Faculty Bibliography

Because there is no standard reporting of injuries in jails and prisons, the national burden of head trauma during incarceration is unclear. We report on a case of repeated head trauma in the New York City (NYC) jail system, data on the incidence of head trauma and mild traumatic brain injury (mTBI), and compare those findings with national estimates. The case report revealed 64 injurious events over two years, 44% resulting in a head injury and 25% resulting in emergency hospitalization. During the 42 months of this analysis, 10,286 incidents of head trauma occurred in the NYC jail system. Mild TBI occurred in 1,507 of these instances. The rate of head trauma and mTBI was 269.0 and 39.4 per 1,000 person-years, respectively. The lack of reporting head trauma in correctional settings means that national prevalence estimates of these critical health outcomes miss the vulnerable cohort of incarcerated individuals.

The proliferation of jails and prisons as places of institutionalization for persons with serious mental illness (SMI) has resulted in many of these patients receiving jail-based punishments, including solitary confinement. Starting in 2013, the New York City (NYC) jail system developed a new treatment unit for persons with SMI who were judged to have violated jail rules (and previously would have been punished with solitary confinement) called the Clinical Alternative to Punitive Segregation (CAPS) unit. CAPS is designed to offer a full range of therapeutic activities and interventions for these patients, including individual and group therapy, art therapy, medication counseling and community meetings. Each CAPS unit requires approximately $1.5 million more investment per year, largely in additional staff as compared to existing mental health units, and can house approximately 30 patients. Patients with less serious mental illness who received infractions were housed on units that combined solitary confinement with some clinical programming, called Restrictive Housing Units (RHU). Between 1 December 2013 and 31 March 2015, a total of 195 and 1433 patients passed through the CAPS and RHU units, respectively. A small cohort of patients experienced both CAPS and RHU (n = 90). For these patients, their rates of self-harm and injury were significantly lower while on the CAPS unit than when on the RHU units. Improvements in clinical outcomes are possible for incarcerated patients with mental illness with investment in new alternatives to solitary confinement. We have started to adapt the CAPS approach to existing mental health units as a means to promote better clinical outcomes and also help prevent jail-based infractions. The cost of these programs and the dramatic differences in length of stay for patients who earn these jail-based infractions highlight the need for alternatives to incarceration, some of which have recently been announced in NYC.

Inmates represent a vulnerable population with increased rates of trauma and posttraumatic stress disorder (PTSD). However, little is known about the rates of trauma and PTSD among male inmates with acute psychiatric illness. This prospective, randomized study was conducted to assess the current rates of trauma and PTSD in this population. The sample consisted of 48 patients admitted to a hospital jail psychiatry service in New York City. Subjects were administered the Life Stressor Checklist-Revised and the Structured Clinical Interview for DSM-IV-TR Disorders, PTSD Module (SCID-I). The rate of PTSD diagnosis via SCID-I was 46.2% as compared to 2.1% diagnosis via clinical interview. All participants reported a history of at least one stressful and/or traumatic event, and many of these events occurred during incarceration. These results demonstrate that a great deal of trauma and PTSD goes unrecognized and untreated in this population, indicating the need for more effective treatment interventions.

Abstract There is a well-established and growing body of evidence from research that adolescents who commit crimes differ in many regards from their adult counterparts and are more susceptible to the negative effects of adjudication and incarceration in adult criminal justice systems. The age of criminal court jurisdiction in the United States has varied throughout history; yet, there are only two remaining states, New York and North Carolina, that continue to automatically charge 16 year olds as adults. This review traces the statutory history of juvenile justice in these two states with an emphasis on political and social factors that have contributed to their outlier status related to the age of criminal court jurisdiction. The neurobiological, psychological, and developmental aspects of the adolescent brain and personality, and how those issues relate both to a greater likelihood of rehabilitation in appropriate settings and to greater vulnerability in adult correctional facilities, are also reviewed. The importance of raising the age in New York and North Carolina not only lies in protecting incarcerated youths but also in preventing the associated stigma following release. Mental health practitioners are vital to the process of local and national juvenile justice reform. They can serve as experts on and advocates for appropriate mental health care and as experts on the adverse effects of the adult criminal justice system on adolescents.

LEARNING OBJECTIVE: After participating in this activity, learners should be better able to:Evaluate emerging concepts of identification, treatment and discharge planning for individuals who are experiencing a first psychotic episode while detained in the criminal justice system. ABSTRACT: The United States incarcerates more people than any other nation in the world. The system of jails and prisons that holds those individuals has become the largest provider of mental health care in the country, with rates of psychotic illness many times higher than in the community. A subset of this population includes individuals experiencing their first episode of psychosis who are untreated and are new to the rules of institutional settings. Retrospective and anecdotal reports indicate that many individuals in the criminal justice system have first-episode psychosis, yet no published information is available about the actual rates. For these patients, behavior associated with psychotic symptoms may have led to their arrest, but correctional facilities are poorly equipped to identify their needs and to provide the type of comprehensive treatment needed to improve functional status, quality of life, and illness recovery. Even as first-episode programs are flourishing in community settings, we know little about how to identify, engage, possibly divert, and treat these patients in settings designed as punishment. Efforts should be made both to reduce the number of these individuals inappropriately prosecuted within the criminal justice system and to begin in-jail efforts to engage them in treatment, in anticipation of their eventual return to the community.

OBJECTIVE In New York City, individuals gravely disabled by substance use disorders repeatedly present to emergency rooms yet rarely remain in treatment for more than several days and often sign out against medical advice. Although these individuals are at high risk of death and often lack the capacity to make treatment decisions, the laws in New York State are unclear about whether substance use disorders qualify as mental illnesses for the purpose of involuntary hospitalization. To better understand the national landscape of civil commitment law, with a specific focus on substance use disorders, a review was conducted of mental health statutes in all 50 states and the District of Columbia (D.C.). METHODS Two independent reviewers examined all state mental health statutes using LexisNexis and Westlaw search engines. RESULTS A total of 22 states, including D.C., do not reference substance use disorders in their statutory definitions of mental illness. Of the 29 that do, eight include substance use disorders and 21 explicitly exclude them. In addition, nine states have separate inpatient commitment laws specifically addressing substance use disorders. CONCLUSIONS Civil commitment statutes vary greatly by state in terms of clarity and specificity regarding which mental illnesses are included for the purpose of involuntary hospitalization. Mental health professionals and policy makers should discuss whether individuals gravely disabled by substance use disorders, a complex and vulnerable population, should be more widely included under standard civil commitment law.

A growing number of individuals with mental illness are receiving psychiatric treatment in the criminal justice system. However, mental health problems facing individuals immediately after arrest and before arraignment have not been adequately studied. In New York City, prearraignment arrestees who require psychiatric hospitalization are temporarily transferred from police custody to correctional custody and admitted to the Bellevue Jail Psychiatry Service (BJPS) for treatment. The purpose of this study was to gain a better understanding of the impact of this jail hospitalization on the legal disposition of this vulnerable population. A retrospective chart review was conducted of 204 consecutively admitted male patient-arrestees on the BJPS. Results showed that admission to the BJPS delayed arraignment by an average of 8.03 days, with longer delays for individuals arrested outside of Manhattan. Although these delays are considered acceptable under legal precedent, concerns arise about the therapeutic impact of this practice on newly arrested individuals with severe mental illness.