Last year, there were enough pills for depression prescribed inside the state’s prisons to give one to every man, woman and child in Sioux Falls.
Inmates were given more than a quarter million dollars’ worth of mental health medications that year, with 16 of the top 25 most-dispensed drugs designed to treat mental health.
Drugs for high blood pressure, allergies and shingles fill out the list.
The figures, compiled as a result of an Argus Leader records request, paint a picture of an inmate population that struggles with mental illness at a much higher rate than the general public and is less healthy overall.
It also offers what advocates see as further proof that the mental health infrastructure in South Dakota often fails to offer help those who need it most.
“Far too many people are getting sent to prison because they didn’t get good mental health services outside the walls,” said Phyllis Arends, director of the Sioux Falls chapter of the National Alliance on Mental Illness. “If we had better services outside the prison, we wouldn’t have to spend so much on prescriptions.”
It’s a reality state officials say needs to be dealt with.
Chief Justice David Gilbertson called for a task force last week to study the pre-sentence delays in competency examinations exposed by an Argus Leader investigation.
But Gilbertson and other state officials say solving the acute problem of lengthy pre-trial incarceration is only one step in addressing the complex relationship between mental health and the criminal justice system.
“I know there are people in prison who are criminals who have severe mental illness issues, and I know that a judge or a jury decided they were a danger to society,” said Jim Seward, a general counsel to Governor Dennis Daugaard. “What I don’t know if there are people in prison who are there simply because society doesn’t know what else to do with them.”
Med list focused on mental illness, heart conditions
The Department of Corrections doesn’t have any medical or psychiatric staff. Instead, mental health services come through the Department of Social Services, with the Department of Health administering medical care for inmates at the state’s three main adult correctional facilities in Sioux Falls, Springfield and Pierre.
Medications are dispensed and tracked through the health department, which compiled two drug lists for the Argus Leader. One tracked the 25 most-prescribed drugs, the other listed the top 25 medications by cost.
Mental health drugs are heavily represented on each list. Fluoxetine, the generic equivalent of Prozac, tops the quantity list, with 39,533 doses in fiscal year 2014.
Adding in medications such as Bupropion (Wellbutrin), Venlafaxine (Effexor) and Sertraline (Zoloft) puts the total number of pills dispensed for depression alone at 151,235.
Drugs for bipolar disorder and anxiety to the list puts the total number of mental health medications at 236,695 doses.
The remaining list includes two drugs for high blood pressure, two for nerve pain, two for arthritis and one each for allergies, acid reflux and lack of sunlight (prescription Vitamin D).
That figure doesn’t track exactly to the number of inmates, according to Joan Adam, director of Correctional Health. The average daily count of inmates hovers around 3,500 at any given time, but hundreds come and go each year.
The system also doesn’t track which inmates were prescribed a medication but stopped taking it or switch to something else because of adverse side effects.
“That inmate may not be on (their medication) the whole time,” Adam said.
On the cost side of the list, two of the three most expensive drugs are used to treat schizophrenia. Those drugs are both Abilify, prescribed at doses of five and 10 milligrams. A 20 milligram version comes in at number 11 on the list.
All told, taxpayers spent $156,155 on Abilify in fiscal year 2014. Another $7,192 was spent for Olanzapine, a drug used for bipolar disorder and schizophrenia.
Thirteen of the 25 most expensive drugs are generally prescribed for mental conditions, costing a total of $278,875.
The remaining drugs on the expense list cover psoriasis, nerve pain and shingles, diabetes, fibromyalgia, asthma and cancer. The overall cost of the 25 most expensive medications is $476,714.
Outside the prison walls, profile of prescriptions differs
Websites like WebMD and Medscape track medications for the general population, and the difference is stark. Those sites list Synthroid, a thyroid medication, as the top seller in the U.S. last year, followed by Crestor for high cholesterol and Ventolin inhalers and a handful of medicines for diabetes and high blood pressure.
Only one of the Top 10 sellers is related to a mental condition: Vyvanse, which treats attention-deficit hyperactivity disorder.
“What we see in the general population is a lot of drugs to counteract lifestyle,” said Dr. Dan Heinemann, chief medical officer for Sanford Health. “This (inmate) list is different from what it would look like if I took a Top 25 list of patients at Sanford.”
