Third World conditions in a First World country? That’s what we here at Doc Gurley call The Fourth
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World. Here’s some news from this far-off (and yet so up-close) land:
A new, well-designed study shows that we may not have emptied the state’s locked psychiatric facilities of the past (remember One Flew Over The Cuckoo’s Nest?). Instead, we just renamed them. Prison (the long-term state option), not even jail (the shorter-term city option), is now the locked ward of the mentally ill. Prison guards, in comparison, make Nurse Ratchet seem all touchy-feely and sweet.
Is that just someone’s opinion? Finally, there’s actual data. Get a load of these numbers from a great summary in Medscape of a long-overdue ”retrospective cohort study of all 79,211 inmates who began serving a sentence between September 2006 and September 2007 in the Texas Department of Criminal Justice System, the nation’s largest state prison system.
They determined the number of incarcerations in the past 6 years among 5 groups of inmates:
No psychiatric disorder (the reference group; n=71,333).
Major depressive disorder (n=3252).
Bipolar disorder (n=2402).
Schizophrenia (n=849).
Nonschizophrenic psychotic disorders (n=1375).
Inmates with these 4 disorders (10% of the total number!) were 1.6 to 3.3 times more likely to have 4 or more incarcerations during the previous 6 years, compared with inmates with no psychiatric disorder.”
In Understatement of the Year Award fashion, the authors note: “Many people with serious mental illness move continuously between crisis hospitalization, homelessness, and the criminal-justice system.”
So what can be done? Unfortunately, a pretty large subset of people suffer from a combination of mental illness, addiction, and (pick your favorite third- or more- item: head trauma, severe developmental delay, poor impulse control, personality disorder, poor/no social support).
Now imagine taking this person and let’s lock him/her up with no services and almost no human contact (and what contact exists is NOT, ahem, therapeutic). Now suddenly open the door and send them out to the street, where the only thing readily available is…drugs (which, by their very nature, destroy what little impulse control/insight/social support might still exist). Is anyone surprised that it ends badly? Anyone?
Even from a crime-prevention strategy, it makes no sense. Let’s not even talk about cost.
The authors of the study suggest “Potential strategies to reduce recidivism in mentally ill prison inmates include diverting individuals with serious mental illness to appropriate community-based mental-health services in lieu of incarceration, linking newly released mentally ill inmates with community-based services, and developing specialized correctional mental-health facilities.” The accompanying editorial goes further to add “at-risk individuals who are resistant to psychiatric treatment could benefit from assisted outpatient treatment (court-ordered civil commitment).”
Bottom line: For an awful lot of people, when we got rid of Nurse Ratchet, her starched hat, and the TV room, all we really did was replace her with a beefy guy, a nightstick, and an electronically-monitored isolation cell.
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Doc Gurley is a Board-certified Internist physician and the only Harvard Medical School graduate to have been awarded a Shoney’s Ten-Step Pin for documented excellence in waitressing. 
I’m pretty much convinced that in the minds of most Americans, it’s more important to punish people than to prevent crimes or achieve justice.
Doc Gurley,
Re: the Fo urth World: schizophrenics in jail, prison, etc. My daughter is in the psych services area of San Francisco’s County Jail 8. She’s a violent (yes, there are violent schizophrenics; it’s the *why* that’s important, however), paranoid schizophrenic, 25 years old, and a former genius-level (not a parental exaggeration) Lowell H.S. graduate.
I am trying to find/build a support base for parents of adult schizophrenics who cannot, in the state of California, get ANY information regarding their profoundly mentally ill children. Also, I cannot for the life of me get the attention of the psychiatrists in San Francisco General Hospital — Drs. Leary and/or Dilly. I simply want to know what the hospital’s policy is re: releasing obviously, gravely, profoundly mentally ill patients without medical attention and without an evaluation. Why is that? How can they get away with that, Doc? Is it to their advantage to keep parents IN the dark? To do anything they dang well please with the mentally ill? Think about it: in psych units, there is NO oversight. With the medical personnel going overboard on HIPAA and “patient’s rights” they can throw my daughter and others like her, who desperately NEED medical attention, out on the streets — over and over.
Why is that??
Rozelle Trizuto
415-971-9650