Keeping mental health patients stable and out of jail
Jesse Harrison’s parents used to have to call the police to get him to come out of his bedroom, so it’s something of a triumph he took visitors up there himself.
His psychiatrist, Rob Weisman, follows him up a narrow carpeted staircase into the attic room. The light was broken, so it was very dark. An unmade bed is on one side of the room, and an asthma nebulizer sits amid Styrofoam cups and other trash on the floor in front of the TV.
“We’ve got to get you cleaned up in here,” Weisman says.
Harrison is schizophrenic and smokes a lot of marijuana.
Weisman visits Harrison at least once a week to check up on him. Weisman is part of a Forensic Assertive Community Treatment team out of the University of Rochester, a special program that aims to keep people with mental illness out of the hospital and out of the criminal justice system.
“I wanted to talk about the medicine we give you. We give you that long-acting injection. Is it working?” Weisman asks.
“Yeah,” Harrison replies.
“How does it help you, if at all?” Weisman wants to know.
“I’m really doing well since then,” Harrison responds in a quiet voice.
“Does it make you feel less anxious?”
“Yeah,” Harrison replies, still mumbling. “I haven’t wanted to harm myself or anything like that.”
Assertive Community Treatment teams were first developed in the 1970s as a way to help people with severe mental illness live on their own, outside of institutions. The teams are made up of experts, such as psychiatrists, psychologists, social workers and employment specialists, who are on call 24 hours a day, seven days a week. ACT teams are expensive. But early studies showed they saved money by keeping people out of the hospital. The Rochester FACT team is a new spin on the approach — trying to keep people like Harrison not just out of the hospital, but also out of jail.
It sounds unlikely that a man who spends months at a time hiding in his room needs a whole support team to keep him out of jail.
“He’s not a hardened criminal or gang banger. He happens to live in a very bad area,” Weisman says. “[He] is at risk because of his drug use. And when he does go out, he’s involved in some card games, and a little bit of gambling and trouble can find him.”
This team of specialists meets clients where they are, literally: at home, on street corners, or, even under bridges. Dr. Steve Lamberti, another psychiatrist on the Rochester team, says the trick is to figure out how to treat the clients medically and understand why they keep getting in trouble with the law.
“Is it driven by their addiction? And if so, how so, are they selling drugs?” he says. “Are they appearing drunk in public? Is this somebody with DWIs, and that’s their channel into the criminal justice system?”
Lamberti’s team has just finished collecting data for a study to see how well their program works. Early results suggest their clients spent less time in jail, less time in the hospital and were more engaged in their outpatient treatment. The more complicated question is whether the program saves money.
In the short-term, FACT teams are expensive.
“If you’re running a clinic and you hire a psychiatrist, you could either get that psychiatrist to run a FACT team, which has on average about 50 patients,” Lamberti says. “Or you could get the psychiatrist to see outpatients … it would be more like 1,000.”
It seems that in the longer term, though, the money you save on hospitalization and incarceration should add up. And earlier studies suggested the traditional ACT teams did save money by keeping people out of the hospital.
But in the early days of ACT teams, psychiatric patients were often hospitalized for years, which was very expensive. Nowadays, it’s rare for people to stay in the hospital for more than a few days, or at the most, a few months.
“The cost savings aspects of Assertive Community Treatment programs may have changed,” says Eric Slade, a health economist at the Department of Veterans Affairs who has studied ACT teams. “To the extent that public agencies are expecting savings from Assertive Community Treatment, that assessment may need re-evaluation.”
There’s also the question of how long somebody like Jesse Harrison will need his intensive support team.
“A success for Jesse is getting him mobile, moving him out of his attic room,” Weisman, his psychiatrist, says. “Getting him to get medical care as well as accept mental health care. And get him to minimize, what we call harm reduction related to his substance use.”
All of those interventions will probably keep him out of the hospital and out of jail, but what remains to be seen is whether it will save any money.
Roth’s reporting on mental illness and the criminal justice system was supported by a Soros Justice Fellowship.
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