doors, these two have come to see eye-to-eye on a crucial point: Inmates like him don’t belong here.

The man has been in 23-hour-a-day lockdown for a year and a half now. Like most of his fellow residents in what’s known as administrative segregation, he is mentally ill. Brief interactions with the staff are nearly the only contact he has with the world outside his cramped cell.

As a shortage of funding has depleted options for those in need of treatment for mental illnesses, there’s still one place that can’t say no – jail. Inpatient psychiatric beds have dwindled to 1,093 for the state’s entire population, according to state human services data, a decrease of 20 percent from five years ago. People with mental illnesses are more than five times as likely to wind up in jail or prison.

“Years ago, we deinstitutionalized mental-health treatment,” says Boulder County Sheriff Joe Pelle. “People felt it was shameful that we had people in custody or locked up in mental-health facilities. Now, instead, we lock them up in jail.”

The burden on jails is growing. A 1992 jail survey found that 11 percent of Colorado inmates had a serious mental illness, according to research by Public Citizen’s Health Research Group and National Alliance for the Mentally Ill. This year, 10 county jails surveyed by I-News reported that, on average in 2013, 18 percent of their inmates were mentally ill.

Sheriffs say the trend is noticeable from year to year. At the Douglas County jail, for example, the number of mentally ill inmates has grown 10 percent in the last three years, even as the general daily population has dropped 28 percent.

Once they’re in, inmates with behavioral-health problems have more trouble getting out. The seven metro Denver counties in 2008 found that mentally-ill inmates stayed an average of five times longer than other inmates. In Pueblo, an inmate detained for a misdemeanor stays an average of 28 days; mentally-ill inmates jailed for similar offenses stay between 171 and 180 days.

“Jails and prisons have become the warehouses for people who aren’t getting treated elsewhere,” says Attila Denes, a captain at the Douglas County jail. “It’s among the most expensive and least humane” ways to provide care.

Solitary confinement is routine. Even as Colorado’s new state prison chief, Rick Raemisch, has pledged to remove mentally-ill prisoners from isolation because of concerns that it is counterproductive and inhumane, jailers say they still use 23-hour lockdown to keep staff and other inmates safe.

Becoming a last resort

The confinement of thousands of mentally-ill Coloradans in jails and prisons can make a striking contrast with the sensibilities of the people whose job it is to confine them.

Alcala first took a job as a receptionist at the Pueblo jail 30 years ago to get health insurance for her newborn son. Her ambition to become a deputy was stoked by a supervisor who told her she was hired “to look pretty and answer the phone.”

It was in the ’90s that she became aware of the prevalence of mental illness in the jail; there was a woman who smeared feces on the wall and an inmate who licked the floor. Alcala recalls that the detention officers had no real tools for handling what they simply saw as strange behavior.

Alcala and other staff have worked to acquire the skills to communicate with inmates in the throes of a crisis. When she enrolled in crisis-intervention training eight years ago, says Alcala, “I wish I’d had it 15 years earlier.”

Sheriffs increasingly are enlisting mental-health professionals to improve care for the mentally ill in jail by training detention officers to communicate through a crisis and by offering therapy to inmates.

John Parsons, who was released from the Pueblo jail in March, says he got help from a jail-based program called Moral Reconation Therapy – a type of cognitive behavioral therapy – to handle his depression, anxiety and alcoholism.

“MRT told me how to handle the stresses and pressures of life in the way normal people do,” Parsons said in April.

Jagruti Shah runs the state’s offender mental-health programs, overseeing a budget of about $2.7 million to help connect inmates with treatment for substance abuse and co-occurring mental-health disorders. The programs run in 33 counties, reaching about 90 percent of the state’s jail population.

Shah says the programs have had some success in treating inmates while they’re jailed.

But the short-term stay of most inmates means they walk out with only a few days’ worth of medication. Outside, care can be hard to come by – both before and after incarceration.

“Quite often, people don’t have the opportunity to engage in these treatment programs until they hit the front door of the jails,” Denes says.

Pueblo inmate Erin Hedden says she tried.

After symptoms of bipolar disorder emerged when she was 28, Hedden was prescribed a laundry list of drugs. Each one failed until she found a combination that worked: Prozac and Zyprexa.

But when she left a job as a nursing assistant to work on her mother’s ranch, Hedden lost her insurance. At $1,000 a month, the medication was out of reach. It took three months for the symptoms of mania to resurface, and Hedden says she sought refuge in crystal methamphetamine.

Three years later, Hedden is in jail on a four-year sentence for drugged driving. She was behind the wheel in a crash that killed Linda Sue Sublett, a 69-year-old woman she never met.

The county now pays for her Prozac and Zyprexa.

Paying for confinement

Two miles northwest of the jail, on a road spiked with wind-driven tumbleweed, is the campus of the Colorado Mental Health Institute at Pueblo, one of only two state psychiatric hospitals.

Beds at the state hospitals have disappeared steadily even as Colorado’s population has boomed, the victim of federal and state budget cuts and a change in philosophy that emphasized removing people from institutions. In 1980, there were 1,103 public psychiatric beds in Colorado; in 2014, there are 553, many of them earmarked for those charged with or convicted of crimes.

