Yves here. The original title of this article at Kaiser Health News was Use Of Psychiatric Drugs Soars In California Jails. One reason to bring the story to reader attention is that I am skeptical of the premise that the drugs are always being administered as a result of prisoner needs. For instace, while many people take anti-depressants, it’s hard to see a jail going to the trouble of making sure an inmate in jail, who is typically there for a short stay, gets his supply of Prozac. But a schizophrenic is an entirely different proposition.
In other words, I wondered if any readers were in a position to sanity check the thesis of the article, that the rise in the level of drug administration is the result of more mentally ill people being on the street, and therefore winding up in jail, plus better diagnosis. The article does mention that drugs can also be used to manage unruly inmates but downplays that as a contributing factor. The reason for my reservation is that now that what used to be “boys will be boys” behavior is now treated as grounds for pulling out the prescription pad, it isn’t hard to imagine that a lot of this “better screening” is similarly about making life easier for the people in charge.
The number of jail inmates in California taking psychotropic drugs has jumped about 25 percent in five years, and they now account for about a fifth of the county jail population across the state, according to a new analysisof state data.
The increase could reflect the growing number of inmates with mental illness, though it also might stem from better identification of people in need of treatment, say researchers from California Health Policy Strategies(CHPS), a Sacramento-based consulting firm.
Amid a severe shortage of psychiatric bedsand community-based treatment throughout the state and nation, jails have become repositories for people in the throes of acute mental health crises.
The number of people with mental illness in jails and prisons around the nation is “astronomical,” said Michael Romano, director of Three Strikes & Justice Advocacy Project at Stanford Law School, who was not involved in the research. “In many ways, the whole justice system is overwhelmed with mental illness.”
Contributing to the problem in California is that county jails received a large influx of inmates from state prisons to jails as a result of a federal court order to ease prison crowding. In 2011, the U.S. Supreme Court ordered California to reducethe prison population because of overcrowding linked to poor medical and mental health care that it said constituted cruel and unusual punishment.
Three years later, a state propositionreclassified some felony crimes as misdemeanors, meaning offenders went to county jails instead of state prisons.
The new analysis, based on survey data from 45 of California’s 58 counties, opens a window into how the state is coping with the influx. “We think this is the first part of a more systematic discussion about what is going on in the jails and in the broader community with respect to mental health,” said David Panush, a co-author of the report by CHPS, funded in part by the California Health Care Foundation. (California Healthline is an editorially independent publication of the California Health Care Foundation.)
Across California and the U.S., far more people with mental illness are housed in jails and prisons than in psychiatric hospitals. That poses well-documented challenges: Insufficient staff training and patient treatment have contributed to inmate suicides, self-mutilation, violence and other problems.
One complaint among advocates for the mentally ill has been poor access to psychiatric prescriptions to treat such conditions as schizophrenia and bipolar disorder. The medicationsinclude antipsychotics, antidepressants, anti-anxiety drugs and others.
Jail officials in California say they are trying to better identify inmates who can benefit from such drugs. The numbers suggest that may be working. According to the analysis, an average of 13,776 inmates in the 45 California counties were on psychotropic medications in 2016-2017, up from 10,999 five years ago. But the portion of inmates on psychotropic medications varies widely by county, from 8 percent in Glenn to 32 percent in Sonoma and Napa, according to the analysis. The report is based on data from the Board of State and Community Corrections, an independent state agency.
In Los Angeles County, whose jails have been described as the largest mental institution in the country, about 30 percent of the 18,000 inmates are mentally ill and most of those diagnosed are on medication, said Joseph Ortego, chief psychiatrist for correctional health services in L.A. County. Although some still are missed in the screening process, he said, the county jails have improved identification and treatment of inmates and expanded staffing as part of a 2015 settlement with the U.S. Justice Department. The department had alleged inadequate mental health care and suicide prevention in the jails.
Overall in jails, some experts say, medications are likely underprescribed. “You need enough mental health professionals to treat the very large numbers of mentally ill people in jails,” said H. Richard Lamb, professor emeritus of psychiatry at the USC School of Medicine. These medications are among the most critical parts of psychiatric treatment, he added: “There probably aren’t enough.”
