We're a little crazy, about science!

When Crazy becomes a Crime


My friend has a glass eye, you would never notice and unless you knew the story you might not think anything of it. His older brother did it. Yes, you read that correctly, in a schizophrenic rage he gouged out his eye and almost killed him. He never held what happened against his older brother, he was sick, how could he? At least that was his logic. The courts didn’t agree, he would not be allowed to visit his brother while he resided in prison, even ten years [and several appeals] after the fact. Unfortunately he isn’t alone, new research has linked tighter Medicaid policies governing antipsychotic drugs with increased incarceration rates for schizophrenic individuals.

This new research comes amid ongoing and in my opinion well overdue media scrutiny over whether cutbacks in mental health actually save money, when other costs [such as jail time] are taken into account.

Some health plans require an extra approval step before tests or treatments can be ordered for patients. This step — known as prior authorization — is intended to “encourage” physicians to select cost-effective options by requiring justification for the selection of more expensive options. It’s a process similar to giving you just enough pain killer to make it livable, not not actually take the pain away.

So it makes sense that prior authorization policies which were by state Medicaid programs aim to reduce costs associated with some medications, especially those drugs used to treat schizophrenia. However, an unintended consequence of these policies may be that more mentally-ill patients are being incarcerated, raising questions about the “cost-effectiveness” of these formulary restrictions.

In the study, researchers found that states requiring prior authorization for atypical antipsychotics had less serious mental illness overall, but higher shares of inmates with psychotic symptoms than the national average. The study concluded that prior authorization of atypical antipsychotics was associated with a, get this, 22 percent increase in the likelihood of imprisonment [compared with the likelihood in a state without such a requirement].

“This paper demonstrates that our policies around schizophrenia may be penny-wise and pound foolish,” says Dana Goldman, director of the Leonard D. Schaeffer Center for Health Policy & Economics at the University of Southern California.

“Limiting access to effective therapy may save States some Medicaid money in the short run, but the downstream consequences — including more people in prisons and more criminal activity — could be a bad deal for society.”

The researchers examined survey data from 16,844 prison inmates in states with and without restrictive authorization requirements which was overlaid with state Medicaid policies and data. As well as usage rates of atypical antipsychotics [a newer drug class that is frequently targeted by prior authorization requirements].

The study’s findings come amid a wave of scrutiny surrounding the cost and consequences of failing to adequately provide for mental health care, including the nexus between shortchanging mental health and rising prison expenditures.

“The media has picked up on how incarcerating the mentally ill raises a range of troubling concerns, from the high cost of incarceration, to the inadequate treatment of mentally ill inmates, and the potential for self-inflicted harm among these patients,” says Darius Lakdawalla, Quintiles Chair in Pharmaceutical Development.

“At the same time, the American public is increasingly worried about untreated mental illness triggering violent behavior in the community. Our study suggests state Medicaid policies may be part of the solution to these problems.”

As for my friends older brother, well he is going to be behind bars for awhile, now on proper medication you would never know anything was even wrong with him. So while the cost to taxpayers might be higher when we send our mentally ill to prison, the cost to families that have to deal with the policies is much, much higher.

I get it, out of sight, out of mind. But is that any way to treat your fellow man?

Want to know more? You can read the full story —here!

Dana Goldman,, John Fastenau,, Riad Dirani,, Eric Hellend,, Geoff Joyce,, Ryan Conrad,, & Darius Lakdawalla (2014). Medicaid Prior Authorization Policies and Imprisonment Among Patients With Schizophrenia The American Journal of Managed Care, 20 (7) : 2014;20(7):577-586

7 responses

  1. Irit

    This story is a sad reminder of the need for mental healthcare reform in our country. I think that medication and therapy have to be used as the first line of treatment. It’s sad that insurance companies have the power to change the way patients are being treated. I can’t help but think that if people were diagnosed and treated properly early on (as seen fit by their doctors, not an insurance company) then a lot of violent/criminal acts could be prevented.


    July 26, 2014 at 8:51 pm

    • Totally agree, it’s sad that we hold people responsible for actions they have no control over because they can’t get the medications they need. Thanks for taking the time to say something!


      July 27, 2014 at 10:26 am

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