I Would File this Under Inappropriate Professional Behavior

Dangerous doctors slipping through the cracks

It took the discovery of guns and grenades to suspend the license of a psychiatrist who some say should have come under scrutiny years earlier

By Megan Twohey, Tribune reporter 8:50 p.m. CST, February 24, 2011 posted on http://darkestcloset.blogspot.com/

One night a Crestwood police sergeant doing a routine building check noticed an open door to the office of psychiatrist Joel Carroll. Stepping inside the cluttered office, he discovered roaming cats, a Colt AR-15 assault rifle and other guns, ammunition, military-grade smoke grenades, sex toys, and pornography.

"Well, for the lack of better terminology, we considered it a pigsty," Sgt. Thomas Kaniewski testified about his April 2009 discovery. "It looked in complete disarray. We couldn't believe that someone could actually conduct business in an office like that because of the conditions it was in."

When state regulators determined that Carroll had engaged in sexual misconduct and committed other violations of the state Medical Practice Act, they suspended his license, proclaiming him "a danger to his patients," according to state records.

But the psychiatrist's practice could have been shut down years earlier, after the Illinois Department of Corrections in 2007 found that Carroll — as a state contractor — committed inappropriate conduct with a female inmate and barred him from working in a prison, a Tribune investigation showed.

Critics say the case raises questions about a crucial part of the medical disciplinary system.

State agencies, county prosecutors, insurance companies, and health care employers and associations are mandatory reporters — they're required to report potentially dangerous and unprofessional doctors to medical regulators, who can bar the doctors from practicing and keep patients out of harm's way.

But the mandatory reporters sound few alarms, and when they do, regulators rarely take action, the Tribune found. There were 348 mandatory reports filed with the state in 2009. That's out of nearly 46,000 physicians statewide. In only one case did the Illinois Department of Financial and Professional Regulation respond by suspending the physician's license, records show.

Sue Hofer, a department spokeswoman, said it can take longer than a year to discipline a doctor following a mandatory report. She said regulators frequently learn of a dangerous doctor from members of the public before being told about the doctor from a mandatory reporter. If they are already investigating, she said, the regulators don't make a separate record of the notification.

But in the case of Carroll, the corrections department provided no notification that the psychiatrist had breached security during a visit to the inmate and allegedly made a sexual advance toward her, even though state agencies must report any potential violation of the Medical Practice Act. Carroll's actions might have amounted to "dishonorable, unethical or unprofessional conduct" — a violation under the act that can lead to suspension — but regulators were robbed of the opportunity to seek disciplinary action, said John Goldberg, a former medical prosecutor.

"The Department of Corrections should have reported, but these agencies hardly ever do," Goldberg said. "If they had, the regulators could have opened an investigation that at the very least asked: What's the explanation for your actions against this inmate? What else is this doctor doing?"

Regulators also were not contacted at the time by Wexford Health Sources, the contracting agency that fired him after his administrative lockout from the prison system. Health care employers must report terminating or restricting a doctor's privileges based on actions that may directly threaten patient care. Elaine Gedman, a spokeswoman for the Pittsburgh-based company, said that in 2007 the "Department of Corrections did not necessarily disclose their rationale for revoking an employee's clearance."

"When we look at this, we realize there are places where dangerous doctors get caught, where they're identified, but no one reports it, or the state doesn't take action," said Gary Schoener, a Minneapolis psychologist who has consulted on thousands of medical misconduct cases across the country.

Sharyn Elman, a corrections spokeswoman, said prison officials believe they did not have to report Carroll to regulators because they could confirm only that he breached security during a visit to the female inmate, not that he engaged in sexual misconduct as alleged.

But after police stumbled on the office, regulators received documentation from the Department of Corrections indicating "the doctor had told that inmate that he would take her to Mexico, and hugged her and kissed her," a medical investigator said during a 2009 disciplinary hearing.

Carroll, who could not be reached for comment, said in the hearing that the inmate made a pass at him, not vice versa.

The psychiatrist maintained his practice while he worked in the prison system from September 2006 to February 2007 and during several months in 2009 while he worked at medical centers for veterans in Danville and Marion.

His personal appearance was concerning to patients and other observers, as was his office, according to testimony.

One former patient said the psychiatrist went shoeless with holes in his socks. A pharmacist questioned whether he was really a doctor.

"He looked messy, unkempt," the pharmacist testified in a disciplinary hearing. "I was surprised at his appearance. He did not look, to me, like any physician I had ever met before. … He was wearing a T-shirt. It did not appear to be clean. It was very wrinkled. He was unshaven."

Carroll's former secretary said the presence of pornography and guns in the office was disturbing.

"The point is, putting myself aside, why does a doctor — a psychiatrist — have guns in the office with psychiatric patients?" she said during a hearing. "That's the problem."

When asked about the weapons in his office, Carroll said he collected them for fun and protection. He told authorities he had close to 100 guns stored in the walls of a Skokie home, state records show. Carroll had a firearms license.

The police never arrested Carroll. During the disciplinary hearing, Kaniewski said he did not know whether Carroll's assault rifle was a type that is illegal for him to own, only that he thought it was cause for concern. (Crestwood police Chief Theresa Neubauer did not respond to written questions or calls seeking comment.)

While law enforcement did not pursue charges against Carroll, state regulators determined that having these weapons at his office amounted to dishonorable, unethical or unprofessional conduct.

The former secretary, who first had been a patient of Carroll's, said she was surprised when he visited her behind bars and then offered her a job immediately after she finished serving time for a drug conviction.

Carroll gave her presigned prescriptions to use when he was out of the office, she said. The woman, a recovering drug addict who had no medical training and suffered from bipolar disease, would pen prescriptions for patients — a violation of drug laws, a Drug Enforcement Administration official testified.

"The medications would range from antidepressants all the way up to controlled substances such as Methadone," the woman explained during the hearing.

Carroll took the woman to New Mexico when he attended a conference and they shared a hotel room, according to the secretary's testimony. Carroll denied it, but she testified he walked around in his underwear and made an unwelcome sexual advance toward her.

When the secretary quit after the state launched its investigation, Carroll showed up at her home more than once, prompting her to call Chicago Ridge police, records show.

"Because after the investigation started, he went and he bought more guns and he just … I don't trust him today," she said in a hearing.

Carroll admitted he spent numerous nights at the home of a patient who suffered from anxiety and panic disorder, state records show. Regulators alleged he took nude pictures of her while she was asleep, threatened to have her committed, masturbated in front of her and attempted to climb through her bedroom window while she was in bed with her boyfriend — all of which he denied.

