The status of psychiatric services for individuals leaving jails and
prisons and reentering the community mirrors that of services for
deinstitutionalized patients in the community 30 years ago, said forensic
psychiatrist Ken Hoge, M.D.FIG1
Ken Hoge, M.D.: "People are released every day with mental illness
with no regard for how they are going to get treatment when they are
Credit: David Hathcox
Which is to say the situation is not good.
In fact, "abysmal" is how Hoge described it last month at a
symposium titled "Hot Topics in Psychiatry and Law" at APA's 2008
"Five out of six people reentering the community do not receive any
services at all, and recidivism is high," Hoge said. "Even in
those areas of the country that have excellent outpatient mental health
services—which is not the norm—the impact" on
reincarceration rates among the mentally ill is essentially zero. Whatever we
are doing now, it doesn't work."
Hoge is chair of APA's Task Force on Outpatient Forensic Services and is a
clinical professor and director of law and psychiatry at New York University
School of Medicine.
Also speaking at the session was Paul Appelbaum, M.D., on legal issues
surrounding university students with mental illness, and Debra Pinals, M.D.,
on legal issues involved with the purchase of a gun by people with a history
of mental illness. Appelbaum, who was then chair of APA's Council on
Psychiatry and Law, is the Elizabeth K. Dollard Professor of Psychiatry,
Medicine, and Law and director of the Division of Psychiatry, Law, and Ethics
at Columbia University. Pinals, a member of the Council on Psychiatry and Law,
is co-director of the Law and Psychiatry Program and an associate professor of
psychiatry at the University of Massachusetts Medical School.
Hoge described an American legal landscape that has turned harshly
punitive, with the U.S. far outstripping other countries in rates of
incarceration—now up to 700 per 100,000 population.
He also said that the number of mentally ill persons cycling through the
nation's jails and prisons is "staggering"—roughly a million
It is not uncommon, he said, for patients in this population to have
anti-social personality disorder or schizophrenia in combination with a
substance abuse problem.
"You don't see a lot of those people even in the most difficult
public mental health situations," he said, because over time they have
been systematically transferred from the public mental health system to the
Reentry from prison into the community is difficult enough for people who
do not have a mental illness; difficulties are compounded for those who
"The system problems in this area are simply astronomical,"
Hoge said. "If you think about how much work it takes to get people out
of the state mental health system and get them back into the community, then
imagine having to coordinate that with a judicial process and a transportation
system that has little or no regard for therapeutic ends. People are released
every day with mental illness with no regard for how they are going to get
treatment when they are released."
Hoge did close with more hopeful information about a program in California
that targeted $50 million to counties to create their own innovative systems
for dealing with mentally ill persons reentering the community from jail or
prison. Preliminary data comparing the counties' innovative programs with
treatment as usual showed small but significant decreases in jail time and
improvements in treatment outcome.
Hoge suggested that targeting such innovative services at particular
subgroups of patients—such as those who are younger—may prove
In other issues confronting forensic psychiatrists, Appelbaum, who is also
a former APA president, outlined the widely publicized case of a student at
George Washington University who was suspended from school and barred from
campus after seeking treatment at George Washington University Hospital
(Psychiatric News, June 2, 2006).
The student sued the university for violation of the Americans With
Disabilities Act and two statutes in the District of Columbia prohibiting
discrimination against those with mental illness, as well as for emotional
distress and invasion of privacy because the student's medical record was
reported to the administration after the student admitted himself to the
The case was settled out of court.
Appelbaum said the case represented an example of "how not to design
university policies dealing with students in psychological distress."
But he said it is also illustrative of the difficult place in which colleges
and universities find themselves: if a student with mental illness commits a
violent act or suicide on campus and it can be proved that the administration
knew about the student's condition and did nothing to prevent the act, the
university can be sued.
The policy of university officials "is then typically one of 'get
those kids off campus,'" Appelbaum said. "They believe they can't
be sued if [a suicide or violent act] occurs off campus."
Clearly, he said, between the risk of high-profile violence or suicide and
the liability risks associated with action or inaction, "our
universities don't know where to turn."
Appelbaum said the council and the APA Corresponding Committee on Mental
Health on College and University Campuses has set up a joint work group to
develop draft guidelines to assist university officials dealing with these
issues: the rights of students, the rights of a campus community and the
obligations of a college or university, and the appropriate legal treatment of
sensitive information, among others.
Pinals said the shootings last year at Virginia Tech also highlight the
ambiguous nature of laws surrounding the purchase of guns by people with
mental illness or a history of mental illness.
Pinals said the National Instant Criminal Background Check system, which
was instituted in 1998 as part of the Brady Handgun Violence Prevention Act,
is a database of people prohibited from purchasing firearms. The database, to
which states can contribute if they wish, includes some individuals with
mental illness. After the Virginia Tech shootings, many people questioned how
the shooter—who had a history of mental illness—had gotten access
"It turns out that the student had been committed to involuntar y
outpatient treatment," Pinals said. "For registry purposes in the
database, that was not considered the same as involuntary inpatient
Moreover, not all states have contributed to the database registry. As a
consequence, a recently passed federal law mandates states to develop a
database of people who are prohibited from purchasing certain firearms,
including individuals with particular mental health histories (Psychiatric
News, February 1).
So where does APA stand on these issues?
"It was very clear to us as psychiatrists that we need to take a
stand that supports efforts to prevent violence," Pinals said. But at
the same time, she said, there is a fine line between protecting the community
and protecting the rights of people who may have had a mental illness in the
past but may be without risk of violence today.
She said APA's Council on Psychiatry and Law is wrestling with issues such
as who should qualify to be in such a database and for how long, whether there
should be procedures for removing one's name from the database, how to prevent
unwarranted use of registry information, and especially whether a database
registry is the best way to prevent violence.
She said the council is working on a draft resource document that it hopes
to have completed by September for review at APA's fall component meetings.▪