by Art Levine
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MENTAL HEALTH HAS BEEN IN AND OUT OF HEADLINES FOR YEARS, SUPPLEMENTED by periodic lip service about reform after a tragic mass killing. Yet we should still care about fixing a system that has gone so awry, even if you or a loved one aren’t struggling with a mental illness. Why? Because so many people have been damaged by a mental health system that doesn’t work and is too often run like a racket. By some measures, about 20 percent of Americans have some sort of mental health condition, and sixteen million adults and children face disabling mental illnesses and emotional disturbances. The impact is devastating.
Mental illness is the largest single cause of disability, across all categories of injury, brain disorders and illness. The most serious mental illnesses (including schizophrenia, bipolar disorder and long-term major depression) play a major role in driving more than 40,000 Americans to kill themselves each year—more than the total number of car crash fatalities and well over twice the number of homicides. Overall, the nation’s suicide rate across virtually all age groups has soared to its highest level in thirty years, especially among middle-aged men and teenage girls. At its very worst, the system is so bad that roughly two million people with serious mental illness go to jail each year, cycling in and out of local jail systems that hold nearly 11 million people annually. As Miami-Dade County Judge Steven Leifman, who has pioneered model community-based alternatives to jail, points out, “Because no comprehensive and competent community mental health treatment system was ever developed, jails and prisons once again function as de facto mental health institutions for people with severe and disabling mental illnesses”—the “New Asylums.”
The largest psychiatric facility in the country is actually the Los Angeles County Jail. Over 20 percent of its 17,000 inmates each year suffer from serious mental illnesses—worsened by guard beatings, neglect and cover-ups that have led to the convictions of over 20 current and former Los Angeles County Sheriff’s Department (LASD) officials on violence-related charges. This book provides an especially close look inside the LA County women’s jail, where some LASD deputies gave an account of the death of an inmate, Unique Moore, apparently due to medical neglect, in October 2014 that doesn’t square with the eyewitness accounts of her jailmates. As many as fifty deputies and the department now face a wrongful death lawsuit.
Yet adding hospital beds—often proposed as the best alternative to jails or suicide—is no true solution for a system already so callous that some counties engage in “Greyhound therapy.” In 2013 the Sacramento Bee found that not only are people just dumped on the street in California after being released from the hospital, but in Las Vegas, they were given one-way tickets to places they didn’t know and then told to call 911 when they got there. Some never survived: In January 2015, for instance, a thirty-three-year-old man checked into the Texoma Medical Center in Sherman, Texas, complaining of his suicidal intention to jump off a bridge to the staff at the hospital, which is owned by Universal Health Services (UHS), the nation’s largest chain of inpatient behavioral health facilities with $9 billion in annual revenue. Ten days later, according to a federal safety report obtained by The Dallas Morning News, he was kicked out and shown to a bus stop. The next day, he was found dead after jumping off of a Dallas bridge.
Amid today’s laissez-faire regulatory climate and broken community care system, the tragic cycle of failed hospitalizations, homelessness and jail can cost taxpayers as much as $1 million per patient over time until, all too often, they die far too young.
Unfortunately, as this book shows, with most national mental health advocacy organizations and professional groups compromised by drug money, it will be up to grassroots members of those groups, taxpayers and political leaders concerned about waste, preventable deaths and the need for cost-effective care to drive meaningful reforms. By introducing you to those whose lives were endangered by harmful care and to the people working to make a change, it is my hope that Mental Health, Inc. will help bring some sanity to our understanding of a mental health system run amok.
CHAPTER 1
Drugging Our Kids: Corporate Greed Joins Government Corruption, Apathy
IT WAS OBVIOUS ENOUGH TO DR. STEFAN KRUSZEWSKI THAT THE DEATH of this behaviorally troubled seventeen-year-old boy placed in a Texas facility could have been prevented. The scholarly, fifty-two-year-old Harvard-trained psychiatrist had only recently started working as a full-time consultant to the Pennsylvania Department of Public Welfare, investigating the quality of care, abuse and fraud. The boy, writhing from a deadly seizure after being regularly plied with two antipsychotics, died in December 2002, a few months after Kruszewski assumed his post. It was only the first of several preventable, medication-related deaths—and neglect and abuse—that he flagged for his superiors before they fired him about a year later for protesting and documenting the maltreatment of children under the state’s supervision.