Another former patient who had turned to Carroll for treatment of severe anxiety said she was confused when he showed up unannounced at her family's Crestwood home. He allegedly tried to kiss her as he was leaving, which prompted her to cry to her mother.

The psychiatrist allegedly returned to the house more than 20 times, records show. The woman and her mother testified he would lay his body against the doorbell and throw rocks at her window.

"It upset me. I was crying. … I did call his telephone and asked him to please don't come to my house," the former patient said in a medical disciplinary hearing.

Carroll said he only threw rocks at the woman's window once. He denied he tried to kiss her.

When she realized the Department of Corrections and Wexford Health Services had taken action against Carroll in 2007 but had not informed regulators, she was outraged.

"This guy should have been out years ago," the woman said. "This should never have happened to any of us."

Withdrawal from the drugs wasn't the only hard part, she said. Her anxiety, already debilitating, worsened.

She is afraid to leave her home, she said, for fear that Carroll will be outside.

mtwohey@tribune.com

:Considering Recovery as a Process" by Dr. Larry Davidson

As reported in February 25, 20011 Vol. 2, issue 7 Recovery to Practice Newsletter. Posted at http://darkestcloset.blogspot.com/

Considering Recovery as a Process

A Continuation of What Does It Mean to Say That Recovery Is ‘Nonlinear’?

by Larry Davidson, Ph.D., RTP Project Director

Some readers of last week’s Highlight responded with concern to the author’s statement that she did not believe that she would ever fully recover from bipolar disorder—they worried that the author either had lost hope or was not aware that full recovery is indeed possible within the context of bipolar disorder. The remainder of the author’s narrative, however, described the many ways in which she had improved her life and been effective in moving the disorder into the background, representing the many ways in which she was indeed “in recovery.” Her story provides a very rich and useful example of how recovery can be a process as well as an outcome.

There are many paths to recovery, and each person must find his or her own way to deal effectively with mental illness. For many people, accepting that the condition will not go away—at least any time soon—is an important step along that journey. Patricia Deegan has been perhaps the most eloquent spokesperson for this aspect of recovery, capturing it in what she describes as “the paradox of recovery”:

… that in accepting what we cannot do or be, we begin to discover who we can be and what we can do. Thus, recovery is a process. It is a way of life. It is an attitude and a way of approaching the day's challenges. It is not a perfectly linear process… (1996, 13)

The author of last week’s Highlight began her story by noting the significant role this realization had played in her own recovery. Whether her recovery will eventually lead to a complete and full recovery from bipolar disorder, only the future will tell. It is important, nonetheless—and perhaps especially in these circumstances—to realize that recovery can be a nonlinear process that does not necessarily lead to anywhere else. It can be, as Deegan suggests, “a way of life.”

A previous Highlight dealt with the issue of the nonlinear nature of recovery when understood as an outcome.

this week’s Highlight will deal more in depth with the way in which recovery as a process is nonlinear as well. While all of the points previously made about recovery as an outcome remain true of recovery as a process, there are some unique aspects of recovery as a process that warrant their own explanation.

The first thing we must clarify is what we even mean by “recovery as a process.” Recovery as an outcome is fairly straightforward and commonly understood, as its meaning in this situation is similar to its meaning in other medical conditions: recovering from a serious mental illness means no longer having the illness, and therefore no longer experiencing its signs or symptoms. But what does it mean to say that recovery can also be a process?

Recovery viewed in stages. Some people take recovery as a process to mean an earlier stage where a person is on the way to recovering from the illness—meaning that while the person’s behavioral health and life may be improving, he or she has yet to recover fully. According to this view, recovery as a process remains linked to the notion of recovery as an outcome; thus, the process of recovery should be considered to be one of recovery (as opposed to simply coping) only if it is leading the person toward an optimal clinical outcome. Otherwise, recovery could be used to refer to any experience a person with a mental illness is having, including any setbacks and relapses. This position helps us to avoid the problematic situation in which “recovery” comes to refer to just about everything—and therefore comes to mean nothing at all (Roe, Rudnick, & Gill, 2007).

Several models of recovery follow this perspective and break the overall process down into a number of components, one following from the other. John Strauss and I (1992) proposed one such model that focused on the person’s efforts to reconstruct an effective sense of self, moving from being hopeful to enacting a positive sense of self to using the self as a resource for managing the illness. The State of Ohio was the first to use such a model to inform policy and practice, suggesting that a person progresses from being unaware of the illness and dependent on others to being aware of the illness and independent in relation to others, with a few steps in between (Townsend, Boyd, & Griffin, 2000). Since then, several other models have been put forth by researchers and clinicians around the world. All features the stages of having lived a life a before the illness, grappling with the illness, and, eventually, moving beyond the illness. All of these models have intuitive appeal, and can be useful in understanding what a particular person may be grappling with at any given time (Davidson, Roe, Andres–Hyman, & Ridgway, 2010).

As useful and intuitively appealing as they are, however, the problem with all of these recovery models is that they are, unfortunately, linear. They stipulate a linear process in which the person goes from stage 1 to stage 2, and so on over time. And even in those cases when the model’s proponents insist that the components are interrelated and not necessarily linear (as Strauss and I did back in 1992), such models have a tendency to be taken both literally and linearly by many people using them—even though we know that recovery is not linear.

Non-linear process. Is it possible to view recovery as a process in an explicitly non-linear way? To understand “recovery as a process” not as an earlier stage on the path to full recovery, but rather as separate and distinct from “recovery as an outcome”? Rather than viewing recovery as a process as leading in a linear fashion to recovery as an outcome, can we sever the connection between the two in order first to understand recovery as a process on its own terms? What would that look like?

One way to de-link recovery as a process from its associations with outcome is to accept that, for some people (like the author of last week’s Highlight), traditionally defined clinical outcomes may not change much over time. This does not mean, however, that the person’s life as a whole might not change substantially in other ways. A disability model does not require people with developmental disabilities to acquire IQ points to conclude that their lives had improved considerably based either on our efforts, their own efforts, or a combination of both. Individuals with developmental disabilities can be taught how to navigate their communities, can attend school, or can join a swimming team without seeing any appreciable change in individual IQs. This does not detract from the fact that their lives have been significantly enriched as a result. 

The same thing may also be true for someone with a mental illness, who may be accompanied to church, go out to eat with friends, or bring gifts to his or her nieces and nephews at the family Christmas party without any appreciable change in his or her mental illness. Being in recovery in this sense has to do with pursuing and participating actively in a meaningful and pleasurable life within the limitations imposed by the disability. Though one might argue that involvement in these activities constitutes an outcome, the only outcome in this scenario is that the person is able to actively pursue the kind of life he or she wishes to lead. Within the context of much of behavioral health, the process of living one’s life is not ordinarily considered an outcome.

