e-Texas e-Texassmaller smarter faster governmentDecember, 2000
Carole Keeton Rylander
Texas Comptroller of Public Accounts

Recommendations of the Texas Comptroller


Chapter 11: Public Safety and Corrections

Improve the Treatment
Received by Mentally Ill
Persons Held in Custody


Summary

The growing population of mentally ill offenders in the Texas Department of Criminal Justice (TDCJ) is not receiving new, more effective medications for the treatment of schizophrenia and other psychoses. The Texas Department of Mental Health and Mental Retardation (MHMR) has developed a nationally recognized “medical algorithm” system that provides consistent treatment using the most effective medications. TDCJ and the Texas Youth Commission should review the cost benefits of MHMR’s system to determine its potential for long-term savings from reduced prison hospitalization, better patient functioning, and fewer repeat offenses by mentally ill offenders.


Background

At present, more mentally ill Texans can be found in prisons and county jails than in state mental hospitals.[1] From 1988 to 1998, the number of mentally ill offenders housed in the TDCJ facilities increased at a higher rate than the total prison population. In 1998, 15,716 mentally ill offenders were being treated in the prison system, about 11 percent of the total prison population of 143,803.[2] (This does not include the number of prisoners who refuse treatment, fail to be assessed correctly, or have a prior history of mental illness but no current symptoms.)

In 1999, the Texas Youth Commission (TYC) assessed 42 percent of its population as emotionally disturbed (2,309 of 5,524 youths). TYC had only 341 beds available for their treatment.[3]

Upon release, mentally ill inmates commit new offenses at a higher rate than other inmates. Compared to the general population, they are more likely to have three or more prior convictions.[4] Improved treatment of the mentally ill while incarcerated and following release, therefore, may be one answer to lowering the state’s recidivism rate.

TDCJ’s services for the mentally ill include both inpatient treatment, which requires confinement in a mental hospital, and outpatient treatment, which provides medication and/or counseling to offenders capable of functioning in the general prison population. At present, TDCJ does not use some state-of-the-art medications and treatment options because of their higher cost.


Texas Medication Algorithm Project

MHMR has developed the Texas Medication Algorithm Project (TMAP) to provide consistent treatment options for three major types of mental illness: depression, bipolar disorder (manic depression), and schizophrenia. Medical algorithms are processes designed to integrate available research information with clinical experience to develop user-friendly, step-by-step decisions for treatment.

Under TMAP, a patient is treated with the most effective medications first, because the longer a psychotic episode goes untreated, the longer it will last and the worse it is likely to become. The newer medications used in TMAP cost more than older drugs but have fewer negative side effects.[5] A preliminary MHMR evaluation of TMAP demonstrated improvements in patients’ conditions. TMAP has been nationally recognized, and has received a grant for more than $300,000 from the Robert Wood Johnson Foundation for the education of other states’ mental health agencies.[6]

MHMR will report on TMAP’s clinical outcomes by the end of 2000, and it will report on its cost outcomes in Spring 2001. This study is one of the most extensive of its kind with more than 1,400 participants. Dr. Steve Shon, MHMR’s medical director, believes TMAP could be used to treat mentally ill offenders upon release and reduce their recidivism rate. Correctional systems in other states, including California, Ohio, and Missouri, recognize TMAP’s value and are working toward constructing similar systems.[7]


Children’s Medication Algorithm Project (CMAP)

MHMR has also created the Children’s Medication Algorithm Project (CMAP) for the treatment of childhood depression and attention deficit/hyperactivity disorder (ADHD). CMAP emphasizes proper assessment and diagnosis, the exploration of all treatment options, the use of the most effective medications with the fewest side effects as first-line treatments, and appropriate psychiatric follow-up.

At this writing, MHMR is testing CMAP at four community mental health centers. A study summarizing the results of this pilot project should be completed in Spring 2001. The next phase of CMAP will evaluate the algorithm treatment for benefits and cost.


