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Mental Health Issues: The Impact of Explosive Growth

Posted on: Saturday, 6 August 2005, 03:01 CDT

Las Vegas is one of the fastest growing regions in the nation. Each day, the population grows by 175 people who move into the area (63,802 over the previous year). Clark County is 7,881 square miles and in addition to Las Vegas, also includes the cities of Henderson, North Las Vegas, Boulder City, Laughlin and Mesquite. Each of these communities has contributed in their own right to the state's growth. In 1960, the census for Clark County listed 127,016 residents (64,405 in Las Vegas). Today, the area has 1.7 million inhabitants, with more coming. Although the rest of the state is attractive to many people coming from other regions, no other areas are as appealing as southern Nevada. Clark County currently makes up 74 percent of the state's population of 2.3 million.

Growth has brought both success and challenges. Economically, Las Vegas has faired well considering that its only substantial industry, outside of the Nellis Air Force Base, is gaming and tourism. Its gross revenues last year were estimated to be in excess of $33 billion. And yet despite this appreciable flow of income, the communities of southern Nevada have found it difficult to keep up with this phenomenal growth.

Some of the most profound consequences of this inability to keep up with demand have been felt by those working in, as well as served by, various social services. Both private and public juvenile service providers cannot keep up with demand. Hospitals are often on divert status as a result of too many mental health patients taking up emergency room beds, resulting from too few psychiatric facilities being available to meet their needs.

One-third of emergency-room beds and one-fifth of detention beds are occupied by mental health patients. And more than one-tenth of the prison beds are also occupied by mental health patients. Sound familiar? Welcome to the criminal justice system in southern Nevada. And that system is feeling the pinch of this growth in a major way. Law enforcement, the courts, prisons and all their related services, have felt the need to evaluate their roles and examine the scope of their duties in order to focus their efforts in fulfilling their respective and collective responsibilities. Legislative changes as the state has matured have impacted law enforcement, corrections and everything in between.

Taking on Dual Responsibility

The Las Vegas Metropolitan Police Department is charged with law enforcement responsibilities for Las Vegas and all residential and public areas of this large county. Historically, the department has had fewer police officers (1.7) per 1,000 inhabitants than the national average (2.2). In an effort to address this shortage, the voters were asked to support additional taxes to finance the needed officers to bring the average up to two per thousand. To the surprise of many, in this time when cost cutting in government is the trend, the voters approved the measure and the matter is now before the state Legislature.

The characterization of police officers as mere enforcers of the law has never been accurate and diminishes their actual role in the communities. In addition to apprehending violators of the law, police officers are often the first to confront many social issues, through both opportunity on the job and by default. They encounter issues like neighborhood decay (abandoned vehicles, vacant buildings, etc.), abused children, homelessness and the mentally ill. The police department has examined its response to these and other social concerns, often because there is no other adequate resource to be found. In 2003, the police department adopted the Crisis Intervention Training (CIT) model. A total of 151 police officers and 52 correctional officers were trained in the proper response to psychologically unstable or mentally ill individuals. The officers completing the CIT course have become a valuable resource in the community and in the Clark County Detention Center. Situations that may have otherwise risen to the critical level have consistently been de-escalated to the most reasonable resolutions available. For example, there has been a significant reduction in violent situations.

Las Vegas attracts both the affluent and the desperate. Its booming economy draws a myriad of fortune seekers. Many homeless people have found Las Vegas to be an attractive destination; it has cheap food, mild climate and apparently, it is a good place to call home for a while. Many of the homeless are unemployable due to alcohol or other chronic substance abuse. Others suffer from various mental health issues. Any of these conditions will often place them in contact with law enforcement.

The Wrong Location

The Clark County Detention Center is a jail facility with a daily inmate count of more than 3,200. It receives upwards of 59,000 bookings per year, from 30 local and state agencies. In working with social workers, staff psychologists and physicians, correctional officers with CIT training offer a resource in stabilizing some of the approximately 700 inmates whom require some level of psychological intervention or treatment, a significant number that again is attributable to the lack of psychiatric services in the community. The argument is made by the criminal justice and medical community that many of the inmates would in all likelihood not be in the criminal system if the appropriate investment could be made to stabilize them in their communities. Two of the facility's 57 housing units have been dedicated to housing inmates who can benefit from the officers who have CIT training. Since adopting the program, the facility has found a reduction in violent incidences. Once stabilized, inmates often are able to be re-integrated into the general population.

Court Creation

In early 2003, in response to the burgeoning numbers, the Mental Health Court Advisory Committee was established to develop a grant to fund a mental health court. That funding, in the amount of $150,000, was received in September 2003 and Clark County's 8th Judicial District Court Mental Health Court opened in December 2003.

The goals of this court were to reduce recidivism and the costs related to repeated incarceration, decriminalize the severely mentally ill, provide comprehensive services throughout the system and protect public safety. The actual process the courts follow begins with a screening by either a social worker or nurse at the time of arrest and booking. If the detainee signs a release and consents, there is a psychiatric evaluation to determine the severity of mental illness and an appropriate referral. The referral is sent to the mental health coordinator, the public defender, the city attorney and the district attorney. The coordinator, district attorney and public defender screen against the established criteria, and if those criteria are met, they refer the detainee to the court as a mental health court candidate.

At the initial arraignment, the judge confirms with the public defender and the defendant that there is an interest in mental health court and if confirmed, schedules a status check for one week hence. Southern Nevada Adult Mental Health is notified of the referral and a caseworker interviews the detainee within two days if still in custody. The caseworker notifies the court of the appropriateness of the referral and the reasons for the decision and, if accepted, the district attorney and public defender begin negotiations. The case is bound over in mental health court and a plea agreement is taken. There are weekly team meetings and, most important, the detainee is diverted from the criminal justice system.