Quality of life. Separating the quality of a person’s life from his or her behavioral health status is important for a number of reasons. For one, a person’s diagnosis does not define him or her as a person. No two people with schizophrenia are going to be any more similar than any two people who happen to be, say, psychologists or nurses. Secondly, the different aspects of mental illness typically wax and wane for most people over time, with improvements in any one domain only loosely related to improvements in other domains (Strauss & Carpenter, 1977; Strauss, Hafez, Lieberman, & Harding, 1985). Not only is recovery as an outcome non-linear, then, but it is also made up of different domains of functioning that are relatively independent of one another. I may seem “more recovered” when I get a job, but may at the same time hear more voices. Or perhaps I hear fewer voices when I work, but then find that I cannot spend time with friends or family because I become too anxious. We unfortunately know little about what leads to, or predicts changes in, the course of serious mental illnesses. Whereas reductions in symptoms might influence future symptom levels, they may not influence work or social functioning, and none of these factors may relate directly to quality of life.

In this sense, it becomes difficult to equate recovery with symptom or functioning levels in people with prolonged conditions. If we equate recovery with a decrease in symptoms or an increase in functioning, then we can readily imagine circumstances in which a person in recovery “gets worse.” People often experience an increase in symptoms or a decrease in functioning in response to important life events, such as experiencing the death of a loved one, being fired from a job, or suffering a grave disappointment. More importantly, a person in recovery can experience an increase in symptoms in response to positive life events, such as moving into one’s own apartment, starting a new job, or falling in love. Should such symptom exacerbations mean that these participants are no longer in recovery? No.

Waiting, at a price. What is the importance of accepting that some symptoms or impairments may not go away—at least for an extended period of time—and that the person can pursue and be “in” recovery nevertheless? Consider the young man who is told that he cannot be referred for supported employment until he has been clinically stable for 3 months or the woman who is advised to wait on her dream of becoming a mother until her symptoms abate. What if these outcomes of symptom cessation or clinical stability, as defined by caring others, never occur? What may have been lost in the waiting? As has been true for those who have had to struggle for their civil rights, for many people with mental illness, this insistence on waiting has come at a very high price (Davidson, 2006).

For example, one of the core criteria of supported employment may be rapid job placement, regardless of symptoms. Some well-meaning practitioners, however, may continue to insist that people not be referred to supported employment, or not pursue employment on their own, until they have achieved some inchoate state of stability. From these practitioners’ perspectives, the best thing a person can do to recover from the illness is to minimize the daily stress he or she has to deal with while convalescing. From the person’s perspective, however, prolonged unemployment, poverty, and empty time may be more stressful than attempting to work in the face of symptoms. (We are aware of no studies showing that unemployment promotes recovery.) Similarly, some practitioners continue to view each episode of symptom exacerbation as a relapse and each stay in an acute-care setting to be a readmission, even though from the person’s point of view, these occurrences may represent, or be a consequence of, a movement forward in their lives. These are the unanticipated and unintended side effects of continuing to view recovery primarily as an outcome, an ideal state of health, toward which all processes must flow.

For this reason, among others, we suggest focusing primarily on the process of recovery—that is, on supporting people in their efforts to lead full lives in the face of serious mental illnesses, rather than on achieving a more distant and elusive outcome. Though a life with the illness may not be the optimal outcome from anyone’s point of view, it might be the best that many people can hope for in the foreseeable future. In these cases, we suggest that entering into and pursuing a better life in the face of mental illness poses an extremely important and valuable challenge irrespective of outcome, not only for that person, but also for those of us privileged to be offering care.

For further reading:  

Davidson, L. (2006). What happened to civil rights? Psychiatric Rehabilitation Journal, 30(1), 11–14.

Davidson, L.; Roe, D.; Andres–Hyman, R.; & Ridgway, P. (2010). Applying Stages of Change models to recovery in serious mental illness: Contributions and limitations. Israel Journal of Psychiatry, 47(3), 213–21.

Davidson, L., & Strauss, J.S. (1992). Sense of self in recovery from severe mental illness. British Journal of Medical Psychology, 65, 131–45.

Deegan, P. (1996). Recovery and the conspiracy of hope. Presented at the Sixth Annual Mental Health Services Conference of Australia and New Zealand, Brisbane, Australia.

Roe, D.; Rudnick, A.; & Gill, K.J. (2007). The concept of ‘‘being in recovery.’’ Psychiatric Rehabilitation Journal, 30(3), 171–73.

Strauss, J.S., & Carpenter, W.T. (1977). Prediction of outcome in schizophrenia: III. Five-year outcome and its predictors. Archives of General Psychiatry, 34(2), 159–63.

Strauss, J.S.; Hafez, H.; Lieberman, P.; Harding, C.M. (1985). The course of psychiatric disorders III: Longitudinal principles. British Journal of Psychiatry, 55, 128–32.

Townsend, W.; Boyd, S.; & Griffin, G. (2000). Emerging Best Practices in Mental Health Recovery. Columbus, Ohio: Ohio Department of Mental Health, Office of Consumer Services.

Quote from Joe Pantoliano, Founder nkm2

“We know years of ingrained socialization causes people to recoil or isolate anyone with the scarlet letter of mental illness. Just saying the magic words "mental illness" can cause a deep-seated defensive reaction in many people. However, we also know that by releasing the talents of those with mental illness — by giving them the opportunity to use their outstanding artistic and intellectual skills — we will vastly improve the world.”

- Joe Pantoliano, Founder & President of nkm2, activist, actor, film maker

http://nkm2.org/blog/main/

Abortion Does Not Increase Mental Health Disorders

Authors of a new study of Danish women and girls have concluded that having a first-trimester abortion does not increase a woman’s risk of developing a mental health condition. Of the 365,550 individuals studied between 1995 and 2007 who either gave birth for the first time or had an abortion, the latter group – 84,620 women – had roughly the same rate of seeking psychiatric help before the abortion as afterward. On the other hand, of those who gave birth, the rate of those who sought help in the year after delivery was significantly higher than the rate of those who sought help before having a child. Authors of this study, published in the New England Journal of Medicine, suggest that the stresses of parenthood, coupled with hormonal changes and less sleep, may explain the increase. To read the free abstract, go to http://www.nejm.org/doi/full/10.1056/NEJMoa0905882

FDA panel advises more testing of 'shock-therapy' devices

By David Brown Washington Post Staff Writer Friday, January 28, 2011; 10:10 PM

An expert panel advising the Food and Drug Administration decided Friday that electroconvulsive therapy (ECT) machines should undergo the same rigorous testing as new medical devices coming onto the market - a decision that could drastically affect the future of psychiatry's most controversial treatment.

