Overmedicating Young Inmates Called Chemical Restraint

Print

Youths incarcerated across Louisiana and the New Orleans metropolitan area are getting dosed with potent antipsychotic drugs even when they have not been diagnosed with the conditions – typically, bipolar disorder and schizophrenia – that the drugs were developed to treat, records show.

Twenty-two percent of psychiatric medications in eight Louisiana institutions investigated by The Lens were of this kind, while just five percent of available diagnoses made in those institutions were for bipolar disorder, and no diagnoses were for schizophrenia. The disproportionate numbers raise the specter of the drugs being used as a means of chemical restraint rather than appropriate treatment, experts in juvenile justice contend.

The drugs also have dangerous side effects such as a rise in serum cholesterol levels and weight gain.

Lax recordkeeping and habitual reluctance by public institutions to comply with public records law makes it impossible to assess the exact scope of the problem.

A law wrangled through the state Legislature in 2010 by Rep. Damon Baldone (D-Houma) will set across-the-board minimum standards that juvenile facilities must meet starting in 2013. For now, however, Baldone acknowledges that there are “huge inconsistencies in the different juvenile facilities across the state.”

“It’s a crap shoot,” Baldone said. “Some places have good treatment and others need improvement.”

The Lens set out to investigate the use and possible abuse of psychiatric medications in local youth jails after the newspaper Youth Today ran a nationwide investigation of chemical restraint.

The Lens approached four parish-level and four statewide facilities, asking each for records showing how many detainees have been diagnosed with a mental health condition, what mental health diagnoses had been made, and what prescription medications were being used to treat those youths.

None of the eight facilities provided all of the information requested. One parish took six months to comply with our request and then released diagnoses but not medications, while Jefferson Parish declined to release any information on the L. Robert Rivarde Memorial Home for juveniles, citing inmate privacy concerns — even though The Lens did not seek individual client records or the names of juvenile inmates receiving treatment.

The most common mental health diagnosis among juveniles at facilities that turned over records was “conduct disorder,” a condition whose symptoms are difficult to distinguish from the causes and effects of being an adolescent in a juvenile detention facility, according to the American Academy of Child and Adolescent Psychiatry: defiant, impulsive behavior, drug use and criminal activity, for example.

Together with attention deficit hyperactivity disorder and marijuana/cannabis dependence or abuse, conduct disorder is one of three conditions that make up almost half of mental health diagnoses in the juvenile facilities whose records we were able to access.

Prescription drugs administered to juvenile inmates ran the gamut of those available on the market, but with a disproportionate use of so-called second-generation atypical antipsychotics.

These drugs originally developed for bipolar disorder and schizophrenia, are administered four times as often as the conditions actually crop up among incarcerated youth in the facilities studied.

Click here to look at a statistical spreadsheet.

•••

At the four parish-level facilities, very few prescriptions were being written. Because stays are limited to a few weeks, these facilities tend to adopt a hands-off approach to diagnosing and treating mental health conditions, allowing juveniles to continue taking any medications they arrive with; prescriptions are then routinely refilled, no questions asked.

In New Orleans, the Youth Studies Center recently hired a psychiatrist to work with youth but other parishes make do with licensed clinical counselors, who are qualified to make diagnoses but not to prescribe medication.

In a psychiatric emergency, the response can be ad hoc and sometimes quite primitive. For example the Florida Parishes juvenile detention center still keeps a restraint chair in storage, in case a child becomes suicidal and nothing else can be done immediately. Before the center had the chair, which has not been used in four years according to a center manager, it used to rely on a football helmet to prevent suicidal juveniles from smashing their heads into the floor and walls.

Part of a trend that has pushed mentally ill children into adjudication rather than medical care, New Orleans lost its last public mental health beds for juveniles in 2009 when Gov. Bobby Jindal closed the New Orleans Adolescent Hospital. The nearest comparable facility is now across Lake Pontchartrain at the Southeast Louisiana Hospital in Mandeville.

“Just before we closed we had five clinics, a crisis service, outreach teams, and we only had about 15 beds, down from 124 in 1991,” said Dr. Martin Drell, the Adolescent Hospital’s clinical director for 19 years. “Bobby Jindal not only closed the hospital, but with it, he closed the outpatient system, which is what people I don’t think realize.”

The hospital’s closure has placed more pressure on local juvenile facilities, said Captain Andre Dominick, director of the St. Bernard Parish juvenile detention center.

“When they closed that down, we had no place left to go,” Dominick said. “There’s not too many private clinics that want to deal with a juvenile in shackles.”