“It was clear that they didn’t want real investigations,” he says. In most cases that he reviewed, his bosses didn’t even bother to respond to his findings. This teenager had a history of severe seizures, Kruszewski discovered while reviewing the medical records. But the facility ignored the youth’s condition by taking him off his anti-seizure medication and instead placing him on two antipsychotics: the new, heavily marketed Zyprexa and the older Thorazine. The boy was just one of thousands of kids—usually court-ordered and unable to live with their parents or family members—shipped out of state to often cheaper, poorly regulated facilities.
Children’s deaths and injuries from antipsychotics at the time drew little local notice and certainly no national attention. But years before the overdrugging death of Rebecca Riley in Massachusetts became headline news, Kruszewski was exposing a dangerous pattern of prescribing that continues today generally unimpeded. The New York Times reported in December 2015 the troubling account of an eighteen-month-old California boy, Andrew Rios, who had violent seizures that couldn’t be controlled by an epilepsy drug. Rios was then prescribed the powerful and illegally marketed Risperdal for an “off-label” use that led him to scream in his sleep and interact with people that he saw when hallucinating.
Pharmaceutical companies have worked hard to make this wider use of antipsychotics possible. They’ve employed intensive lobbying of the FDA, joined by legal—and sometimes illegal—payoffs to academics, FDA advisory committee members and state officials, supplemented by countless deceptive or patently false studies. As a result, the drug industry has succeeded in driving the FDA-approved age for dispensing most antipsychotics down to as young as five years old for certain dubious diagnoses. These questionable or sweepingly applied kiddie diagnoses, such as bipolar disorder in grade-schoolers, also include the purported “irritability” of autistic children.
The use of all antipsychotics has at least doubled among children and youth since 2001, with at least seven million prescriptions—whether through Medicaid or private insurance—written each year, based on an analysis of just 60 percent of retail pharmacies. Remarkably, most of these kids don’t have a diagnosed mental disorder at all. Contrary to previous optimistic reports of a drop in prescribing for those under the age of twelve, the Times showed that by 2014 prescriptions for Risperdal, Seroquel and other antipsychotics rose 50 percent for children two and under to nearly 20,000—even after all the major manufacturers had already paid billions to settle federal lawsuits alleging their fraudulent promotion of these dangerous drugs. In 2015, long after Kruszewski uncovered that Medicaid-subsidized Pennsylvania children were killed by overmedication, the Office of Inspector General for the US Department of Health and Human Services (HHS) reported that more than 90 percent of the estimated two million kids on Medicaid who received antipsychotics are prescribed them without the approval of the FDA—or “off-label”—and hence for fraudulent uses. Even so, federal and state Medicaid agencies today reimburse all the $1.8 billion in government spending for these drugs for all ages without question. For those who remain on Medicaid
in the Trump era, overuse of these mostly generic medications could well increase because they offer an illusory quick-fix replacement for time-consuming therapy and social work support requiring adequate staffing levels.
Antipsychotics aren’t the most widely prescribed psychiatric medications for children, but they are among the most dangerous. For the nearly forty-one million psychoactive prescriptions of all kinds given to US kids, close to 60 percent are for stimulants prescribed for ADHD, whose side effects can include anxiety and psychosis. Now nearly one in five high school boys purportedly has ADHD, due largely to what medical experts see as “overdiagnosis” due to faulty evaluations and social pressure to use stimulant drugs to improve school performance and control behavior. Two-thirds of those ADHD-diagnosed youths take stimulants, but the use of antipsychotics for this loosely diagnosed illness is soaring. According to Reuters, the most common diagnosis for children eighteen and under who received antipsychotics was for the unapproved use for ADHD. Indeed, a Columbia University research psychiatrist found that 90 percent of all prescriptions for antipsychotics for kids were for off-label uses, even for the privately insured.