The majority of the 18-member committee said not enough is known about ECT, also known as "electroshock" or simply "shock" therapy, to allow the devices to be used without more research into its usefulness and hazards.

If the agency follows the panel's advice, which it usually does, the two companies whose machines are used in the United States will have to provide evidence of the therapy's safety and effectiveness either from existing research or new studies. If the FDA isn't convinced, the devices could be removed from use.

The panel's opinion is the latest chapter in ECT's seven-decade history, during which the treatment has been lauded as a lifesaver, villified as a form of legally sanctioned torture, and has seen its popularity rise in recent years after a long decline.

ECT machines deliver an electrical current to the brain, inducing a generalized seizure in which the patient briefly loses consciousness. How that may be therapeutic or cause permanent memory loss - the side effect most frequently mentioned by patients - isn't known.

About 100,000 Americans undergo ECT each year, usually getting about a dozen treatments over several weeks. Some then get "maintenance" ECT every few weeks, as the therapeutic effect, when it occurs, often doesn't last. The treatment is most often used for depression and has also been prescribed to patients with schizophrenia, catatonia, and more recently, to some violent children with autism.

"It was the best possible outcome we could have gotten," said John Breeding, 58, a clinical psychologist from Austin who says the procedure should be banned. He testified before the panel at a two-day meeting in Gaithersburg.

For some patients, ECT epitomizes what they view as the coercion and lack of respect for the patient's point of view that is unique to psychiatry. That's also largely how it's been depicted in popular culture, most famously in the book and film "One Flew Over the Cuckoo's Nest," where it was a tool of punishment and social control of mental patients.

"I lost not only my memories of the time I was subjected to this torture but I was robbed of almost all memories from about 2003, two years before treatment, to 2008, three years after treatment stopped," testified Evelyn Scogin, a special-ed teacher who got ECT after a suicide attempt. Her statement was read by a friend because Thursday's snowstorm stranded her in the Charlotte airport.

Other patients described ECT as a lifesaving, if mysterious, treatment worthy of wider use.

Among them was Kitty Dukakis, the 74-year-old wife of 1988 Democratic presidential nominee and former Massachusetts governor Michael Dukakis. She first got ECT at age 63, and continues to get it once a month.

"It is not an exaggeration to say that I don't think I would be alive without ECT. It has been a miracle in my life," she said.

One proponent, a nurse from Baltimore, drove through the snow on her day off to read a grateful Christmas card from a patient, choking up as she did.

"I actually think it's more controversial than abortion," Amy Lutz, a 40-year-old mother of five from Villanova, Pa., said of ECT, which her 12-year-old autistic and manic-depressive son gets regularly.

She brought with her two poster-size photographs of the boy, his face and hands bloodied from self-inflicted blows. She told the committee that ECT, tried after a half-dozen other therapies, stopped the violent behavior and increased her son's achievement in school.

A 1976 law requiring safety and effectiveness of all new medical devices permitted ones in longstanding use, including ECT machines, to stay on the market. Later, however, Congress told the FDA that those grandfathered-in devices either had to undergo rigorous testing or be officially "reclassified" as already-proven to be safe and effective (although, in some cases with special warnings about their use).

In addition to patient testimony, the advisory panel heard FDA staffers describe their analysis of hundreds of ECT studies.

As a group, the studies tended to be poorly designed and with too few patients to allow the drawing of firm conclusions. Many failed to follow patients long enough to discover the duration of ill effects. Ones done decades ago studied techniques and electricity dosages different from current practice.

The FDA staff reported the existing research suggests that for depression, ECT is more effective than placebo or "sham" shocks and after a month more effective than antidepressants.

In terms of hazards, the FDA staff's review found the treatment is associated with "impairment in orientation, memory and global cognitive function immediately after ECT and up to 6 months." Certain aspects of memory may return to baseline after six months. "Autobiographical memory" - recollection of events in one's life - appears to be at greatest risk. High-dose electric current and current applied to both sides of the brain are associated with more thinking and memory problems.

Panel member Christopher A. Ross, a psychiatrist and neuroscientist at Johns Hopkins University, asked if the published studies identified any risk factors that predisposed patients to memory loss and thinking impairment.

"Evidence-based data for that issue just doesn't exist," said Peter G. Como, a neuropsychologist at the FDA.

Panel Chairman Thomas G. Brott, a neurologist at the Mayo Clinic's campus in Jacksonville, Fla., said he was amazed that essentially no research had been done on ECT's effects using functional MRI imaging, repeated brain wave (EEG) studies, or autopsy examinations of patients.

"I tried to look and saw very little. I concluded that the evidence is not there to decide either way," he said.

“Some Thoughts about Black History Month”

 by Makia Maishna Newman from the Stomp Newsletter www.cnsantistigmaprogram.org

For me, the month of February always brings with it many thoughts and emotions, some easy to explain, others not.
I am an African-American woman, born in the 50s, raised through all of the social upheavals of the 60s, 70s, and 80s. Now we here are in the 21st Century and it seems strange that we’re still having some of the same conversations about race now that we had during those “difficult” days back then.

Why is race such a “hot button” topic in this county? After all, we have an African-American president, (something I thought I would never see in my lifetime) for the first time in history. In so many ways, African Americans are progressing in every arena of life, and enjoying greater freedoms that we as a people ever have before. In the minds of many people, African-Americans have overcome; there is no need for any further discussions, there isn’t any need for “Black History Month”, etc., or is there?

I attend Leadership Oakland XXI, a monthly series of leadership training classes that has been a joy to be a part of. I’ve been challenged, stretched, and enlightened to what it takes to be a person called to leadership during these difficult times in our county, state and country.

We cover various topics every month; government, human services, media, just to name a few. January’s class topic was “Diversity and Inclusion”. It was a very difficult topic to discuss, but I felt it was presented in a very honest, caring, and sensitive way by Chris Scharrer, the Executive Director for the Leadership Oakland program and the various speakers we heard from throughout the day.

One of our activities included watching a video called, “Race, the Power of Illusion” a documentary done by California Newsreel that took an in depth look at some of the reasons the United States still grapples with the problems of discrimination, and inequitable treatment of people of color in this country. It was heartbreaking, informational, and very emotional for me to watch. There were things discussed in this video that I had never heard before. I cried then and I cried for two days after I saw it.

