Perkins patients can be the toughest to treat

As a new chief executive at Clifton T. Perkins investigates what led to two recent slayings at the state's maximum security mental hospital, he will confront a facility full of patients who have become increasingly hardened and troubled.

The system of caring for the nation's most mentally ill has changed over time, and those sent to places such as Perkins are now more likely to be veterans of the criminal justice system, substance abusers and hard to treat.

Figuring out how to manage the group of patients, while maintaining security, falls to Dr. David S. Helsel, who just finished his first week on the job at the troubled hospital and has already asked for money for staff.

"Bad outcomes don't necessarily mean bad care," said Helsel. "Sometimes bad things happen to very well-run hospitals. …The population at state hospitals is definitely sicker than it used to be."

More than 200 patients are treated at any one time at the Jessup facility, and like other such state mental hospitals, Perkins cares for the most dangerous patients sent by the courts — those charged with or found not responsible for crimes including murder, rape and assault.

Because of a movement toward out-patient care that began decades ago, there are far fewer hospital beds around the nation for the mentally ill, forensic psychiatrists say. Those not committed don't always want or seek treatment and often end up in the criminal justice system.

An estimated 15 percent of those in the nation's prisons are mentally ill, said Dr. Steven K. Hoge, director of the Columbia-Cornell Forensic Psychiatry Fellowship Program, who has no connection to Perkins.

At one time, many of them would have been sent to a state institution before they committed a crime. He said in the 1950s, there were 560,000 patients committed to state hospitals and the nation's population was about half what it is today. Now, there are just about 35,000 people in hospitals, and the rest are treated through voluntary out-patient services.

"That's led to a changing dynamic at places like Perkins," he said. "Patients coming in no longer have a track record in the mental health system, they have a lengthy track record in the criminal justice system. They've learned to be prisoners, not patients, and it's a problem."

The patients are also more likely to be addicts — 35 percent of those in state mental hospitals also have a substance abuse problem, according to the "Textbook of Hospital Psychiatry" written by Dr. Brian M. Hepburn, executive director of the Maryland Hygiene Administration, which oversees Perkins.

The mix can pose big trouble in an institution. A 1998 study published in the Archives of General Psychiatry found that substance abuse significantly raised the rate of violence among mental patients and in the general population, but that a higher percentage of patients were addicts.

Hoge says many of those who come to a state psychiatric facility who are deemed not fit to stand trial are treated, usually with medications, and after a few months they are restored to competence.

Those found not guilty by reason of insanity could live in a place like Perkins for years or decades because there is a high likelihood of they won't stay on their medications, they are likely to return to substance abuse or they've had bad interactions with other people.

Others have an anti-social personality disorder, and resist treatment or respond poorly to it. These are the toughest cases because they must be taught there are consequences to their actions. Hoge said these kinds of patients tend to accumulate in state psychiatric hospitals.

"People who respond to treatment generally don't need to be closely monitored or guarded to ensure safety," he said. "But patients who have anti-social tendencies or have learned to follow the prisoner code of behavior pose significant risks even when their psychotic illness is under control.

"If someone steals their tennis shoes or disrespects them, they may get a knife and plan to stab and kill the person in retaliation. … Management of patients with criminal propensities is an extremely difficult process. It is not simply a matter of psychiatric assessment and treatment of symptoms"

Hoge and others say getting more early treatment for the mentally ill may help institutions such as Perkins, but budgets are an obstacle.

The National Alliance on Mental Illness, an advocacy group, says many remain in prisons or jails, where they are under-treated or not treated at all. The group estimates $9 billion a year is spent on prisoners with mental health issues a year — there are an estimated 5,500 prisoners in Maryland who are mentally ill, according to the Bureau of Justice Statistics.

And the situation isn't likely to change soon. NAMI pointed to data from the National Association of State Mental Health Program Directors Research Institute that shows from fiscal years 2009 to 2012, $1.6 billion was cut from state mental health budgets.

Maryland, however, is one of 22 states that has increased its spending on mental health over that period, an increase of less than 2 percent that officials from the state Mental Hygiene Administration attribute to the rise in expanded Medicaid coverage.

In all, Maryland paid for inpatient care, mainly in general hospitals with psychiatric wings, for 9,700 people in fiscal 2011, up from 8,600 in 2008. The state provided 123,500 people with outpatient services in 2011, up from 92,300 in 2008, the Mental Hygiene Administration reported.

Most every state reports a shortage of beds in state psychiatric hospitals that often take the long-term and toughest cases. Court-related cases now take up about 40 percent of them, according to the "Textbook of Hospital Psychiatry."

For those who didn't get treatment, or insufficient treatment, before they committed a crime and ended up at a place like Perkins, staff members must constantly use their judgment. They have to ensure that individuals are treated properly and that everyone is safe, said Dr. Howard Zonana, a professor of psychiatry at Yale, which has trained professionals who work at Perkins.

He said killings are rare, though statistics are hard to come by — at Perkins there were the two recent patient-on-patient slayings and a third about a year ago. But those are the only ones reported in the facility's 52-year history.

There were 267 assaults by patients on other patients or staff in fiscal 2011, though few required hospitalization.

"Clinical judgments are made all the time; people can change overnight," said Zonana, also the medical director of the American Academy of Psychiatry and the Law.

"Reports are done every day," he added. "Safety is always an issue. You try and manage."