Jindal’s office did not respond to a request for comment.

Inmate files are getting thicker and thicker, as the root causes of the antisocial behavior go unaddressed, Dominick said. Eighty percent of the inmates at his center are repeat offenders, most having been at the facility five or six times, often as a result of breaking probation terms on a single charge like possession of marijuana.

“You can tell by the thickness of the file, the recidivism rate,” Dominick said, pointing to the stack of files on his desk. “Like, this one here — he’s been here 11 times.”

Will Harrell, a federal monitor of juvenile justice systems, said kids are increasingly finding themselves in local centers like the one in St. Bernard Parish because of the decrease in community-based mental health services.

“Kids who have no business in the juvenile justice system in the first place are in there,” Harrell said. “And they have no access to adequate mental health treatment.”

Once juveniles are caught up in the local system, they are in a pipeline that frequently leads to state charges and eventual incarceration in a state facility, an environment very likely to exacerbate underlying psychiatric problems.  Records show that a total of 112 juveniles have been placed on suicide watch over the last year in three of the four state juvenile institutions that complied with our records requests.

Both at the local and state level, the patchiness in mental health care means there is a greater likelihood that physicians will rely on medication to simply calm down disruptive juveniles, Harrell said.

“There are some youth who should receive medications who aren’t,” Harrell said. “But there’s also kids who are being medically restrained. Sometimes it’s easier to deal with disruptive kids by drugging them, than doing anything else.”

From Dominick’s perspective, a diagnosis of mental problems is simply a tool that can lead to basic counseling for a juvenile. He works with Ron Koval, a licensed clinical counselor, to diagnose juveniles with a variety of conditions so that they can receive such counseling.

Koval, who is qualified to make preliminary diagnoses but not to prescribe medications, said he often diagnoses inmates with “oppositional defiant disorder” as a way to engage with them. Symptoms of oppositional defiant disorder include common adolescent behaviors such as refusing to follow orders given by adults and being resentful of authority.

“Primarily the ones that don’t have a psychiatric issue, we diagnose as oppositional defiant, and that’s where we start doing the character development to start help them choosing not to go the wrong way,” Koval said.

Tom Jarlock, who runs the Florida Parishes juvenile detention center, said he thinks that diagnoses, however well intentioned, are often a gateway to inappropriate medications administered to manage youthful inmates, not to treat them therapeutically.

“If you look at the dispensation of ADHD (attention deficit hyperactivity disorder) meds across the country, I think one of the things we are trying to do is keep boys from being boys,” Jarlock said. “It seems like, especially in the school environment where managing boys can be difficult, that I think we go to the pill bottle too quickly.”

It’s a perspective shared by Megan Faunce, who worked for five years, until 2009, as a statewide advocate for juveniles in the justice system, with full access to medical records.

“Pretty much every kid I met in the system was on Seroquel,” Faunce said. “The kids knew, if they wanted to be on it, they knew to say ‘I can’t sleep,’ or ‘I’m having nightmares’ so that they could be diagnosed with post-traumatic stress disorder and qualify as SMI, or significantly mentally ill, and then they would get on Seroquel.”

On the other hand, Faunce said, she met plenty of juveniles with genuine mental health needs who went undiagnosed because they did not pose a behavioral problem for staff.

•••

Seroquel, the brand name for quetiapine, is a second-generation atypical antipsychotic. Other such drugs include Risperdal (risperidone), Abilify (aripiprazole), and Zyprexa (olanzapine), and all are being heavily ordered by youth facilities.

Records show the Swanson Center for Youth, a state facility in Monroe, stocks 400-milligram dosages of Seroquel, a hammer to the head easily four times the standard dosage. And even smaller dosages are often unwarranted. A juvenile at the Youth Studies Center in New Orleans was being given a 100-milligram dose of Seroquel, despite having a simple diagnosis of attention deficit hyperactivity disorder. A spokeswoman for the city pointed out that the drug had been prescribed before the juvenile arrived at the facility.

Atypical antipsychotic drugs limit psychotic episodes among schizophrenics and patients with bipolar disorder by abating the transmission of dopamine from within the brain. But they also block transmission of serotonin, another important brain chemical, and can have a numbing effect.

“I could tell a kid had gotten on these drugs because of the vacant expression,” Faunce said. “They were like little zombies.”

