Youth prescribed psychotropic drugs much more often for behavior modification

Recently, in an item titled "Hypothesizing reasons for continued crime declines," Grits mentioned the theory that new and improved pharmacology is a contributing factor to reduced crime, particularly juvenile crime. So I was interested to see data describing the growth in behavior modification drugs given to youth, particularly for attention deficit disorder. According to Reuters:

From 2002 to 2010, the use of ADHD drugs grew by 46 percent -- or some 800,000 prescriptions a year. The top drug dispensed to adolescents was the stimulant methylphenidate, also known as Ritalin, with more than four million prescriptions filled in 2010.

"What the article is suggesting is that the number of children that we are treating for attention deficit disorder has gone up," said Dr. Scott Benson, a child and adolescent psychiatrist and a spokesperson for the American Psychiatric Association.

"For the most part I think the overall increase reflects a reduction in the stigma," he told Reuters Health. "It used to be, ‘You're a bad parent if you can't get your child to behave, and you're a doubly bad parent if you put them on medicine.'"

Dr. Lawrence Diller, a behavioral pediatrician who has written extensively about ADHD, was more critical of the rise in stimulant prescriptions, noting that the U.S. is far ahead of other countries in its use of the drugs.

"You have to look at how our society handles school children's problems. It's clear that we rely much, much more on a pharmacological answer than other societies do," Diller said. "The medicine is overprescribed primarily, but under-prescribed for certain inner-city groups of children."

See the abstract from the paper described. Overall, prescriptions for youth have recently declined, but mostly that's because of a reduction in antibiotics given out, a reaction to their massive over-prescription in years past. At an instinctive level, Grits is not a fan of the idea of medicating kids to instill good behavior as opposed to, say, teaching them. I understand the "stigma" attached to drugging one's kids to rein in bad behavior and part of me considers it justified (certainly IMO it should be a last resort). But Grits remains open to the notion that such medications have reduced misbehavior and even criminality among youth, though I've never seen someone try to quantify the scope of that effect. Whether that's a good or bad thing overall depends on whether the drugs also reduced creativity, stifled emotional development, whether they prevent acquisition of tools for self-control sans medication, and a host of other aspects that can't be measured by student behavior scores or crime-rate data.

I also wonder about the suggestion that psychotropic drugs are "under-prescribed for certain inner-city groups of children" (read: minority youth). Another article from the journal Pediatrics published this month declared that "Maladaptive aggression in youth is increasingly treated with psychotropic medications, particularly second-generation antipsychotic agents. Multiple treatment modalities are available, but guidance for clinicians’ assessment and treatment strategies has been inadequately developed." But if assessment and treatment strategies have been "inadequately developed," I'm unclear how they can make the normative assessment that psychotropic drugs are "under-prescribed for certain inner-city groups of children"?

According to another article from Pediatrics, "In children and adolescents the Second Generation Antipsychotics (SGAs) represent the class of psychotropic drugs whose use has grown more significantly in recent years: they are primarily used for treatment of patients with disruptive behavior disorders, mood disorders and pervasive developmental disorders or mental retardation." Notably, though, the side effects of using antipsychotics for behavior modification in non-psychotic youth are only beginning to be understood. According to this article, "In randomized studies, adverse effects were usually relatively minor, easily predictable and manageable, whereas long-term open-label studies have indicated that some adverse event, such as the metabolic effects, may be severe and potentially life threatening on the long-term."

The relation between pharmacology and crime reduction is an issue Grits would like to delve into deeper. The medical landscape has changed dramatically in the last decade regarding psychotropic drugs for youth, but the public policy implications remain poorly understood. We know the pharmaceutical companies benefit from these trends, I just hope it's also true that the kids do.

Townsend: 52% in Texas youth prisons suffer mental health problems

It's been frequently observed that adult jails and prisons are becoming society's de facto inpatient mental health facilities because they incarcerate so many offenders with serious mental illnesses. But if official data are to be believed, that may be even more true in the juvenile system. Reporting on a House Corrections Committee hearing yesterday on juvenile justice, AP says ("Mental health issues common among youth prisoners," Mar. 7) that:

More than half of the people in Texas' youth prisons have a moderate or high need for mental health care, and officials should improve their early intervention efforts to help those young people before they end up behind bars, the head of a new state agency told lawmakers Tuesday.

Cherie Townsend, executive director of the Texas Juvenile Justice Department, said more than 52 percent of teens and other youngsters held at the state's six juvenile detention facilities have been diagnosed with at least moderate mental health problems.

Including those with at least some kind of mental health care needs would make that tally much higher, she said.

"The numbers are increasing, and the percentages are increasing," Townsend told members of the Texas House Corrections Committee, referring to the number of juvenile detainees who have mental health problems and their proportion of the state's total youth population at detention facilities.