There were so many things that I didn’t know about race relations in this country. I didn’t know that a brick wall was constructed on 8 mile road, to divide the city of Detroit from the surrounding cities and townships to make it possible for those cities that happened to be too close to the border of Detroit could still receive good credit ratings and be able to get access to loans and other financial considerations that people living in the inner cities were systematically denied.
I didn’t know that the suburbs were created to give better housing opportunities to the veterans that returned home from WWII needing housing that was very difficult to find in those days, and that the African American soldiers were systematically denied equal access to better housing, by our government, and the practices weren’t outlawed until President Lyndon B. Johnson signed the Fair Housing Act in 1965.

There was a lot of information given that day and the jumbled feelings and sadness I had when I left my class have lingered with me even though it’s been a month since we had this session.

Why do I write about this in a newsletter that’s dedicated to mental health issues? What’s “race” got to do with anything anyway?

It has a lot to do with it. In 1999, Dr. David Satcher, wrote Mental Health: A Report of the Surgeon General, that gave an in-depth analysis of the state of the mental health system in this country. In 2003, he wrote a supplement to the original document, Mental Health: Culture, Race, and Ethnicity, where he determined that “Culture Counts” and that “many aspects of mental illness are influenced by race and ethnicity.”

He also determined that minority populations:
Have less access to mental health services
Receive poorer quality of services
And are under-represented in mental health research
Minorities also have greater exposure to racism, discrimination violence, and poverty, all of which adversely affect mental health.
http://www.surgeongeneral.gov/library/mentalhealth/cre/execsummary-3.html

This is why we must to get beyond our personal discomfort with discussions about race in this county, people’s lives are at stake, literally!

In spite of all of this, I still have faith and I have to believe that there will come a time in our country that we all will overcome, that everyone, no matter what their ethnicity, race, etc., will be judged by our character and not the color of our skin like Dr. Martin Luther King, Jr. said so many years ago. I have to believe that future generations will be able to walk together in peace and unity just to have the strength to go on. I have seen kindness and compassion in the eyes of other people of varying backgrounds, when I myself have had experiences that have left me shaken to my core. I have seen people take the high road in their response to racism or discrimination that was blatant, and that is enough to help me not to sink into the despair that sometimes tries to pull me under the clouds of darkness and feeling of heaviness that so often accompany these types of situations.

I too have a dream and I believe that one day I will see it come to pass. I will see my children, grandchildren, and others that I care about so deeply will have the opportunity to live, work, and play in that better place, free from fear, hatred, ignorance, intolerance, and the like. I choose to believe and live free.”

African-Americans Likely to Delay MH Treatment

At the age of 12, former NBA player Thabiti Boone witnessed his severely depressed mother attempt suicide when she jumped from a six-story building and landed at his feet.

“When she was jumping off the roof, I took in all of the depression that caused her to jump,” says Boone, describing the incident in a public service video sponsored by the Substance Abuse and Mental Health Services Administration. He said that although he felt as if everyone was waiting for him to “break down” mentally, no one sat down and talked with him about how he was feeling.

Too often, Boone’s experience is echoed in the African American community when it comes to talking about mental health. Mental illness is brushed under the carpet, ignored, or stigmatized. But a new campaign by SAMHSA is designed to raise awareness of mental health problems among young adults in the African American community hopes to get more people talking about the issue -- and ultimately getting the help they need.
The ads will encourage and educate young adults to step up and talk openly about mental health problems, and that they are not alone in their struggle. The television, radio, print, and Web ads feature real personal stories of African Americans dealing with mental health problems, and they aim to engage those in the community to support young adults who need help.

While 58.7% of Americans with serious mental illness received care in 2008, only 44.8% of mentally ill blacks received services, according to SAMHSA's 2009 National Survey on Drug Use and Health. The prevalence of serious mental illness is highest among those age 18 to 25, but according to SAMHSA, those people are the least likely to receive services or counseling.

“African Americans are more likely to delay seeking treatment until their symptoms are more severe and are more likely to discontinue or stop treatment once it is started,” says Paolo Del Vecchio, associate director for SAMSHA’s office of Consumer Affairs, which offers resources and programs to address mental health.

There are a variety of mental health disorders ranging from depression and anxiety problems to phobias and more serious issues such as schizophrenia and bipolar disorder, says Annelle Primm, director of minority and national affairs at the American Psychiatric Association.

Symptoms of mental instability can include changes in mood, sleep activity, energy level, or appetite; an inability to remember, concentrate, or think; and delusions or hallucinations. But Primm says that having just one of those symptoms in a fleeting sort of way, doesn’t mean that someone has a mental illness. But when the symptoms are grouped together over a long period a time a person should seek help.

Although a lack of health insurance is one of many reasons mental health care is not sought in the black community, many neglect treatment because the stigma associated with it can cause shame and embarrassment. Also, the belief by some religions that mental health problems can be cured through prayer and faith is another reason why some people do not admit they aren’t well or seek professional help, says Del Vecchio.

So instead of getting the help they need, many people suffering from mental illness self-medicate with alcohol and illegal drugs.

"The disparities that African Americans experience in accessing mental health care can be overcome through increased awareness and education,” said Kathryn A. Power, director of SAMHSA’s Center for Mental Health Services. “Raising the African American community’s understanding and attention to these issues will provide greater opportunities for recovery from mental health problems.”

http://www.blackenterprise.com/2010/03/02/challenging-the-stigma-of-mental-illness/

Resources
-- The Stay Strong Foundation
-- National Alliance on Mental Health
-- The Black Mental Health Alliance
-- Mental Health America
-- Black Psychiatrists of America

Reprinted from STOMP Newsletter. www.cnsantistigmaprogram.org

Celebrate Black History Month by Respecting Cultural Competancy in Mental Health

This is an article by Mark Lamont Hill, Assoc. Professor at Columbia University.

"The Black Community Is In The Midst Of A Mental Health Crisis

There's A Relationship Between Freedom And Mental Health"

from TheLoop21 June 24, 2010

Mental health or lack thereof is at the root of a lot of society's ails.

http://theloop21.com/society/ron-artest-reshaping-the-conversation-black-mental-health

Annual BrainStorm Poetry Contest

(note from blogg editor-I know nothing about this organization, I am just passing this on. Please investigate before resoponding!)