Pueblo Sheriff Kirk Taylor says the state psychiatric hospital sends its patients to the jail when they lash out or act violently, including people who previously have been found not guilty by reason of insanity. At the same time, Taylor and other county jail officials complain that the state hospitals frequently turn away inmates who are put on emergency mental-health holds because they pose a danger to themselves or others.

“These people don’t need to be in jail,” Taylor says. “They need to be in a therapeutic community.”

Bill May, who heads the state hospital in Pueblo, believes it’s appropriate for some of its patients to be arrested and sent to jail if they commit a crime while stable in treatment.

Meanwhile, state psychiatric hospitals can’t receive people on mental-health holds unless they’ve been treated and cleared first for any physical problems, says Dr. Patrick Fox, a Colorado Department of Human Services official who oversees the hospitals. He suggests taking inmates to the emergency room.

At issue, in part, is the question of who bears the high costs of housing mentally-ill inmates. Psychotropic medications, additional security and lengthier stays all add to the costs. A seven-county study in the metro Denver area found the cost of accommodating seriously mentally-ill inmates to be about $44.7 million a year in 2010, up from $36.5 million in 2006. Costs haven’t declined since then and likely have increased, says Regina Huerter, director of Denver’s Crime Prevention and Control Commission.

Like the homeless, mentally-ill inmates often have trouble meeting judges’ standards for bail, which take into account qualifications such as stable housing, employment and family support, says state public defender Douglas Wilson. This is despite the fact that their crimes may be low-level offenses.

“The reality is, most of the time, what we’re talking about is trespasses, the guy who roller-skated into somebody’s garage because he thought it was a roller rink, public urination,” says Sheriff Gary Wilson in Denver.

Denver recently found that the 99 people most frequently jailed for low-level offenses had a high rate of mental illness – about 35 percent. They also frequently were homeless and addicted to alcohol or drugs, adding to the complexity of treating them.

Some get into more trouble behind bars, committing crimes that lengthen their stays, says Sheriff David Walcher in Arapahoe County.

“They commit crimes on the inside; there are assaults on staff. They tend to get more charges when they’re in jail,” Walcher says. “They’re a more challenging population overall.”

On the inside

From their stark walls to their locked doors to their narrow, light-deprived spaces, jails are meant to confine criminals, not promote recovery.

“There’s nothing soft about what we do,” Alcala says. “We’re built for offenders.”

Hedden has sharp memories of her episodes in 23-hour lockdown. The 35-year-old inmate, who is being treated for social anxiety and depression along with bipolar disorder, says her last 12-day stay there led her to a breakdown.

“All day long, it’s a cacophony of voices, of screams, of shouting,” she says. “There is no human interaction except for what’s between you and the guard, and who you can yell at next door through the wall. The loneliness is overwhelming. I get a sense of intense anxiety like I just want to claw at the door. I just want to get out. I would do anything to get out. I beg to get out.”

A growing understanding of what it means to isolate people who have mental illnesses is leading to changes in the state prison system.

When former prisoner Evan Ebel shot dead prison chief Tom Clements last year, the incident raised questions about Ebel’s time in solitary confinement and his direct release into the community. Clements’ replacement, Raemisch, has criticized the overuse of solitary confinement nationwide and has pledged to stop placing mentally-ill inmates in administrative segregation. And the state Legislature recently passed a bill – now pending Gov. John Hickenlooper’s signature – banning long-term solitary confinement for seriously mentally-ill prisoners.

But 23-hour lockdown still is widely used as a tool to control mentally-ill inmates in jails.

Jailers in Douglas County, Arapahoe County, Boulder, Pueblo and elsewhere say they try to minimize the use of it, but none said they were considering doing away with it.

“Most jails are pretty close to full, if not overflowing,” says Denes, in Douglas County. “Sometimes when you have people classified as dangerous offenders and you have people packed into a housing unit, the reason that you use (23-hour lockdown) is to prevent victimization of inmates from other inmates.”

Staying out of jail

The best hope for cutting the costs of jailing mentally-ill inmates may be to keep them out of jail in the first place.

Some jurisdictions have built mental-health courts – also called wellness courts – intended to divert people from jail to treatment. Some, like Denver, are pushing to enroll inmates in health insurance, so they can get the care they need once they leave jail.

The state’s flagship project for improving mental-health treatment – a planned network of crisis centers, now stalled amid a lawsuit – may help direct people to settings more appropriate than jail, says human services official Fox.

For now, Colorado’s jailers and their inmates are stuck dealing the best way they can with a broken system.

The Durango Herald brings you this report in partnership with Rocky Mountain PBS I-News. Learn more at rmpbs.org/news. Contract Kristin Jones at kristinjones@rmpbs.org.

About this series

This is the second part of a three-part series about how ignoring mental illness costs us all. Part 3 will be published at a later date.

Part 1: A number of patients who repeatedly visit hospital emergency rooms suffer from an underlying mental illness. These “frequent flyers” rack up eight times more in medical costs on average than their peers, part of the enormous financial costs of mental illness in Colorado.

Today: People with mental illnesses in Colorado are more than five times as likely to be housed in jails or in prisons than in hospital psychiatric beds. Solitary confinement of the most seriously ill is common in county jails.

Part 3: Family members of people with mental illness who are in danger of harming themselves or others say they can’t find treatment when they need it. Even with a backdrop of mass tragedies in Colorado, timely intervention remains a conundrum.

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