Long wait times to see a psychiatrist

At the jail, inmates can wait weeks, sometimes months, to see a psychiatrist.

In one case, an individual had previously been on an antidepressant medication but hadn’t taken it in several months. To be prescribed medication, individuals must typically see a psychiatrist. According to the jail’s psychiatrist queue, obtained by a public records request, as of Oct. 1, the person had been waiting to see a psychiatrist for 95 days.

Another individual wanted to restart the antidepressants they’d taken at the jail before. Despite their request being labeled “priority,” they’d been in the psychiatrist queue for 48 days as of Oct. 1.

A third individual, who was described as suffering from bipolar disorder, schizophrenia and depression and had prior outpatient treatment at Mercy Behavioral Hospital, had been waiting to see a psychiatrist for 54 days.

Wait times can vary, and the queue has been shorter at times. Even in October, when records showed lengthy waits for some inmates, the average time an inmate had been waiting was 13 days.

For eight months of 2020, two full-time psychiatrist positions sat vacant, while the jail had just one psychiatrist seeing patients virtually. The jail hired a second psychiatrist in August; according to Williams, his contract expired in November, and he was replaced in early December.

On Oct. 1, there were about 200 inmates waiting to see a psychiatrist, according to the records, though the number of people waiting at any given time can vary. Chief Deputy Warden of Healthcare Laura Williams said individuals who do not have a prior mental health history can wait around six weeks. According to Williams, that mirrors the average wait time to see a psychiatrist in the community.

Williams said in a September interview with PublicSource that psychiatrist wait times depend on individual circumstances. “Anybody who is in an acute crisis, our correctional officers or our healthcare staff, regardless of job title, will make that recommendation and they’ll be seen immediately,” she said.

Hauber said the long wait times sounded concerning, especially if individuals were previously taking antidepressants consistently. He said not every request made by inmates is urgent: “We have people who come in all the time [asking for medications] when the only medicine they’ve taken is at the jail. If the medicine is that critical, why weren’t they on it when they left the jail?” Still, it’s important to evaluate individuals quickly to determine how acute their needs are, Hauber said.

According to the American Psychiatric Association’s 2016 report, “Psychiatric Services in Correctional Facilities," jails should have one full-time psychiatrist for every 75 to 100 patients on psychotropic medication.

“For a jail of that size, they should have [psychiatrists working] 92 hours a week,” Arizona-based psychologist and correctional mental health expert Joel Dvoskin said. ACJ currently has one full-time psychiatrist and two part-time psychiatrists, plus two additional psychiatrists who “provide periodic support,” according to Allegheny Health Network. “That’s actually pretty good,” Dvoskin said. “It’s not enough, but I think it’s common for jails to not have enough these days, so it’s certainly not horrible.”

Dvoskin said almost every jail and prison in the country is having difficulty finding psychiatrists and other medical staff like nurses, especially during the pandemic. “If they’re having trouble recruiting psychiatrists, they are not the Lone Ranger.”

Jail Oversight Board member Terri Klein said she was not aware of the wait times for psychiatrists.

The jail’s suicide rate has been a problem for over a decade, with eight deaths between 2015 and 2019 — the most of 67 county correctional facilities in Pennsylvania, though when controlling for population size, the jail’s suicide rate falls in the middle of the pack, with some jails having more suicides per capita and some less. ACJ is the largest county correctional facility in the state, based on the size of inmate population; the second largest, Philadelphia’s Curran-Fromhold Correctional Facility, had two suicides over the same time period.

In 2019, the jail hired the National Commission on Correctional Health Care to assess its suicide prevention practices and make recommendations.

David Sacks, a psychologist who quit his position as a mental health specialist at ACJ after three weeks, said the mental health sick call queue was also long. According to Sacks, he and his colleagues did not see individuals in the order in which they had been waiting, even though those individuals were “presumably still in distress,” he said.

By the time he was finally able to see some of those individuals, Sacks said they were no longer at ACJ. “They may have been in the Department of Corrections. They may have been in the community. We have no way of knowing,” he said. “But they were undertreated. That was a problem.”

Sitting in intake for days

Upon arrival at the jail, individuals are brought to the medical intake department for medical and mental health screenings. The process is meant to be quick and efficient; Pennsylvania state law requires “all inmates admitted to [county correctional institutions] receive a health care screening performed and recorded by a person with health care training within 24 hours of admission.”

Yet the ACJ is so short on staff that individuals are often made to sit in the department for a day or more, according to internal reports and first-person accounts. “They’d be in the same clothes, sitting in those chairs, for days,” said Jodi Lynch, a nurse practitioner who resigned in August.

According to the jail’s most recent annual inspection report on Dec. 5, 2019, “Inmate medical records were observed to ensure that the inmates are being seen by medical [professionals] within 24 hours of commitment for an initial health risk assessment,” the Pennsylvania Department of Corrections reported. The department found that the jail was “in full compliance” with statewide correctional standards.

When asked about the recent wait times over 24 hours, Pennsylvania Department of Corrections Press Secretary Maria A. Bivens wrote in an email that the department “does not have investigatory authority” over county jails — rather, that authority is held by the Allegheny County Jail Oversight Board — and that the jail’s next inspection is not yet scheduled.

Allegheny County Jail Board member Terri Klein declined to comment on the intake wait times.

Several former employees told PublicSource that individuals waiting in intake would sometimes not get their medications or would be experiencing untreated drug or alcohol detox symptoms for over a day, putting their health in danger.

“Somebody might’ve been on medication, and we wouldn’t know for three days,” said Dr. Gail Kubrin, a psychiatrist who left ACJ in 2019. “So they would get more psychotic, because the people that were supposed to make that connection weren’t doing it.”