Clear Results

During the first six months of operation, 19 cases were enrolled through this process, including 11 diagnosed as bipolar, seven as schizophrenic and one psychotic disorder. These 19 individuals accounted for 385 prior arrests, nearly all with detention required. Fifty-eight of these arrests took place in the 12 months prior to admission into the program. During the first three months of treatment, there were only seven arrests. More specifically, the 12 months prior to treatment resulted in a combined 1,715 days in the Clark County Detention Center. The seven arrests during the first three months resulted in 100 days, a reduction of more than 400 percent.

Many of the representatives of the southern Nevada criminal justice system have been working together to address common issues like mental health and its impact on the system and community. Clark County Sheriff Bill Young, who heads the Metropolitan Police Department, invited key elected and appointed criminal justice officials to come together and form the Criminal Justice Advisory Council, to identify opportunities for improving effectiveness and efficiency. Earlier this year, the Criminal Justice Advisory Council pled with the governor and the state Legislature to fully fund the requested support for improved mental health services in the southern part of the state. The plea was acknowledged by the governor who committed to providing this needed resource.

An examination of history was critical to determining how to address this issue. In the 1980s, most of the community mental health programs were eliminated due to statewide budgetary constraint\s. As funding was gradually restored, little was directed to meet the needs of the mental health system. Additionally, mental health beds specifically targeted for individuals in the Nevada criminal justice system were last built in the 1970s and exist nearly 500 miles from the current population center, Las Vegas. Privately operated programs received some government funding, but again, funding was reduced in 2001 and 2002 due to budgetary issues and many of these programs had to close their doors to mental health patients, leaving the criminal justice system as a "court" of last resort for responding to the issues of the mentally ill.

Addressing the Needs

As the beginning of this article indicates, the problems have yet to be resolved. So the coalition of organizations and agencies previously described began to address specific needs that were mutually identified in 2004. The first need identified was funding for a community triage center with secure capability for patients in need of such. The Las Vegas metropolitan area needed a facility open 24 hours a day, seven days a week, where individuals in mental health crisis can walk in or be brought by family, friends or first responders. It should have the capability to provide assessment, medication and secure holding for individuals in need of emergency observation.

The next need identified was for full funding for the construction and staffing of the state psychiatric facility. The request was that the already planned new psychiatric hospital should be fully built, not phased in, and fully staffed upon its opening in early 2006. Current demand for services demonstrates the need for a fully constructed and staffed facility. The facility should include the capability for medical screening of patients in order to eliminate hospital emergency rooms from the process.

The third area identified was for funding of a state dual- diagnosis program, including long-term comprehensive out-patient care. Available data from area criminal justice and emergency medical services showed the need for immediate development of dual- diagnosis services for individuals who suffer from both a mental illness and another disability, often substance abuse. It was also recommended that there be an increase in the rate of reimbursement for Medicaid to encourage development in the private sector.

Another need was for the expansion of the mental health court. Preliminary results, as indicated earlier, are very encouraging. It was recommended that the court be expanded to include, on an indefinite basis, at least 100 clients at any point in time. Steps should be taken to ensure not only the long-term funding of the court, but the funding of the necessary support and aftercare services required to minimize recidivism. Another idea was to create community mental health centers for immediate attention to walkins. Many individuals need quick access to prescription renewals and cannot or will not wait for an appointment. They need to be seen when there is a need, and the current four state medical clinics cannot begin to handle the caseload.

Developing a registry of mental health consumers in the criminal justice system is also an area of need. Although potentially controversial, adopting a patient registry with privacy safeguards would permit a more accurate system of determining the scope of need and assist in future planning for the care of the mentally ill. Additionally, those highest users of emergency medical care services could be offered alternative high levels of attention to avoid overloading the emergency system. Encouraging expanded training of law enforcement personnel, including correctional officers, in the handling of individuals with mental illnesses will also be of assistance in alleviating these problems as well.

This massive undertaking, simultaneously by multiple community groups and individuals, beginning in 2004 resulted in a significant increase in recommended funding for mental health services in Nevada to the 2005 Legislature. Perhaps the clearest evidence of this is Assembly Bill No. 549, passed by the 2005 legislation, referred to the Committee on Ways and Means on behalf of the Legislative Committee on Health Care. This bill recommends approximately $450,000 per year for mobile crisis health teams in southern Nevada, more than $3.2 million for the 28-bed inpatient annex over two years, $500,000 per year for the recruitment of psychiatrists, funding for psychiatry trainees and doctors at the School of Medicine of the University of Nevada, and funding for medical screening at the mental health hospital in Clark County.

Clearly, this bill shows the power that can be brought to bear by a focused community effort of both individuals and agencies. Although the mental health crisis will not simply go away as a result of these efforts, the future is much brighter with the possibility of major improvements.

What does all of this mean for the criminal justice system? As indicated, an inordinate part of the system, from law enforcement through corrections, is devoted to addressing the needs of mental health patients who could have been handled at a less costly alternative had such an alternative been available. This concerted effort by the community in impacting the legislative process, and perhaps ultimately even the laws that deal with this area, has had excellent initial results. Although it may take time for the results to trickle through the system, every diversion results in more time and resources to address the primary responsibilities of the criminal justice system - criminal offenders.

Howard L. Skolnik is assistant director for industrial programs at the Nevada Department of Prisons. Capt. Henry C.H. Hoogland, is booking bureau commander for the Las Vegas Metropolitan Police Department at the Clark County Detention Center.

Copyright American Correctional Association, Incorporated Aug 2005

Source: Corrections Today

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