Not everybody, though, agreed that Texas youth prisons are morphing into insane asylums. One legislator suggested perhaps overdiagnosis played a role:

Rep. Charles Perry suggested authorities might be classifying too many young people as having mental health problems.

"I'm a little nervous about the discussion," said Perry, a Lubbock Republican, "because I know kids that act out that have no mental health issues, and just act out because they act out."

I don't doubt that mentally ill youth disproportionately end up in youth prisons and it wouldn't surprise me if the ratio is greater than in the adult system. But I also agree with Rep. Perry that youth in the juvenile justice system may be diagnosed with mental illnesses too frequently, and sometimes inappropriately, in hope that their behavior issues can be medicated away - or as so-called "chemical restraint." Hell, it's well known that some schools and psychiatrists promote psychoactive drugs at relatively young ages to counter children's behavioral problems, even for non-delinquents. Foster children are also reportedly overmedicated. So it's unsurprising that youth who've worked their way up to outright criminal behavior have racked up enough diagnoses and prescriptions over the years to appear on paper as though they're suffering from a mental illness. In some cases, that's surely true. But particularly with some common diagnoses, often the child's most fundamental problems stem from other issues like, say,  a crappy home life, absent or ineffective parents, poverty, grief, etc..

Recently Grits mentioned the irony that the Texas Youth Commission had prescribed an off-label antipsychotic medication more than 3,000 times during the same period that the AG was suing the company for marketing the drug for use with juveniles without adequate FDA testing. Given such examples and the ubiquity of overmedicating children, I'm not sure it's appropriate to define the number of mentally ill youth by the number receiving some psychoactive drug. Those medication decisions in some instances may tell us more about our society's desire to fix every problem with a pill than they do about the real mental health needs of the majority of Texas youth prison inmates. (Grits can't back that assertion up with data off the top of my head, but that's my sense.)

That said, I also notice Townsend's 52% number is for youth with "at least moderate mental health problems." By contrast, when similar numbers are calculated in the adult system, they only include diagnoses for the three categories of severe mental illness prioritized by the Department of State Health Services - major depression, schizophrenia, and bipolar disorder. So, though 52% sounds like a much larger number than the 1/4 to 1/3 of offenders with mental illness in the adult system, those aren't apples-to-apples comparisons. Perhaps if you included those with "moderate" mental illness in the adult system, the number would rise above 50% as well. Last week the House Criminal Jurisprudence Committee heard testimony that the adult justice system often ignores treatable mental health problems like anxiety disorders that can have as significant a crime-causing effect as the "big three" diagnoses.

What do you think? Are there disproportionately that many more mentally ill inmates in youth prisons than adult ones? Is the statistic misleading because of over-diagnosis and over-prescription? Or are youth inmates being treated at appropriate levels - dealing with "moderate" instead of only "severe" mental illness - and it's the adult system that's underdiagnosed, because the state doesn't document any but the most extreme mental ailments?

Here's the link if you want to watch the 4+ hour hearing for yourself.

TYC prescribed drug while Attorney General sued over its off-label use with children

Here's an ironic story from a Dallas TV station that speaks as much to the overmedication of youth in the juvenile justice system as to flaws in Medicaid billing. It opens:

The state won a $158 million settlement last month from a pharmaceutical company that the Texas attorney general said promoted an antipsychotic drug for uses not yet approved by federal regulators.

Attorney General Greg Abbott said Johnson & Johnson marketed Risperdal as the drug of choice for children and the elderly for schizophrenia and dementia even though the Food and Drug Administration had not approved its use in children or the elderly.

Yet while the state was suing J&J, the Texas Youth Commission, one of the state's largest purchasers of pharmaceuticals, prescribed it nearly 3,000 times to youth in the Texas prison system, according to financial documents uncovered by NBC 5.

The state's lawsuit, which was filed in 2006, said the state excessively paid pharmacies that dispensed prescriptions for Medicaid patients for a range of unapproved uses.

TDCJ secured death-house drugs under long-expired license

Though from a public-policy perspective I could care less by what method executions are carried out, one has to be impressed with the investigation that allowed death penalty opponents to make this argument, as Jordan Smith reported in the Austin Chronicle:

According to lawyers for condemned inmate Cleve Foster, the Texas Department of Criminal Justice has been illegally purchasing lethal injection drugs. According to the attorneys, Maurie Levin of UT School of Law, and Sandra Babcock of Northwestern University School of Law, the state's prison agency has been purchasing controlled substances – including drugs used for lethal injections – under the Drug Enforcement Administration registration certificate assigned to an entity that hasn't existed for nearly 30 years. "[A]s a result, we believe that TDCJ is unlawfully in possession of an unlawfully dispensing controlled substances," the lawyers wrote in a letter to U.S. Attorney General Eric Holder.