“I've gone through almost my whole withdrawal from heroin abuse on the floor of intake,” said Justin Rape, who was formerly incarcerated at the jail. Rape has been at the jail multiple times, his most recent stay in 2018, and said he has waited in intake for at least two days every time, often longer. He called the experiences a “nightmare.”

“The lack of medical staff in processing is a common occurrence and nothing ever seems to be done to correct it,” one interal employee report reads. “This practice not only places the inmates well being [sic] in danger, but also that of the Officers.”

The report and another similar report, both from July 3, states there were no mental health staff members present to monitor a woman who had been put in a suicide gown (a garment used to prevent inmates from harming themselves). “We had an inmate on suicide watch [text redacted by county] no one from mental health did checks on her,” one of the reports says, though it notes corrections officers were present to check on the individual.

When asked about the reports, Arizona-based psychologist and correctional mental health expert Joel Dvoskin said there “has to be a dedicated staff person whose job it is to make sure those checks are conducted as required by policy, and that needs to be at least once every 15 minutes at random intervals.” It’s not clear from the reports whether checks every 15 minutes occurred.

A third report claims on July 16, multiple inmates were in the processing department for over 24 hours. “The reason for this is that for the last two days the processing department has been short staffed,” the report said.

When asked on Dec. 14 about reports that inmates had been waiting in intake for up to three days that weekend, Warden Orlando Harper said in an emailed statement: “When staffing is a challenge, decisions are made to shift resources to where they are most needed. ... That was the case on Friday and Saturday as medical staff were directed to other critical needs, but on Sunday morning, medical was at intake to clear those inmates and allow them to be assigned to a pod and transferred from intake.”

Employee schedules, obtained by PublicSource through two Right-to-Know requests, indicate the shortage of intake staff. Between Sept. 1 and Nov. 5, at least three shifts had only one medical employee scheduled to work in the intake department and at least seventeen shifts had only two medical employees scheduled, instead of the intended five or six.

Former staff members told PublicSource the shortage of staff in intake put inmates’ health at risk. “When you have a nurse that is trying to do medications, screening for health issues, when they’re forced to rush through because they’re so overwhelmed, things can get missed,” said a nurse, who resigned from her position after over a decade at the jail and requested anonymity for fear of retaliation by ACJ management.

An open letter penned by medical employees in May to several journalists, legal advocacy groups and public officials echoed the concern. “Medical intake, in the processing area of the jail, is shut down for 8 to even 16 hours a day because there are no nurses to work there,” it reads. “This happens frequently and, as a result, inmates are not receiving the proper treatment in intake or anywhere else in the jail because staff [are] simply not able to reasonably complete all the duties assigned.”

At the October Jail Oversight Board meeting, Chief Deputy Warden of Healthcare Laura Williams responded to public comments regarding the issue. “I’m not certain which other way to address it other than this happens. … We have made every effort to fill every vacancy within this area,” she said, adding that there are staff on site to address all immediate needs. “This is obviously not an ideal scenario, and it’s not the way that we choose to staff, but it is something that we frequently have to react to when we do not have staff that report for duty,” she said.

In a PublicSource interview, Klein from the jail board noted that the board is arranging exit interviews with “key” former staff members to gather information about why they left. “If we find information that we think is actionable, then I think that is something we could take to the jail administration,” Klein said. The board has conducted one interview to date, with ongoing discussions about future interviews.

Missed medications

At the jail, medications are supposed to be given each morning and evening. Yet according to numerous former employee accounts, medications were often given late or missed altogether, and medication errors were common.

Hauber, who left his position as a psychiatrist at the jail after his three-year contract expired last year, said he and his colleagues would find medication errors “constantly,” including medications being mistakenly swapped, incorrect doses and gaps in refills. Hauber said he saw patients who had withdrawal seizures or exacerbated psychiatric symptoms because they didn’t get their medications regularly. He attributed many of the errors to the jail’s pharmacy, which he said would “never, ever have been allowed to function” under other management. “It appeared to never have been held accountable, and when you brought those problems to administration there was never, capital N, never any attempt to try to correct it,” he said.

Current and former inmates told PublicSource they had experienced withdrawal-like symptoms from missing their medications. Thomas Stultz said when he first arrived at the jail in March 2019, he didn’t receive his prescribed Lexapro or Concerta for eight days. “By day 2, I was hallucinating and couldn’t sleep due to the feeling of electric shock up my spine and into my brain,” Stultz wrote in a letter to PublicSource. According to Harvard Medical School, antidepressant withdrawal symptoms can include “brain zaps,” or a feeling of electric shock to the brain.

“Technically [the symptoms are] not dangerous, but if you don’t know what it is, you can end up feeling suicidal because you’re worried, you’re scared, you’re in this other environment, you can’t do things on your own. So you’re really at the mercy of the system,” Hauber said. “And the system needs to be doing a better job of taking care of these things.”

Former employees said medications were given at inconsistent times or accidentally skipped.

“I know from experience on my pod specifically, morning meds that were ideally supposed to be given at 8 were given at 10, which is not a huge deal. But they’re not given until 2 or 3 p.m., or they’re not given at all because now it’s the next shift and I’m going to give them night meds. Absolutely that happens,” said Stephanie Richards, a psychiatric aide who resigned in October 2019.

In a March 2019 email to jail management, Chuck Timbers, a nurse practitioner who said he was terminated for breaking social media policy, raised the issue of medication errors to management. “There have been occasions where medications have been ordered and unfortunately the patient that the medication is ordered for is not receiving the medication,” Timbers wrote.

Many former staff members attributed missed medications to not having enough staff. “There would be nights that I would give medications to 800 inmates,” said Kasi Kovach, a nurse who said she was terminated in January for intending to give medication to an inmate without a guard present, an accusation she denies. “There were times where inmates wouldn’t get their medications at all.”