Drug Costs

Older drugs used to treat mental illness cost, on average, $250 a year per patient, while newer, more effective drugs cost on average of $3,000 a year.[8] Even so, the newer medications represent major innovations in the treatment of schizophrenia and other psychoses. A national study has shown that the use of these newer drugs reduces the use of expensive mental health services such as hospitalization, thus offsetting the medications’ higher costs.[9]

The TMAP and CMAP studies are expected to show additional economic benefits, such as reductions in the number of inmates and juvenile offenders in TDCJ and TYC psychiatric hospitals and reduced recidivism. Furthermore, reducing side effects and increasing the ability of the mentally ill to function should reduce the number of aggressive outbursts and increase safety within the prison system.


Recommendations

  1. The Texas Department of Criminal Justice (TDCJ) should review the costs and benefits of the Texas Department of Mental Health and Mental Retardation’s (MHMR’s) Texas Medication Algorithm Project to determine how it could be applied to mentally ill inmates in TDCJ.

    The cost benefit results from MHMR’s TMAP study should be completed in fiscal 2001, giving TDCJ enough time over the next biennium to review the data and determine its benefits and costs for the prison population.

  2. The Texas Youth Commission (TYC) should review the benefits of MHMR’s Children’s Medication Algorithm Project (CMAP) to determine how it can be applied to children in TYC facilities.

    TYC should review MHMR’s CMAP and determine its potential benefits for juvenile offenders with major depressive disorder and attention deficit hyperactivity disorder. Early treatment can have a long-lasting effect on children with these conditions.

  3. The Texas Council on Offenders with Mental Impairments (TCOMI), in conjunction with the Texas Criminal Justice Policy Council (TCJPC), should oversee the review conducted by TDCJ and TYC and report on its results to the Legislature.

    TCOMI’s oversight of TDCJ’s review will help safeguard the best interests of mentally ill offenders. TCJP’s experience with cost analyses will be beneficial to TDCJ and TYC.


Fiscal Impact

These recommendations would have no fiscal impact. TMAP is an innovative, nationally recognized program that should be reviewed by TDCJ and TYC to determine its implications for their populations.

If the cost-benefit analysis of TMAP and CMAP shows favorable results and the TMAP and CMAP models are implemented, the cost of treating the mentally ill populations in TDCJ and TYC would increase, and these costs could be paid from funds appropriated to the Correctional Managed Health Care Program. Long-term savings from reduced prison hospitalization, better patient functioning, and reduced criminal justice costs should outweigh higher medical costs. Reducing the number of high-cost mentally ill offenders in state prisons would allow the state to redirect funding to support better treatment.


[1] Interview with Dee Kifowit, executive director of the Texas Council on Offenders with Mental Impairments, July 18, 2000.

[2] Texas Criminal Justice Policy Council, The Public Mental Health System in Texas and Its Relation to Criminal Justice (Austin, Texas, February 2000), p. 18.

[3] Texas Criminal Justice Policy Council, The Public Mental Health System in Texas and Its Relation to Criminal Justice, p. 20.

[4] US Department of Justice, Bureau of Justice Statistics, Mental Health and Treatment of Inmates and Probationers: Special Report (Washington, DC, July 1999), p. 5.

[5] Interview with Dr. Steve Shon, medical director, Texas Department of Mental Health and Mental Retardation, Austin, Texas, March 23, 2000.

[6] Telephone interview with Dr. Steve Shon, medical director, Texas Department of Mental Health and Mental Retardation, Austin, Texas, July 14, 2000.

[7] Telephone interviews with Dr. Lynn Crismon, co-director of the Texas Medication Algorithm Project, University of Texas Southwestern Medical Center, Dallas, Texas, July 19 and October 9, 2000.

[8] Telephone interview with Dr. Steve Shon, November 2, 2000.

[9] Christopher G. Fichtner, Patricia Hanrahan, and Daniel J. Luchins, "Pharmacoeconomic Studies of Atypical Antipsychotics: Review and Perspective," Psychiatric Annals 28:7 (July 1998), p. 381.



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