An inmate’s lifestyle prior to incarceration probably has a lot to do with the prevalence of mental health medications, he said. Many inmates struggle with addiction and self-medicate with street drugs or abuse of prescription medications.
Mental illnesses that appear alongside addiction are referred to as “co-occurring” disorders, and that factor can make treatment more difficult.
“It’s very apparent that many of our inmates have high med needs because of co-occurrence mental illnesses,” Heinemann said.
Nursing inmates with addiction and mental health problems back to health and finding a treatment plan are priorities on the rehabilitation side of the DOC’s work, according to Secretary Denny Kaemingk. Often, the crossing of mental illness, addiction and poor choices plays a role in their commission of a felony crime in the first place.
“It is a challenging job, because you have someone who not only suffers from mental illness, but they’re also criminals,” Kaemingk said.
Psychiatrists, counselors help plan for release
All inmates are assessed by a team of nurses and counselors upon arrival in prison. Some inmates come with prescriptions, others get prescriptions after meeting with counselors and psychiatrists, and more still discover how serious their physical ailments are after a few weeks away from street drugs.
“When you sober up, everything starts hurting in a way you didn’t recognize before,” Kaemingk said.
Alongside the DOH’s nurses and doctors, there are dozens of mental staffers, according to DSS spokeswoman Olivia Waggoner. Three clinical supervisors – one for each main prison location – 11 counselors with master’s degrees and 27 addiction counselors work throughout the DOC system, and contracted psychiatrists spend an average of 200 hours a month with inmates.
There are 138 inmates system-wide classified as severely mentally ill, and they receive the most intensive treatment.
It’s clear from the prescription numbers that far more need some level of mental health care, however, and Kaemingk said that teaching those inmates to manage their symptoms without drugs or alcohol is important for a public that will likely see them again.
Group therapy sessions are available to most inmates, and counselors meet with any inmate who requests a visit.
“There’s been a sea change in recent years, where we recognize that we need to provide the best mental health services to these inmates,” Kaemingk said. “The best public safety service we can provide is to get these inmates well.”
To that end, inmates with physical or mental ailments have a prescription waiting for them at their local pharmacy upon release, and the first two weeks’ worth are paid for. Inmates who need to see a counselor have appointments set up in the community before they leave.
Future steps for mental health and criminal justice
The medications on the Top 25 lists didn’t surprise Kaemingk.
The secretary was a police officer in Mitchell as patients from what had been called the Yankton State Hospital – now the Human Services Center – were released decades ago. The closure or reorganization of state hospitals throughout the 1960s and 1970s was meant to occur alongside a ramp-up of services outside institutions.
“At that time, I don’t think there were enough resources in the community, so a lot of those individuals came into the criminal justice system,” Kaemingk said.
In the decades since then, Kaemingk said, prisons have picked up the slack.
“The DOCs across this nation are, by far, the largest provider of mental health services in the country,” he said.
That’s an unfortunate fact, Arends said. She’s been pleased to see the shift in focus for mental illness at the DOC in recent years, but Arends still believes there are too many people who’ve been failed by their communities.
Whether it’s more intensive case management, earlier or more frequent interventions or simply working to expand the number of providers in a state with a shortage of them, “We need to do something else,” Arends said.
“What we’ve done hasn’t worked.”
Gilbertson spent part of last month at the National Conference of Chief Justices in Washington, D.C., where the topic was mental illness in the court system.
While there, he heard a staggering statistic: Since 1955, the number of psychiatric beds in the U.S. has declined by 95 percent, while the number of people with mental illness in the court system increased 400 percent.
The task force he’s called for to handle delays in pre-trial competency hearings is likely to have a narrow focus, he said, but Gilbertson said the topic of mental illness in the justice system is ripe for discussion.
Mental health courts have been offered in some jurisdictions across the country, for example. The rural nature of South Dakota means that the availability of services for those who need intensive case management is low in some parts of the state.
“Whether we have the number of cases that would justify a mental health court or not would have to be determined later,” Gilbertson said. “Clearly, you would not have the caseload in a lot of South Dakota to make that work.”
All options ought to be on the table going forward, said Seward, who’s acted as Daugaard’s liaison during the state’s expansion of drug and alcohol courts over the past two years.