Some advocates for the mentally ill worry, however, that the drugs are at times prescribed inappropriately. Ron Honberg, senior policy adviser at the National Alliance on Mental Illness, said that because jails have limited resources for treatment, officials may in some instances administer psychiatric medications “to keep people calm and sedate.”
Zima Creason, president and chief executive officer of Mental Health America of California, said medications, while sometimes necessary, are no substitute for comprehensive care for jail inmates.
“Sadly, they just throw a bunch of pills at them because there is nothing else,” she said. Jails still need to provide individual and group therapy, more time outside of cells and sufficient recreation time, she said. “Jail is not conducive for real recovery,” she said. “We are never going to put a dent in the numbers unless we provide a therapeutic environment.”
Like people on the outside, inmates can be subject to involuntary drug treatment but only if a court deems it appropriate, officials said.
Medications are important but are not “the answer to everything,” L.A. County’s Ortego said. “We still need to be ethical and appropriate and do what’s right for the patient and not just medicate them.” He said the county also offers individualized hospital and outpatient care, as well as treatment groups and education. But he said the jails do not have enough exercise yards or spaces for therapy.
Other county jail officials, including Alfred Joshua, chief medical officer for the Sheriff’s Department in San Diego County, said the influx of mentally ill inmates and the rising need for psychotropic drugs stems from a lack of resources for patients in the community. “When they have exacerbations of mental illness, they do many times come into contact with law enforcement,” he said.
Rebecca Cervenak, staff attorney for Disability Rights California, which has repeatedly investigatedjail conditions, said more investment is needed in programs to divert offenders to treatment rather than jail.
Some of the most common charges that bring people with mental illness to jail are drug offenses and parole violations. Those who are homeless frequently get charged with panhandling, public urination and related crimes. Inmates with mental illness also typically stay incarcerated longer than others, in part because of difficulty following rules and coping with the crowded or chaotic environment.
Edward Vega, 47, was taking medications for his bipolar disorder and schizophrenia but had just run out when he was arrested in August 2017 on suspicion of drug possession. He was convicted and spent five months in the San Diego County jail. When he arrived, he couldn’t quiet voices in his head and felt himself losing control, he said. “I knew if I didn’t get my medication, I was going to hurt someone,” Vega said.
A week after being arrested, he said, Vega assaulted a fellow inmate and ended up in isolation, which only made him feel worse. Finally, Vega said, a doctor prescribed medications that helped. Now, three months after his release, he is feeling almost back to normal. “The medication hasn’t totally taken away the voices, but I am able to differentiate reality from fiction,” Vega said.
In addition to trying to improve treatment inside the jails, Los Angeles and San Diego county officials say they are working more closely with community organizations to ensure inmates with mental illness get the services they need after their release.
Vega said a local community group, the Neighborhood House Association, was able to help in his case, ensuring he got meds and other treatment. “Without the medication, I would probably be right back in jail,” he said.
KHN’s coverage in California is supported in part by Blue Shield of California Foundation.
One of the largest psychiatric facilities in the USA is the Cook County Jail.
Interview with the director, a clinical psychologist:
We have had extended interactions with a mentally “off” man who we tried to help, beginning ten years ago. This man slips in and out of prison regularly. Being a sociopath, he has learned to “game” the system. (We wised up and stopped playing along several years ago.)
A wake up call for me was when I helped him get into a local psychiatric facility slash rehab centre to “dry out.” He was suffering from severe dehydration attendant to alcoholism and other drugs use. Two days later, he calls and has me come pick him up. As we are leaving the facility, he pulls off the wrist identification band and throws it out of the car window. “Thanks for the vacation, a——s,” he says. That was the beginning of the end of my efforts on his behalf.
The closing of many of the State run mental institutions was the turning point for this country. It’s one of the reasons that, were I sincerely religious, I would pray everyday that Ronnie Reagan is in H—. Now the burden for dealing with the mentally ill, who, let us be reasonable here, are not strictly responsible for their status, has been devolved onto the general population. With the decay of the extended family in the West, the former networks that handled such ‘problem’ people disappeared, in the main. With the abrogation of the responsibility by the State, these people not only “fall through the cracks,” they really get ground down into the cracks.