Once again, we are hosting the 9^th Annual BrainStorm Poetry Contest for mental health consumers, and we wanted to make sure your organization knew about it. The contest, which is a fundraiser for our literary magazine Open Minds Quarterly, is run each year to showcase the best in consumer poetry. I’ve attached a brochure that includes the rules and entry form; please feel free to circulate either by email or by paper copies. The deadline for entries to arrive here at our office is Friday, March 18, 2011.

More details about the contest can be found here on our website. The entry form can also be downloaded from our site.

If you have any questions about the contest or our magazine – or you wish to be removed from our mailing list -- please feel free to contact me. 

With my regards,

Dinah Laprairie

Editor/Publisher, Open Minds Quarterly

NISA/Northern Initiative for Social Action

680 Kirkwood Dr. Bldg. 1

Sudbury ON P3E 1X3

CANADA

705.675.9193, Ext. 8286

openminds@nisa.on.ca

www.nisa.on.ca

Being, Belonging, Becoming, for all mental health consumers.

NISA is an organization run by and for consumers of mental health services. We develop occupational skills, nurture self-confidence and provide resources for recovery, by creating opportunities for participants to contribute to their own well-being and that of their community.

Safe Schools Amendment Act: Anti-Bullying Legislation

FDA Orders New Cautions on Antipsychotic Drugs

By John Gever, Senior Editor, MedPage Today

Published: February 22, 2011

http://r20.rs6.net/tn.jsp?llr=sqa5umdab&et=1104622119011&s=9110&e=001zc3xfKsSKtg4N1-pYs_DXy5sGZyl_JqZRQ6S__GGivGRdDhhjQAGnT87c4ApeeqM-vZNl8MnT4Kirqg6R8hwMg5U5l4iRyJO-vyN-gJSz1DYsjxvzjDHy8MJ3cp6-5Ae0Vu--LIef1TRTx1HZDtN2FvUT8QEEmyzZtadl_Vib0I= 

WASHINGTON -- All antipsychotic drugs, including older agents as well as second-generation products, must contain new label information regarding their use in pregnancy, the FDA said.

In particular, the new labeling will address the risk of extrapyramidal symptoms (EPS) and withdrawal syndromes in newborns.

"FDA has updated the Pregnancy section of drug labels for the entire class of antipsychotic drugs to include consistent information about the potential risk for EPS and/or withdrawal symptoms in newborns whose mothers were treated with these drugs during the third trimester of pregnancy," the agency said in a notification to healthcare professionals.

The FDA has identified 69 episodes of neonatal EPS or withdrawal in adverse event reports submitted to the agency through October 2008.

Among the symptoms listed in the reports: agitation, hypertonia, hypotonia, tremor, somnolence, respiratory distress, and feeding disorder.

However, blood levels of the drugs involved were not provided in the reports, the agency said, so it was "not possible to determine whether the events resulted from antipsychotic drug toxicity or withdrawal."

Onset of symptoms ranged from birth to one month later, and the severity varied as well. The FDA indicated that some infants recovered within hours while others needed intensive care and prolonged hospitalization.

Most of the cases also involved other potential causes of the symptoms, such as other psychotropic drugs and medical problems associated with the pregnancy or delivery.

"However, there were some cases which suggest that neonatal EPS and withdrawal may occur with antipsychotics alone," the FDA said.

The agency's announcement did not indicate which specific antipsychotic drugs were named in the adverse event reports.

In any event, the FDA is requiring the standardized cautions be carried on all antipsychotic drugs -- 20 different types sold under 23 brand names are included in the order. These range from the first antipsychotic drug used in modern practice, chlorpromazine (Thorazine), to such newer agents as aripiprazole (Abilify) and quetiapine (Seroquel).

All the products are approved to treat schizophrenia; some also have been cleared for bipolar disorder.

The official order can be read at http://r20.rs6.net/tn.jsp?llr=sqa5umdab&et=1104622119011&s=9110&e=001zc3xfKsSKtiUHzIcX1zPrMMeu7RbjgzLOGeS1R5vSEPycP_IGuIFgPwJ3u9br8C6AnbII2XdxeN_WyjYhK84BTUjtiLIYWmDr2X3r0OK45YMuKbnSEBZPwQp673XT2FfUpvaiukBE7ud1I-1iwEiVQ==. 

Mental Health and Medicaid Costs: Why Ignoring Mental Health Is Expensive

http://www.huffingtonpost.com/michael-friedman-lmsw/mental-health-and-medicaid-the-_b_825047.html

Cost containment is one of the major goals of health policy reform in the United States. Because spending on mental health and substance abuse services (commonly called "behavioral health services" when referring to both) is less than 8 percent of all health spending, behavioral health seems an unlikely candidate for substantial savings. But that perception is wrong!

People with behavioral health conditions are at higher risk than others for physical illness and disability, and the cost of medical care for them is, on average, much higher than the cost of medical care for people without behavioral health conditions. Better behavioral health services for this population would be likely to reduce the costs of their physical health care and produce significant overall savings in health spending.

This view received fresh support this week from a very important report from the United Hospital Fund in New York City. Entitled "Providing Care to Medicaid Beneficiaries with Behavioral Health Challenges," the report reveals that Medicaid recipients with mental health conditions are 30 percent to 60 percent more likely to have hypertension, heart disease, pulmonary disorders, diabetes, and dementia. People with substance abuse conditions are 50 percent to 300 percent more likely to have heart disease, pulmonary disorders, and HIV/AIDS.

The United Hospital Fund report also documents far higher spending for Medicaid beneficiaries with behavioral health conditions than beneficiaries without behavioral health conditions. According to the report, average health spending for people with mental health conditions in 2003, (the year studied), was $28,451; for those without mental health conditions it was $15,964. Only 25 percent of the spending for this population was for treatment of mental disorders. "Mental health beneficiaries spending on physical health services ($21,002) was 32 percent higher than comparable spending for non-mental health beneficiaries."
For people with substance abuse conditions, average Medicaid spending was $27,839; for those without substance abuse disorders it was $18,051. Only 24 percent of the spending was for substance abuse treatment. "Substance abuse beneficiaries mean Medicaid spending on physical health services ($21,053) was 17 percent higher than comparable spending for non-substance abuse beneficiaries."

The difference in spending for inpatient services for people with behavioral health conditions and those without is particularly striking. "Average annual expenditure for inpatient treatment [for people with mental illness] was $7017 compared to $3629 for others." For those with substance abuse disorders, inpatient costs averaged $11,738 compared to $3,301 for others. Also striking is the fact that, "the seven-day hospital readmission rate of mental health beneficiaries was 50 percent higher than non-mental health beneficiaries. Substance abuse beneficiaries' rate was 150 percent higher than [others.]"

