California spends big on anti-psychotics

SACRAMENTO, Calif. — California’s prison mental health system has been spending far more on anti-psychotic drugs than other states with large prison systems, raising questions about whether patients are receiving proper treatment.

While the amount has been decreasing in recent years, anti-psychotics still account for nearly $1 of every $5 spent on pharmaceuticals purchased for the state prison system, according to figures compiled by The Associated Press.

Questions about the spending have been raised by the state budget analyst and by the court-appointed authority in charge of buying prison pharmaceuticals, who concluded that California’s inmate mental health professionals appear to overmedicate their patients. Even a former top prison mental health administrator acknowledged that fear of lawsuits often drove the decisions about inmates’ treatment.

Nearly 20 percent of the $144.5 million California spent on all prison pharmaceuticals last year went for anti-psychotic drugs, according to the AP’s figures, which were obtained through requests under the state Public Records Act.

“Why are all these people on meds? A lot of it, I think, we overprescribe on mental health. Anybody who comes in on mental health (referrals), we put on a psychotropic,” said J. Clark Kelso, the federal court-appointed receiver who controls prison medical care.

His office buys psychiatric drugs for the prison system, but he is not in charge of prison mental health care and thus has no say over how often the pharmaceuticals are used.

A separate court-appointed authority, Rhode Island attorney Matthew Lopes Jr., oversees the treatment of mentally ill inmates. He did not return repeated telephone messages for this story.

Kelso, the medical receiver, raised an alarm with prison mental health officials internally three years ago when he identified what he thought was an extraordinary use of anti-psychotics, which in 2008 accounted for 34 percent of all prison pharmaceuticals spending. Spending on anti-psychotics has since fallen from about 26 percent of all prescription spending in 2009-2011 to 19 percent last year.

When he raised concerns, Kelso said he was told that “we have a substantial reliance on drug treatment programs, more so than in other states around the country.”

The comparatively high use of the drugs in California is feeding a debate between doctors and the attorneys representing inmates over whether mentally ill prisoners receive too much medication or not enough. California’s poor treatment of inmates with mental health problems prompted a federal court takeover of that operation and persuaded federal judges to order the prison population sharply reduced to improve prisoner care.

Gov. Jerry Brown’s administration faces a Thursday deadline to tell the court what steps it will take to further ease prison overcrowding by year’s end.

A federal judge recently decided to maintain court oversight of the mental health system, finding that the state continues to violate constitutional standards. More than 32,000 of California’s nearly 133,000 inmates are receiving mental health treatment.

Psychotropic drugs include anti-psychotics, as well as sedatives, antidepressants, stimulants and tranquillizers. Anti-psychotics are generally used to treat schizophrenia and bipolar disorder.

California’s use of the anti-psychotic medications stands out among the nation’s large prison systems, according to comparison figures compiled by the AP.

New York’s prison department spent about 17 percent of its prescription drug budget on all drugs within the psychotropic category at the same time California was spending 26 percent of its budget on anti-psychotics alone.

Texas, which has a unique method of buying low-cost drugs, spent 6 percent of its prison pharmaceutical budget on psychotropic drugs, including anti-psychotics last year, while just 3 percent of Florida prisons’ prescription drug spending is going for psychotropics this fiscal year.

In a report published last year, the independent Legislative Analyst’s Office said California spent about $1,500 annually on psychiatric drugs for each inmate in a mental health program, compared to an average $610 a year per inmate in Florida, Georgia, New Jersey, Ohio and Pennsylvania.

Budget analyst Aaron Edwards, who compiled the report, said his figures included spending on mentally ill inmates by all state agencies and private contractors so the state-by-state spending comparisons would be as direct as possible.

California corrections officials said they have no reason to believe that anti-psychotics are over-prescribed to inmates.

Yet Sharon Aungst, formerly the chief deputy secretary for the department’s Division of Health Care Services, said the treatments given inmates are largely driven by lawsuits, federal court orders and the court-appointed special master overseeing a long-running legal settlement that governs virtually every aspect of inmate mental health care.

Aungst said there was a tendency for prison health care workers to practice “defensive medicine” for fear of triggering a lawsuit or violating federal court orders.

“One of the concerns that our staff always have, if we take someone off the caseload because we don’t think they ought to be on there anymore, and anything goes wrong, then we get clobbered,” Aungst said shortly before she left the department in 2011, at a time when anti-psychotics accounted for one quarter of prison pharmaceutical spending. “So we are playing defensive medicine quite a bit, and so it’s much safer for our staff, because they’re risk-averse, to keep them on the caseload and continue to treat even if we’re not so sure that that’s absolutely necessary.”

She spoke at the time on behalf of the department, with the department’s chief psychiatrist, assistant chief legal counsel and a department spokesman sitting in on the interview.

Dr. Karen Higgins, the chief psychiatrist for the state corrections department, said about 64 percent of inmates diagnosed with serious mental illness are prescribed some form of psychotropic medication, a class that includes anti-psychotics.

“While we do not have data to support the assertion of over-prescribing as an indication of defensive medicine, it is a possibility that we must guard against with appropriate checks and balances,” Higgins said in an emailed response to questions.

She said the department has set up drug-use guidelines and a list of preferred drugs that doctors and mental health workers can prescribe, as well as a computer program to help providers choose the right medication.

The department also tracks doctors’ prescribing practices and requires them to justify their reasons for using more expensive medications that are not on the preferred list. A bill signed into law in 2011 requires that state prison inmates not be given psychotropic medications without their informed consent.

That same year, attorney Ken Karan won a court order prohibiting the department from forcing one of his inmate clients from taking psychotropic medication against his will.

“My feeling is it’s being used as a disciplinary measure, as a way to control people who are not institutional type of people,” said Karan, who is based in the San Diego County community of Carlsbad. “One way to make them comply is to pump them up with dangerous drugs.”

He said he had not seen evidence of that for inmates other than his client because the scope of his lawsuit was narrow.

In another case, the family of Joseph Sullivan won a lawsuit and a $475,000 settlement against the state corrections department in 2009, three years after Sullivan was found hanging by a bed sheet in Chuckawalla Valley State Prison, located in the Southern California desert along the Arizona border.

Experts who reviewed his case as part of the family’s investigation said the 26-year-old was a victim of mind-altering drugs he didn’t need but that were still prescribed by a prison doctor. Sullivan had been prescribed the anti-psychotic drug olanzapine, which goes by the trade name, Zyprexa.

“Joseph was put on psychotropic drugs for no good reason,” said David Springfield, one of the Sullivan family’s attorneys.

An autopsy showed Sullivan had nearly double the maximum therapeutic amount of Zyprexa in his system. The combination of the drug and the isolation and high temperatures within the prison cell likely drove him “to hopelessness and despair,” the autopsy said.

Fellow inmates and a medical expert hired by the family said he had not demonstrated signs of being suicidal before he started taking the drug.

His father, Daniel Sullivan, said a letter from his son arrived a day after his death, in which the younger man said he was looking forward to being transferred to a prison closer to home. In the letter, the son promised, “We’re going to have a new life together. I want to pick up and go forward.”