In some ways, the roots of this pediatric drugging crisis can be found in the corrupting influence of drug company subsidies, marketing and the lack of response by state agencies to the early, potentially fatal abuses uncovered by Kruszewski and other whistleblowers. Both the state-contracted facilities and the drug companies were “exaggerating and mischaracterizing the benefits, effects and use of psychotropic drugs that lacked beneficial or positive effect,” according to Kruszewski’s 2004 wrongful dismissal and free speech lawsuit.
In addition, Kruszewski found at least four children and one adult died due to overmedication, with as many as five antipsychotic medications given at one time to people at facilities in such states as Texas and Oklahoma. His mounting concerns, prompted by the death of a thirteen-year-old child in an Oklahoma center, led him to write a scathing report in July 2003. The child had been given the seizure medication Neurontin, multiple antipsychotics and mood stabilizers without having any medical or psychiatric condition justifying their use. The child then died, apparently due to seizures induced by the medications.
Kruszewski’s report should have been a wake-up call, not only for the state of Pennsylvania but the entire country. His preliminary assessment of the facility was truly horrifying: the children were severely overmedicated with psychotropic drugs, were housed in deplorable conditions and some were being sexually abused by the staff. Kruszewski’s report warned his supervisors that children and vulnerable adults should be removed from this and other dangerous out-of-state facilities while the damaging and needless off-label prescribing of psychotropics should be halted. When he asked his agency to spend a hundred dollars on a coroner’s report on each of the four deaths of children he uncovered, he was told: “That’s not possible.” He argued, as his report said, for the removal of those endangered clients “in order to protect other innocent individuals from morbid and mortal consequences of severe overmedication, including chemical restraints; [and] emotional, physical and sexual abuse.”
On July 11, 2003, one day after his supervisor chewed him out for “trying to dig up dirt,” Kruszewski was fired. The agency “didn’t want to hear anything bad about what was going on,” he says now. “They were just looking for a warm body to put in the position.” He eventually settled a lawsuit in 2007 against the Department of Public Welfare (DPW) for $374,000, although agency officials didn’t acknowledge liability.
In 2005, Kruszewski filed the first of his three lawsuits brought under the False Claims Act, or qui tam filings, against health-care companies; these legal actions attempted to halt the improper prescribing and other abuses akin to those that led to the deaths of children he had investigated.
Kruszewski had firsthand knowledge of the drug companies’ sales schemes. As an influential psychiatrist in a Harrisburg suburb who worked primarily with adolescents and the elderly, and as a professor at Penn State Medical College, he had faced, between 2001 and 2007, a hard sell of Pfizer’s new antipsychotic product, Geodon. Pfizer’s sales reps wanted him to prescribe the drug off-label to kids and the elderly for a host of unapproved uses, including depression and anxiety. He began discovering the dangers this drug posed as early as 2001, and at about the same time, he rebuffed efforts by AstraZeneca to recruit him to push its antipsychotic Seroquel to his colleagues with spurious safety and efficacy claims. That, in turn, led him to secretly file his own fraud lawsuits against Pfizer and AstraZeneca, starting in 2005. (Whistleblowers’ lawsuits traditionally haven’t been made public until government attorneys agree to join the lawsuit and then reach a settlement.)
Kruszewski filed his lawsuits against Pfizer and AstraZeneca to prod the pharmaceutical firms to alter the way they mask their drugs’ real benefits and dangers—consequences that he saw personally with all those dead and damaged youngsters under state care. His lawsuits were ultimately incorporated with other whistleblower claims as part of huge federal settlements totaling nearly $3 billion against the two companies in 2009 and 2010. (Under the False Claims Act originally passed by Congress in 1863, all the whistleblowers involved in a case are jointly awarded a fraction of the funds successfully recouped by the government as a way to encourage reports of fraud.)