The problem, it appears, is that TDCJ has been purchasing controlled substances under a registration number assigned to the system's Huntsville Unit Hospital, which, it turns out, has been closed since 1983. TDCJ medical services are provided by the UTMB, and although the med system has "numerous DEA registration numbers, none of them is actually registered to either the Huntsville Unit," which has been purchasing the drugs, or to the address listed on the registration. "DEA Registration numbers must be renewed every three years," write the lawyers, who are representing Foster, scheduled to be executed April 5. "Assuming the DEA registration number used by TDCJ last month to purchase controlled substances was one originally issued to the Huntsville Unit Hospital, TDCJ has failed, on information and belief, to advise the DEA for the past twenty-eight years of the fact that the Huntsville Unit Hospital no longer exists," and that what actually exists at that location is a prison unit with a warden that is "purchasing and dispensing controlled substances" with a number "registered to a nonexistent entity."

Uh-oh. That doesn't sound so good. And neither does this: According to the lawyers, it appears that the drugs aren't being kept at a pharmacy or by a DEA-registered handler. "At no point is an appropriately licensed or authorized practitioner involved in the dispensing process, and at no point is a prescription written to transfer the controlled substances to a member of the execution team," the lawyers write.

Fascinating. The issue of physician participation in capital punishment is an old and vexed one; I wonder if this is happening because UTMB would not let TDCJ secure execution drugs under their pharmacy license? I can't think of another situation where a controlled substance would be authorized by non-physicians or maintained by un-registered, non-pharmacist handlers.

Even if TDCJ changes their DEA registration to an active entity, that won't resolve questions about the drugs already obtained. There are seven executions scheduled so far this year, with one set for next week; I wouldn't be surprised to see executions postponed over this.

I am not personally a death penalty abolitionist. But even I can see that the faux medicalization of capital punishment through lethal injection is mainly a public-relations ploy, allowing the state to pretend executions are somehow a medical procedure analogous to others performed by healers instead of premeditated, calculated killing. (Consider the absurdist vanity of sterilizing the injection site with alcohol before administering lethal drugs.) The firing squad, hanging, guillotine, even a single bullet to the back of the head would all work just as well. Indeed, a strong argument can be made that a firing squad or bullet to the head may be more "humane." But those methods of killing are messy and difficult to watch, while killing via lethal injection gives the practice a veneer of professionalism and decorum that makes it more acceptable to a squeamish public.

Barring torture and/or intentional prolonging of suffering, IMO the method of killing is far less important than the decision to kill itself, by whatever means. The punishment for murder is the same, after all, whether one uses a knife, gun, garrote, or pushes their victim off the top of a tall building. Similarly, I don't see why it makes much difference how the state kills people it plans to execute, which is why it doesn't seem worth it for the TDCJ to violate federal laws governing controlled substances just to keep the death-house machinery up and running.

Investigating neglect in Lonview death of mother jailed for traffic warrants, denied seizure medication

Brandi Grissom has a feature at the Texas Tribune on the disturbing number of recent inmates deaths at the Gregg County Jail in Longview - nine since 2005 in the smallish East Texas county - focusing particularly on the most recent instance, where a young mother locked up for traffic warrants died after her seizure medication was denied to her. The Texas Civil Rights Project recently complained that poor healthcare in Texas prisons constituted a "secret death penalty," and whether that provocative accusation is justified, certainly in this case it's easy to argue poor jail healthcare turned into a death penalty for Amy Lynn Cowling. And she's not the only one.

Rather than excerpt and comment, those interested should go read the whole thing. Well done, Brandi, and as an aside this is the type of journalism I hoped we'd see from the Tribune when it launched with such deep pockets and its admittedly impressive cadre of writers - not just reporting the same stuff everybody else does from the capital but regional investigative features that folks like me with no resources can't do from Austin, and which local reporters don't have either skills, resources or often editorial backing to perform.

That said, I should add that the Longview News Journal arguably is the best small-town paper in the state (an accolade I don't grant them lightly), and their coverage of this topic has been very good, see:

• Deadly lockup: Young mother's death should prompt review of jail procedures
• Family: Woman who died in lockup got death sentence for speeding 
• Inmate death spurs broader jail probe
• Dead inmate's medical records in 'legal limbo'
• Woman dies in Gregg County jail, family says medication was denied
• Inmate who died was unresponsive after seizures, jailer says
• Second Gregg jailer charged in connection with inmate death
• Jailer charged in inmate's death, four others fired as investigation continues
• Gregg county jailer arrested in connection with inmate's death
• Inmates not guaranteed own prescription medications 
• Inmate's meds weren't on the approved list
• Gregg County jail back in compliance but Upshur County jail isn't
• Woman found dead in Gregg County jail, sheriff and Texas Rangers investigating
• Jails across Texas routinely found noncompliant

This tragic story has benefited from some excellent journalism, which is unusual when such things happen to say the least. So I don't have much to add on the subject - go read what the reporters who actually researched the topic have to say.