The details of when and how are wide open, but Seward said the Governor has always encouraged a data-driven approach to criminal justice.
“As a society, we should study and know if we’re incarcerating people solely because they’re mentally ill. If that’s the case, I think most people would have a problem with that,” Seward said. “If there’s a way we can treat people better or outside the prison, the Governor would say we shouldn’t be afraid to look at those things.”
Top 25 drugs dispensed within the DOC, by cost
1. Abilify 5mg tab, $94,238.90 – Schizophrena/bipolar disorder
2. Copaxone 20mg Inj Kit, $49,849.14, Multiple Sclerosis
3. Abilify 10mg tab, $48,502.72, Schizophrena/bipolar disorder
4. Enbrel 50mg/ml, $32,415.01, Psoriasis
5. Gabapentin 600mg tab, $24,845.03, Shingles/nerve pain
6. Venlafaxine 100mg, $18,169.22, Depression
7. Risperdal Cosnta 50mg/2ml inj, $16,628.40, Bipolar disorder
8. Ventolin inhaler, $16,485.04, Asthma
9. Abilify 15mg tab, $18,649.15, Schizophrena/bipolar disorder
10. Strattera 40mg cap, $14,332.45, Adult ADHD
11. Abilify 20mg tab, $13,413.72, Schizophrena/bipolar disorder
12. Methylphenidate ER 36mg tab, $12,965.52, Adult ADHD
13. Qvar 80mcg inhaler, $12,630.31, Asthma
14. Bupropion 100mg tab, $11,751.59, Depression
15. Lyrica 75mg cap. $11,510.70, Diabetes/shingles/fibromyalgia
16. Lyrica 150mg cap, $10,572.16, Diabetes/shingles/fibromyalgia
17. Darunavir 800mg tab, $9,268.33, HIV
18. Truvada 200/300mg tab, $9,167.64, HIV
19. Amphetamine Combo ER 20mg, $8,603.36, Adult ADHD
20. Methylphenidate ER 27mg tab, $7,930.58, Adult ADHD
21. Qvar 40mcg Inhaler, $7,361.07, asthma
22. Olanzapine 10mg tab, $7,191.80, Schizophrena/bipolar disorder
23. Xeloda 500mg tab, $7,022.50, Cancer
24. Dulera 100-5mcg inhaler, $6,711.75, Asthma
25. Bupropion 75mg tab, $6,497.51, Depression
Top 25 drugs dispensed within the DOC, by quantity
1. Fluoxetine 20mg cap, 39,533, Depression
2. Loratadine 10mg tab, 26,983, Allergies
3. Gabapentin 300mg cap, 25,847, Nerve pain/shingles
4. Citalopram 10mg tab, 25,539, Depression
5. Bupropion 100mg tab, 23,487, Depression
6. Buspirone 10mg tab, 20,602, Anxiety
7. Bupropion 75mg tab, 20,231, Depression
8. Sertraline 100mg tab,17,050, Depression
9. Gabapentin 600mg tab,16,422, Nerve pain/shingles
10. Venlafaxine 100mg tab,16,275, Depression
11. Meloxicam 7.5mg tab, 13,538, Arthritis
12. Oxcarbazepine 300mg tab,13,291, Epilepsy
13. Lamotrigine 25mg tab,11,586, Bipolar disorder
14. Hydroxyzine 25mg cap,11,924, Anxiety/nausea/bipolar disorder
15. Lamotrigine 100mg tab,11,586, Seizures/bipolar disorder
16. Etodolac 400mg tab,11,348, Arthritis
17. Clonidine 0.1mg tab,11,207, High blood pressure/anxiety
18. Omeprazole 20mg cap,11,119, Acid reflux
19. HCTZ 25mg tab, 11,005, Adema/heart failure/cirrosis
20. Vitamin D 1000 units tab,10,466, Lack of sunlight
21. Paroxetine 20mg tab,10,408, Obsessive compulsive disorder/Anxiety
22. Lithium 300mg cap,10,267, Bipolar disorder/Hyperactivity
23. Lisinopril 10mg tab, 9,965, High blood pressure
24. Venlafaxine 50mg tab, 9,120, Depression
25. Prazosin, 1mg cap, 9,087, High blood pressure/anxiety/PTSD