Prior work supported by the United Hospital Fund and the New York Community Trust sheds additional light on the link between Medicaid spending and the co-occurrence of severe behavioral and physical health conditions. A study led by John Billings showed that nearly 60 percent of all Medicaid spending in New York is for 10 percent of the beneficiaries. Two-thirds of these "high cost cases" had severe behavioral health conditions as well as physical health conditions. Most did not get adequate care until their physical conditions became critic and resulted in long stays in hospitals.

Is it possible to improve treatment for people with behavioral health conditions before they become critical and thus bring down overall spending?

Although there are disputes about how to structure a system to improve care for people with both physical and behavioral disorders, there is consensus that earlier interventions with this population could avert health crises and thus reduce health spending. And the fundamental elements of an effective system seem clear enough. Those at highest risk need to be identified before they are in crisis; history of payments by Medicaid makes this possible. Aggressive outreach is needed to locate and engage people at high risk before they are in critical need. Those not identified until they come to emergency rooms, as they frequently do, need to be linked to community-based services immediately. Physical and behavioral health services for them in the community need to be integrated. And fundamental life needs must be addressed -- particularly the need for stable housing, without which little else can be accomplished.

None of this is easy to do; but if it is not done, people with both serious behavioral health conditions and serious physical health conditions will continue to be the high cost Medicaid cases. And most Medicaid spending will continue to be for the 10 percent of Medicaid beneficiaries who have the greatest needs.
Our health care system can continue to largely neglect mental illness and substance use disorders, but at great avoidable cost. Bottom line: forget about mental health, forget about savings.

You and Me By Debbie Suela

If you're overly excited, you're happy

If I'm overly excited, I'm manic

If you imagine the phone ringing, you're stressed out

If I imagine the phone ringing, I'm psychotic

If you're crying and sleeping all day, you're sad and need time out

If I'm crying and sleeping all day, I'm depressed and need to get up

If you're afraid to leave your house at night, you're cautious

If I'm afraid to leave my house at night, I'm paranoid

If you speak your mind and express your opinions, you're assertive

If I speak my mind and express my opinions, I'm aggressive

If you don't like something and mention it, you're being honest

If I don't like something and mention it, I'm being difficult

If you get angry, you're considered upset

If I get angry, I'm considered dangerous

If you over-react to something, you're sensitive

If I over-react to something, I'm out of control

If you don't want to be around others, you're taking care of yourself and relaxing

If I don't want to be around others, I'm isolating myself and avoiding

If you talk to strangers, you're being friendly

If I talk to strangers, I'm being inappropriate.

For all of the above, you're not told to take a pill or are hospitalized, but I am!

When Mental Health Meds Are Out Of Reach, Hospitalization More Likely

Too often, mental health patients have problems accessing or paying for their prescription drugs under Medicaid. The results - longer hospital stays and more emergency room visits - are hard on patients and costly for the entire health care system, a new study finds.

Lead author Joyce West, Ph.D., and colleagues analyzed Medicaid data from 10 states and found that psychiatric patients who reported access problems with their medication visited the emergency department 74 percent more often than those who had no such difficulties.

Of the 1,625 patients West and colleagues tracked, almost a third could not access the clinically indicated or preferred medication because Medicaid did not approve it. Patients with medication access issues experienced 72 percent more acute hospital stays compared to patients without access problems.

Access problems included prescribed medication being discontinued, temporarily stopped or not covered. Some patients had problems making the co-payment.

"What's particularly troubling is that it can often take several trials and many months, if not longer, to find an appropriate medication regimen that a patient responds to," said West, policy research director at the American Psychiatric Institute for Research and Education and an assistant professor of mental health at Johns Hopkins University.

The study appears in the November-December issue of the journal General Hospital Psychiatry.

"There are major clinical risks to psychiatric patients when they're stable on their medication and then switch to a different medication," West said. "Policies to facilitate medication continuity are critically important for this highly vulnerable population."

Policymakers can save money in the Medicaid program by clamping down on medication, but other areas including emergency room visits will undeniably increase, said Ken Duckworth, medical director for the National Alliance on Mental Illness and assistant professor at Harvard Medical School.

"It's another piece in a body of evidence that says what you're doing when you're restricting access to psychiatric drugs is squeezing the balloon," Duckworth said. Psychiatric hospitalization costs $800 to $1,000 a day. "So it is quite expensive for the system," Duckworth said.

Duckworth said incarceration it particularly is important for patients with conditions such as schizophrenia, bipolar disorder and borderline personality disorder to take medications consistently. TERMS OF USE: This story is protected by copyright. When reproducing any material, including interview excerpts, attribution to the Health Behavior News Service, part of the Center for Advancing Health, is required.

General Hospital Psychiatry is a peer-reviewed research journal published bimonthly by Elsevier Inc.

West JC, et al. Medicaid medication access problems and increased psychiatric hospital and emergency care. Gen Hosp Psych 32(6), 2010.

Source:
Health Behavior News Service
http://www.medicalnewstoday.com/articles/211062.php

Videos of Individuals Speaking about Living with Schizophrenia

New York Times Features Videos of Individuals Speaking about Living with Schizophrenia or Schizoaffective Disorder

The New York Times has posted videos in which seven individuals talk about living with schizophrenia or schizoaffective disorder. The interactive site offers readers a chance to comment. To watch the videos or participate in the discussion, go to:http://www.nytimes.com/interactive/2010/09/16/health/healthguide/te_schizophrenia.html

Inmate’s Death Exposes Health Care Problems in Local Jails

The Texas Tribune By BRANDI GRISSOM Published: February 12, 2011

LONGVIEW — Amy Lynn Cowling was 33, she had three children, and her first grandchild was born a day after she died in an East Texas jail — slumped over her bed, clutching a bottle of Diet Dr Pepper, after a day of wailing and seizures.

Amy Lynn Cowling’s mother, Vicki Bankhead, talks with the family’s lawyer, Jarom Tefteller.

Sheriff Maxey Cerliano defends the medical treatment at the Gregg County Jail. Amy Lynn Cowling’s death was the ninth at the jail since 2005.

Ms. Cowling was pulled over on Christmas Eve for speeding and arrested for outstanding warrants on minor charges. She was bipolar and methadone-dependent and took a raft of medications each day. For the five days she was in Gregg County Jail, Ms. Cowling and her family pleaded with officials to give her the medicines that sat in her purse in the jail’s storage room. They never did.

