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For mentally ill inmates, health care behind bars is often out of reach

A man who was declared suicidal by a New Mexico jail and alleges he was then left to rot in solitary confinement for nearly two years is just one of many former inmates who say they were denied essential mental health services while incarcerated at that detention center, which like others across the country has struggled with how to treat the mentally ill.

Stephen Slevin, 57, made headlines last week when a jury awarded him $22 million after he alleged inhumane treatment in the Dona Ana County Detention Center following his arrest in August 2005 on charges of driving while under the influence and possession of a stolen vehicle.

But a search of Dona Ana County court records reveals the detention center was also hit with a class-action lawsuit six months prior to Slevins', in which 13 former inmates alleged their constitutional rights to mental health care had been "continually and persistently ignored."

The lawsuit was settled in 2010, with a judgment of $400,000 for the plaintiffs and a commitment from the county to change its practices.

According to criminal justice experts, many other jails and prisons have struggled to adequately handle mentally ill inmates. Few areas of the country, they say, have the money and resources and staff to handle such a challenging population.

"The Supreme Court has established that you have a constitutional right to a basic level of adequate health care, which now includes mental health care," Thomas Hafemeister, an associate professor at the University of Virginia School of Law, told msnbc.com. "They've recognized that there tends to be limited resources in this setting. As long as a qualified professional has examined the inmate and exercised his or her judgment as to what needs to be done, that's all that is required."

'Cruel and unusual'
But Hafemeister, who has written about alternatives to the traditional criminal justice system for the mentally ill, explained that the definition of a "qualified professional" is a loose one.

"Some would argue for inmates, all that is required is medication," he said, meaning anyone with a medical degree, from a physician to a psychiatrist, could be considered qualified.

"Often it's very expensive. They're only willing to come in for an hour a week, and they zoom through very quickly. It can be a very cursory examination," Hafemeister said.

Slevin was detained for 22 months, released in June of 2007 without ever having been given a trial. By the time he was freed, he was deemed mentally incompetent, and his charges were dropped.

Slevin claims the only response he got while in Dona Ana Detention Center to his repeated requests for antidepressants was an increase in sedatives. Other mentally ill inmates at Dona Ana, according to the class-action lawsuit, struggled to get adequate care as well. One allegedly was punished by a medical technician, who discontinued his medications for two weeks; others complained of side effects but were not offered alternatives, the suit said.

“A jail like Dona Ana County was trying for years to cut costs, and nothing would force them to spend the money that they’re constitutionally required to,” Brendan Egan, an attorney who represented the plaintiffs on behalf of the ACLU and is now in private practice, told msnbc.com. “It’s cruel and unusual punishment. They weren’t willing to put money into it, even though they made money off of this jail. They’re paying the price for how they treated people for years.”

The primary plaintiff named in that suit, Jaime Bravo, was jailed from April 2007 until February 2008 after a domestic dispute. Bravo had depression, anxiety and acute psychosis, the suit said.

Four times during his detainment, Bravo attempted suicide, and each time he was then put in a padded cell or a restraint cell, said court documents.

“On or about November 15, 2007, Mr. Bravo made a fourth suicide attempt, by cutting his arm with a razor blade, necessitating stitches. DACDC staff placed him in a padded cell as a consequence … On or about November 16, 2007, Mr. Bravo tore out his sutures. DACDC staff placed him in a restraint chair as a consequence.”

In jail, mental illness will 'get exponentially worse'
While Dona Ana County was ordered to pay a total of $400,000 to the plaintiffs, a small amount compared to Slevin’s judgment, the bigger reward was that the jail changed how it handled mentally ill inmates, Egan said.

The jail renovated an entire section and “turned it into a very humane and real mental health unit,” he said. Officials also dedicated beds at a separate mental health hospital staffed by jail guards for the sickest detainees.

“Even if you take someone who has a slight mental illness like depression and you put them in a regular jail, they get worse,” Egan said. “[At Dona Ana County], they would just lock them in. They already had issues and you lock them up 22, 23 hours a day – they’re going to get exponentially worse.”

Just last month, the county approved a $2 million plan for a crisis triage center, which would offer an alternative for mentally ill people other than jail – something Egan believes will help.

“There were no mental health facilities or treatment for homeless people on the street, so you would have people on the street getting arrested basically for being mentally ill,” Egan said. “But once they got arrested, the county commissioners didn’t provide resources.”

According to Fred Osher, director of health systems and services policy at the Council of State Governments Justice Center, people with mental disorders are overrepresented in the mental health system.

"There's a variety of factors that contribute, but one of the research studies... looked at two jails in Maryland and three in New York. Seventeen percent [of inmates] met the criteria for mental illness," he told msnbc.com.

Nationwide, prevalence of severe mental illness among inmates is at least 15 percent, said Richard Bonnie, director of the University of Virginia’s Institute of Law, Psychiatry, and Public Policy.

“There are many factors at work here, but many us involved in this field are convinced that diversion from the criminal justice system into mental health services … can alleviate the problem without compromising public safety,” he told msnbc.com via email.

Jail diversion options include drug courts, where a substance abuse program is worked out instead of a jail sentencing; mental health courts, where a behavioral contract including drug tests and treatment appointments is drawn up; and sometimes, assignment to a mental health probation officer who is trained to handle mental issues and knows how to direct someone to health services.

"Lots of people have recognized there's this population with severe mental disorders that just isn't going to do well in a prison population," said Hafemeister, from the University of Virginia Law School.

Care doesn't have to cost more
And it doesn't always have to be expensive to divert those with mental issues, added Osher.

"What many systems are coming to realize is if you provide alternatives, then you can reduce length of stay. You can actually have this be a resource-neutral event. It doesn't necessarily require an infusion of dollars," he said. "We're spending tons of money warehousing, having people in a revolving door without producing good outcomes."

He cited Montgomery County, Md. as a successful example.

"They do a really nice job in screening and identifying folks with mental illness and diverting them when possible," he said. The county also tries get to them in psychiatric programs and help them with re-entry into the community, which reduces chances of them returning to jail, and helps them with their medication management as they transition out.

Similar programs are also happening at Alleghany County Jail in Pittsburgh and Miami-Dade, he said. Riker's Island in New York is undergoing a major transformation with their mental health care as well.

"Good things are happening at Riker's because of a settlement. The folks at Rikers with mental illness were ... without any resources to fend for themselves," he said. Baltimore and Memphis jails have also reformed their mental health care after being subject to lawsuits.

Training police officers to recognize mental illness is another key, Osher said, so those who need medical help can hopefully get diverted to emergency rooms or psychiatric centers before they are sent to jails in the first place - but only if that's not where they should be.

"We're not giving people a pass because they have mental illness," Osher said. "We're not being soft on crime. For those individuals that don't pose a public safety risk, there are these alternatives. There are treatments that can be provided."

Editor's note: An earlier version of this story incorrectly quoted Dr. Fred Osher as saying seventy percent, not seventeen percent, of inmates in a study met the criteria for mental illness. 

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