If there were an expression of the Neoliberal Rule #2, (go die,) this is it.
Unfortunately, to appropriate Reify99’s comment above, the largest psychiatric facility in America today is ‘The Street.’ Nothing good will come of this.
Don’t get me going, because I can definitely identify. In my N. Idaho county I’ve dealt with at least 5 different cases of people suffering from severe mental health issues who were criminalized. If you have mental health issues around here, you get to sit in jail, b/c the police officers are told not to take mentally ill people to be held at the hospital (as they are statutorily empowered) for evaluation because the county’s indigent fund is virtually non-existent.
I’m starting to make waves by continually hammering on Victim Services door about it, because that’s what these people they’re arresting and throwing in jail are …. victims of a malfeasant system.
Which N. Idaho county is that? I’m from Court d’alene! Thought I was surely the only one from the area who reads NC.
Boundary. If you’re ever up North swing by the Wilson Law Firm and ask for the Democratic Socialist. They’ll know who you’re talking about :)
I’d love to have a little mini-meet-up. Great little coffee shop right next door.
“With the decay of the extended family in the West, the former networks that handled such ‘problem’ people disappeared, in the main.”
This is a great insight. One of the most robust findings in the schizophrenia research literature is the positive effect family support has on alleviating and managing the symptoms of mental illness, especially the more major ones like schizophrenia. Though a little dated at this point, this meta analysis provides a good overview.
The closing of state mental institutions without any plans to provide any assistance to these individuals betrays the Social Darwinism at the root of the neoliberalism espoused by Reagan and his ilk. The cover story was that those state run institutions were horrid and, yes, they were. To this day you can still find individuals who were in these institutions where they were treated as animals (caging, chaining, beating). The phrase “a fate worse than death” comes to mind. But this does not excuse the criminal negligence (being kind with that wording) on the part of politicians and administers in failing to provide any sort of assistance to these individuals when they were released from these hellholes. The streets are hell too, and throwing these individuals into that world only served as a way of euthanizing these individuals in the cruelest manner possible. “Go Die” indeed.
On a slightly related note. I had an out of town plumbing job in Tuscaloosa Alabama. The University was building a new chemistry building. An interesting project to be on. Chemistry classrooms have a lot of non standard plumbing and piping in them.
Anyway, on the edge of the worksite, next to a small grove of trees was the relic of an older Psychiatric Institution. It was an originally beautiful case of Greek Revival architecture. It had actual, honest to goodness georgia marble columns in front. Twenty-five foot high and about four foot in diameter. I think there were six of them, in what must have been the formal entranceway. This building was slated for demolition. Some diehard preservationists were raising the money to save the front of the edifice at the least. In one of the back wings of this two story building was a line of jail cells. Eight by eight cubes with a bunk, shackles on the wall and bars for a wall to the corridor. Think something like Sheriff Taylors’ accommodations on “The Andy Griffith Show.” That was the state of the art back in the late nineteenth century.
Sadly, the contractors did an end run around the preservationists and the University and tore the building down, including the marble columns, over a weekend, when no one would suspect them of doing so.
I can still remember the head of the preservation society standing there on the Monday afternoon viewing the wreckage with tears streaming down his face.
Reagan’s solution to institutionalization was to build community mental health centers. From what I recall they were supposed to build 2,000. They actually built 700.
Back in 2006, the DOJ estimated that 44% of inmates in local jails and 61% of inmates in state prisons have mental “problems”.
The increase in treatment in California may be more due to the ACA as much as anything else,
AB 720 was signed in 2013.
Furthermore, in LA County, the county Department of Health Services to over medical care in the jails from the LA County Sheriffs Department in 2015.
So the increase in prescriptions may continue.
This seems to be a follow the money story that hasn’t followed the money.
Behind all this I see a big pharma salesman making a pitch to once again inject corporate influence into the public sphere to increase profit margins.
Basically, someone in a board room had a Eureka moment that there were a bunch of doctors (or NP’s) in the public penal sphere who weren’t being wined and dined like all the doctors in traditional private practice.
An important distinction I would like to make is that psychiatric drugs are invariably not treatment as in an attempt to cure, they are maintenance. Neuroleptics, for example, do not treat psychosis, they are essentially chemical lobotomies that suppress the symptoms along with many other higher brain functions. The same is true of SSRIs. These drugs also develop strong dependence, producing severe withdrawal that can result in extreme behavior.