McLennan County cuts jail pharmacy spending as doomsday deal devolves

The McLennan County Jail claims to have saved $1 million this year by prescribing fewer antipsychotic medications and other pharmacy costs. Reports KWTX.com, "In February 2010, pharmacy costs at the jail were $54,619. In September 2010, expenditures were down to $17,372." While I'm certain there's a great deal of waste on the pharmaceutical side of carceral healthcare, that's a 68% reduction, which seems like an astonishing number.

I wonder: Who can or more importantly will evaluate whether those reductions were medically justified or merely economically convenient? The Commission on Jail Standards doesn't have staff with medical training to evaluate such things. Unless there's a federal civil rights complaint and DOJ investigates, I can't even think who might look into such a thing. Maybe it's completely justified and inmates previously were being severely overmedicated. That happens in the juvenile system, and it wouldn't surprise me if there is some unnecessary medication in the adult system as well. But how do we know medically necessary medications weren't reduced? State regulators can't tell and there's nobody with oversight authority to doublecheck those decisions.

The question of whether medical necessity or economics drove the decline in pharmacy expenditures may well relate to the jail's larger economic situation - leveraged to the hilt with not enough revenue to cover its bond debt. Checking in with a day pass at the Waco Tribune Herald (now behind a subscription wall), I notice more jail related news ("County extends jail contract, accepts lower payout," Dec. 29): "McLennan County extended Tuesday an agreement to keep its downtown jail closed for another six months, but the arrangement will yield a substantially lower financial reimbursement than the original deal." "Lower" is relative, though. The county was supposed to receive $240,000 over the last six months and got nothing. Now they're supposed to receive $60K from the contract over the next six months, but could easily again wind up with nothing.

Regular readers will recall that McLennan County (Waco is the county seat) used the county's credit to issue bonds to build a large detention center, one not needed for their own purposes but built as a speculative venture to house inmates on contract, partnering with private prison company CEC to manage the facility. But the contracts never came, so McLennan actually closed their perfectly good, already-paid-for jail in order to move all the inmates into a pay per head contract facility, just so there'd be some revenue to pay the bonds. I found this mind-bogglingly irresponsible - a veritable doomsday deal, it's been called - but for several years before the recent economic bust the practice was all the rage.

Regrettably, the private prison company appears to hold all the cards in the negotiations and is threatening to walk away from the deal entirely, leaving county taxpayers holding the bag. Reports the Trib:

CEC Senior Vice President Peter Argeropulos told the court last week that CEC felt it would be unable to continue paying a monthly fee because the jail still was operating at a loss.

Most of the money that has come in through the facility has been sent to U.S. Bank to cover payments on the $49 million in project revenue bonds that paid for the jail’s construction.

After enough money is accrued to cover the $3.7 million annual bond payments, the county is paid the monthly fees and CEC keeps the rest.

The county is still awaiting its $240,000 that is due for the past six months of the contract. CEC has yet to receive any money from the jail and is covering payroll and operating expenses itself.

Last week, members of the court suggested alternatives to waiving the fee, including a 90-day waiver, deferring the due date of the payment or reducing the monthly fee to $20,000. Argeropulos said at the time he did not think the company would agree with those options.

Without the public really understanding the magnitude of what was happening, commissioners bet the economic farm on this deal. Said one commissioner, "What people have to understand is that so goes that jail, so goes McLennan County." Readers may recall that County Judge Jim Lewis claimed earlier this year that CEC, not the county, was on the hook to pay off the jail bonds. Now it's clear to everyone this was a pure corporate subsidy: The company profits if it succeeds, but if it fails they walk away and taxpayers must pony up for the debt or default and ruin the county's bond rating. In another recent story ("Company operating new Hwy 6 jail asks county commissioners to waive monthly fee," Dec. 22), the Trib reported that:

The county’s bond rating was used to secure the bonds. If the debt service payments go into default, then the county’s bond rating likely would be affected.

“People keep on saying it’s not going to be a debt of the county, but it is going to be a debt to the county if it goes under,” [commissioner Lester] Gibson said. “A whole lot is at stake with our bond rating. If this project fails, it will create a whole lot of systemic problems.”

No kidding! It's a situation so irresponsible that I'd almost say commissioners deserve what's happened to them except it's not really them who're harmed but the taxpayers whose money they were gambling with.

See prior Grits posts on McLennan County jail financing:

• Will county cost cutting doom speculative jail in Waco?
• McLennan County on the hook for bonds on privatized jail
• Waco taxpayers likely on the hook for jail they were promised would pay for itself
• 'Doomsday Deal': Prison for profit scheme in Waco going bust for lack of inmates
• McLennan County private jail deal creates perverse incentives