“We had one kid come to us on three different psychotropic drugs,” said Cedric Morton, who worked for six years at Bethlehem Children’s Center, a residential treatment facility, before joining New Orleans’ Youth Empowerment Project as an advocate for juveniles. “He would be slobbering from the mouth from 8 a.m to 2 p.m and then take more medication at 3 p.m. This kid was a zombie and because he was a ward of the state, he didn’t have strong advocates outside who would push for him to get off the drugs,” Morton said.

The first generation of atypical antipsychotic drugs appeared in the 1950s, but had serious side effects such as muscle twitching. The second generation appeared in the 1990s and cause less twitching but have a strongly sedative effect that contributes to weight gain and high cholesterol levels.

Because the drugs numb the inmate patient into submission, they also sabotage efforts by youth counselors’ to get juveniles to take responsibility for their behavior, said August Collins, director of youth advocacy at the Youth Empowerment Project.

“We need to set stricter guidelines on prescribing this stuff and quit treating diagnosis of a kid as an assembly line,” Collins said. “We’ve had kids sleeping in classes like they’re stoned out of their minds. It’s difficult to give these kids insight into who they are if they can’t even stay awake.”

Collins estimated that 70 percent of the juveniles he sees are initially overmedicated.

Psychiatrists oppose using atypical antipsychotics to treat conditions other than bipolar disorder and schizophrenia.

“Well-established clinical indications for antipsychotic medications in young people are limited to schizophrenia, bipolar disorder, and irritability associated with autism,” said Mark Olfson, a professor of psychiatry at Columbia University. “Antipsychotic treatment beyond these conditions raises concerns over clinical tradeoffs with known safety risks.”

And the threat – like that of incarceration itself – comes down most heavily on youth with limited economic means. A 2009 study by Columbia and Rutgers universities showed that poor youth are four times more likely to be prescribed atypical antipsychotics than privately insured youth.

•••

At the four state-level facilities studied by The Lens, 25 percent of medications ordered by facility pharmacies were for the potent antipsychotic drugs. Doctors working for Correct Care Solutions—a private Kansas-based correctional health contractor —have prescribed all medications given to youth in Louisiana’s public facilities since the company was awarded the contract in September.

Sherronda Davis has experienced firsthand what she described as over-medication and an inappropriate diagnosis by the state system. Her son, Correando Davis, first went to Swanson at 14 and was in and out of juvenile detention facilities until he turned 18 and was placed in an adult facility.

He was always “a little bit hyper,” Davis said, but she never expected him to be diagnosed with bipolar disorder, as he was at Swanson.

“I feel like they just diagnose the kids to keep them medicated so they don’t have to deal with them,” Davis said.

Now, Davis said, her son is on 600 mg of Seroquel a day.

The state declined to comment on Davis’ case, but Kelly Smith, Health Services Administrator for the Office of Juvenile Justice, said she had not seen overmedication in state facilities generally. Smith said the state’s contracted mental health provider takes responsibility for prescribing medication.

•••

Even when Seroquel is prescribed appropriately, it doesn’t compensate for the worsening lack of community resources for juvenile mental health, according to families coping with mentally ill children.

Davonta Davis was a 7-year-old when diagnosed with attention deficit hyperactivity disorder and bipolar disorder. His mother recalls being troubled by her son’s behavior.

“He set a fire, set the shed on fire, stole a turtle from the teacher; he wandered off; he was throwing rocks at the school,” Shatona Davis said.

By 13, Davis was on the second-generation atypical antipsychotic Risperdal, as well as two other drugs, Vyvanse and Depakote. Despite the drugs, he and two friends held up a Subway sandwich shop on Causeway Boulevard. He was sentenced to two years for armed robbery in the state-run Bridge Center for Youth, where he was switched from Risperdal to Seroquel.

Released from jail four months ago, Davis, now 16, is twitchy and evasive when he talks about his experiences at the Bridge Center.

“I was bored,” he said, shifting in his chair and looking out of the window to face away from the reporter.

To get on Seroquel, he told doctors that he was having nightmares and couldn’t sleep, Davis said. But the medication helped him to sleep and he does not feel like he is over-medicated.

His mother said Davis was shot in the stomach during an altercation a month after his release – an incident the young man declined to discuss.

“I’m glad he’s on the medication,” his mother said. “If you think he doesn’t need to be on it, you try taking him home and controlling him without it. He needed it. But he really needs more than just medication. I know there’s only so many resources they can provide and things they can do for him, but I just have to keep an eye on him all the time and just pray that nobody hurts him.”

Matt Davis is a staff writer for The Lens, an investigative news website covering New Orleans and the Gulf Coast. This article is reprinted here with permission.