While Kruszewski was discovering the ways drug company influence and indifferent agency oversight were causing needless deaths, Allen Jones, a rugged, determined investigator with Pennsylvania’s Office of the Inspector General, was asked by his bosses in July 2002 to look into suspicious payments by Johnson & Johnson to a secret bank account set up by Medicaid’s chief pharmacist, Steve Fiorello. By following the money trail, Jones unraveled a massive drug industry scheme to bilk state Medicaid programs across the country—under the guise of promoting cutting-edge science—with prescribing guidelines that were rigged to favor the new brand-name, risky “atypical” antipsychotics. Along the way, he uncovered a campaign, known as the Texas Medication Algorithm Project (TMAP), to bribe state officials with payments, perks and travel to spread the use of the new atypical medications for a variety of unproven and off-label uses, including for children. (An algorithm is a decision-making tree that outlines which drugs are recommended for “first-line” use with certain symptoms and mental illnesses.) His bosses covered up his findings, and then Jones was fired in 2004 for “misconduct” after leaking his evidence to The New York Times, eventually settling a wrongful dismissal lawsuit against the state that left him with only $1,200 after he paid all his debts.
Unable to find any professional jobs, he lost his home and worked part of the time as a bricklayer while living in his off-the-electrical-grid cabin without running water he’d built in rural central Pennsylvania years earlier. Nearly broke, he waged a lonely battle to alert officials in Pennsylvania, other states and the federal government about the menace this corrupt program posed. “I went through some tough times,” he recalls about his early years after getting fired, “but if I had caved in to them in the face of what I knew about the harm that would come from this scheme, it would have diminished me so much.”
TMAP was a “microcosm of how the drug companies operate: the clinical trial manipulation, the ghostwriting, the biased reporting,” Jones says now.
These strategies turned these antipsychotics, which were originally approved for only 1 percent of the population (people with schizophrenia), into blockbuster drugs that still generate billions of dollars in revenue by treating a far wider array of patients, mostly off-label. With roughly sixty million prescriptions written each year for antipsychotics, according to the research company IMS Health, as many as 75 percent of adults and over 90 percent of young people take the medications for uses that aren’t approved by the FDA. TMAP was the tip of the spear of the industry’s successful marketing war. Yet as a result of Jones’s decade-long crusade, Fiorello was sentenced to prison on felony conflict-of-interest charges for taking drug company pa
yments—and the key government official spreading the sham prescribing guidelines, Texas mental health department medical director Dr. Steven Shon, was forced to resign in 2006 after it was revealed that he and his department’s researchers received lavish trips and more than $2 million from Janssen (the pharmaceutical division of Johnson & Johnson), and other drug companies. Finally, in 2012, years after Jones filed his whistleblower lawsuit, the Texas attorney general joined him and won a $158 million settlement, which J&J offered days into a trial, partly to halt further damaging testimony. Although TMAP has been publicly discredited, its legacy lives on in faked research that has never been retracted and continues to influence the daily practice of physicians.
All these initiatives were supplemented by a growing body of studies by researchers-for-hire that concluded that antipsychotics should be used with a newly-discovered, dubious illness in little kids: bipolar disorder. This array of drug industry-funded scientific propaganda helped set in motion a chain of events that by 2006 culminated in the tragic death of Rebecca Riley, a four-year-old foster child in Hull, Massachusetts, from a toxic amount of prescription drugs, including Seroquel.
In the summer of 2004, Carolyn Riley took her then two-year-old daughter, Rebecca, to Dr. Kayoko Kifuji, a Tufts University doctor, for help with what the mother claimed was her “hyper” behavior and poor sleep. Prodded by the mother’s claims about her girl’s moody behavior, the doctor kept adding more drugs and higher dosages of such off-label sedating drugs as the blood-pressure drug clonidine, Zyprexa and Seroquel. Despite warnings from the school nurse that the four-year-old girl was like a “floppy doll” and could barely walk weeks before the girl’s death, Kifuji prescribed her 835 pills during her last visit. In the early morning hours of December 13, 2006, Rebecca died while sleeping in a drugged stupor next to her parents’ bed.