Ms. Cowling’s death is the most recent at Sheriff Maxey Cerliano’s Gregg County Jail in Longview. Since 2005, nine inmates have died there — most were attributed to health conditions like cancer, diabetes and stomach ulcers — far more than at other facilities its size. Bowie County Jail, in East Texas on the Arkansas border, reported five deaths in the same period, as did Brazoria County Jail, south of Houston on the Gulf Coast. In Williamson County in Central Texas near Austin, the jail reported just two deaths.

Interviews with prison experts and people with firsthand experience with the Gregg County lockup and its medical staff, as well as a review of scores of public documents, reveal a troubled local jail where staff turnover is high and inmates routinely complain about conditions. Criminal justice advocates say the situation in Gregg County is not unique; it is representative of systemic problems that plague local jails statewide.

Sheriff Cerliano defends the medical treatment in his jail and said he does his best to weed out bad jailers. “It’s only about doing the right thing,” he said.

Vicki Bankhead never went a day without talking to Ms. Cowling, her daughter and best friend. “I miss hearing her voice,” Ms. Bankhead said, sobbing. Ms. Cowling became a mother at age 15. She had become addicted to prescription pills and was found guilty in 2001 of possessing a fraudulent prescription. She struggled to keep a job.

Although Ms. Cowling had been clean for several years and was getting treatment at a methadone clinic, Ms. Bankhead said, her daughter had other health problems, including bipolar disorder, heart troubles and a failing kidney. “Amy needed her medication to stay alive,” she said. “That’s why I was begging them to help her repeatedly.”

Public records show that Ms. Cowling told Gregg County Jail officials that she had high blood pressure, arthritis and only one kidney. She reported that she took Seroquel to treat bipolar disorder and that she had been receiving methadone treatment for a decade — but neither of those drugs is allowed in the jail.

State standards require only that jails provide treatment according to the facility’s health care plan. Dr. Lewis A. Browne, the county health administrator and jail doctor since 1992, decides which drugs are allowed. Drugs like Seroquel and methadone, he said, are often traded among inmates for illicit favors.

Gregg County officials said that Ms. Cowling had received appropriate substitute medications.

Reports on her case submitted to the Texas attorney general’s office show that Ms. Cowling began having “seizure activity” while she was in the facility. The morning before she died, a jail nurse called Dr. Browne to report that Ms. Cowling was “hollering and uncooperative.” Dr. Browne told the nurse to give Ms. Cowling a dose of the antipsychotic drug Haldol. When a nurse called Dr. Browne later to report that Ms. Cowling was yelling again, he ordered more Haldol and put her on suicide watch. Ms. Cowling was booked on a Friday morning, and a jailer discovered her dead just after midnight on Wednesday.

Precisely what caused Ms. Cowling’s death remains unknown. A preliminary autopsy was inconclusive. Her family has retained a lawyer.

County officials contend that Ms. Cowling’s death was not their fault. She was not honest with them about all of her health problems, said Robert Davis, a lawyer for the county. “I absolutely do not believe that the jail or jail staff contributed to this inmate’s death whatsoever,” Mr. Davis said.

Expanded coverage of Texas is produced by The Texas Tribune, a nonprofit news organization. To join the conversation about this article, go to texastribune.org.

Sheriff Cerliano, however, concedes that not everything went according to the jail’s policies. After Ms. Cowling’s death, he conducted an investigation that he said showed that one jailer falsified observation logs that night. He fired five jailers and a sixth resigned. (Not all of the firings were related to Ms. Cowling’s death, he said, but were for conduct discovered during the investigation.) Two of the jailers were arrested for falsifying government documents.

Still, he said, the jail staff followed medical protocol in caring for Ms. Cowling. “We do everything we can to take care of inmates,” he said.

Since 2008, Gregg County inmates have filed more than 20 complaints with the Texas Commission on Jail Standards about conditions in the lockup. Most of the complaints were health-care-related; inmates said they could not get medicine and did not receive timely medical attention. An inmate who hanged himself in the jail in 2009 had complained that among many other grievances, he was not allowed medication he had been prescribed on the outside and had not been seen by a doctor.

In letters responding to nearly all the complaints, Adan Muñoz, the commission’s executive director, wrote, “The Texas Commission on Jail Standards does not question the professional opinion of medical personnel.”

Inmates have sued Sheriff Cerliano and Dr. Browne at least twice since 2005, alleging that their constitutional rights were violated by the jail’s deliberate indifference to their medical needs. In both cases, the courts found that Dr. Browne and the jail had attempted to provide adequate care.

Dr. Browne, who has his own family medical practice in Longview, is paid more than $100,000 per year to act as the jail doctor and director of the county health authority. He said that inmate health care was “the toughest medical situation to deal with.” Inmates are often uncooperative and dishonest about their health conditions, he said, and many are drug addicts. Adding to the challenge is that it is hard to retain medical staff, Dr. Browne said.

Medical staff members at the jail are not the only ones with a high turnover rate; records from the sheriff’s department show that in 2009 and 2010, more than 40 percent of the 167 jail employees either quit or were fired.

Sheriff Cerliano said the pay is low for jailers and that they have to go through months of training, pass drug screenings and work in challenging situations.

Lt. David Drosche, who works in the Brazos County Sheriff’s Office and is president of the Texas Jail Association, agreed that retaining jailers is difficult but said that a 40 percent turnover rate is “extremely high.” The higher turnover, he said, results in more inexperienced jailers.

County lockups in Texas are accountable to the Texas Commission on Jail Standards. Before Ms. Cowling’s death, the Gregg County Jail had passed every commission inspection for the last five years. Within weeks after she died, the commission, which reviews county jail deaths, decided the jail was in compliance with state standards.

But the commission does not require that jails meet specific health care criteria, only that they have medical plans on file. It also doesn’t keep track of jail staff turnover.

Diana Claitor, executive director of the Texas Jail Project, which advocates for improved jail conditions, said better health care standards and monitoring of data like staff turnover could help prevent more deaths like Ms. Cowling’s. From January 2005 to September 2009, more than 280 inmates died from illnesses in Texas county jails.

“One of the chief factors playing into mistreatment or neglect would be ill-trained, inexperienced staff,” she said. But with the state budget crunch, pressing the jail standards commission to provide additional oversight is a tough sell, Ms. Claitor said.

Sheriff Cerliano said his jailers already receive more training than is required by state standards and that the medical staff provides the best care possible. Ms. Cowling’s death was unfortunate, he said, but it does not mean that wholesale changes are needed in the way jails are regulated.

“We do have inmates that come in sick,” he said. “It’s incumbent upon us to try to do the best we can.”