For vulnerable people in jail this is especially bad as it means they may be on these drugs long enough to become dependent, then be tossed back on the street with no access to medication and no help coming down – not to mention no actual treatment of their underlying problems.
“An important distinction I would like to make is that psychiatric drugs are invariably not treatment as in an attempt to cure, they are maintenance. Neuroleptics, for example, do not treat psychosis, they are essentially chemical lobotomies that suppress the symptoms along with many other higher brain functions.”
You are right to say that these drugs are used to for maintenance, and I am positive that the increase in the use of these drugs in prison stem from the need to maintain many of the mentally ill now entering prison en masse. However, keep in mind that most treatment of severe psychiatric illnesses cannot occur if psychiatric symptoms are not suppressed and maintained. Auditory Hallucinations are a good example. If you are being told by a voice almost constantly that you are such a POS that you need to kill yourself, treatment just cannot occur. Catatonia, thought blocking, extensive delusions, and many other (often co-occurring) symptoms also prevent any meaningful treatment from being effective.
Again, just to reiterate, you are correct in characterizing drugs are primarily for maintenance rather than curing. Using them as the sole form of treatment is unethical. However, truly effective treatment of severe psychiatric symptoms will typically need to make use of neuroleptics during some stage of a comprehensive treatment strategy.
I have also known a physician who was chief of staff at a hospital where I worked, another who was the go to thoracic surgeon for the area. Nurses said, “If I code he’s the one I want to be walking by,” regarding the former and they would not recommend any other thoracic surgeon to friends and family regarding the latter. It was only later that I learned both were bipolar. One is unlikely to know about these successful “mentally ill” people because of confidentiality. Had the nurses on the medical floors known this about them I think it would have been a different story.
I was truly taken aback by Mr Vega’s assertion at the end of the article that his medication permits him to differentiate reality from fiction. Does such medication really exist? If so, could it be administered post haste to our president and certain members of congress?
I am an internist/hospitalist (not specifically a mental health professional) but I prescribe a lot of psychiatric medications and occasionally deal with inmates who come to the hospital.
FWIW, my general impression is that this is a sane article. Roughly 8-10% of the U.S. population has depression, around 1% has schizophrenia, and add in the other mental health diagnoses probably takes us to 10-20% as a ballpark prevalence in the U.S. The higher end of people medicated quoted in the article was 32%. You could probably account for much of this difference based on some correlation/causation between mental health diagnosis and being in jail. There may be some overtreatment for behavior control, but I am skeptical that it is a big issue given that (I believe) most use of the medication is voluntary and it is easy enough for prisoners to cheek pills. It is difficult to get approval to give hospitalized patients psychiatric medications against their will and even harder to get them to comply with taking it – although if there were some huge use of depot injections I would be a little more suspicious. I doubt that Big Pharma has a huge role in this as has been suggested by other commenters. My limited experience trying to discharge patients to correctional facilities gives me the impression that they have a limited, generic formulary. There’s also the possibility of malingering, and I have definitely seen people hospitalized for both medical and psychiatric reasons just before important court hearings, though I don’t think this would account for a significant percentage of people on these medications.
I’d love to see the contracts the counties are entering to obtain their pills. Has there been a spate of “new” contacts preceding the rise? Whose signing them?
Enquiring minds want to know …
There are so many problems with our mental health and criminal “justice” systems as there are so many many contradictory assertions made about those systems. Just walking the streets of our cities the amount of madness and insanity is hard to miss just as it would be hard to measure that madness and assign statistics to it. I can readily believe a substantial portion of the people tossed away in our prisons and jails have various forms of “mental illness’ — a term which begs the use of medications since that is how we “treat” ‘illness’.
I think I am safe in asserting that whatever proportion of our population fits the rubric mentally ill has not been declining over time and neither has our population and yet make a visit to the state mental hospitals and mental health facilities and you see a system in plainly evident decline. I have read that more and more prisons have been constructed as our criminal laws have created more and more crime we can get tough on. Anecdotally. I have seen a few criminal proceedings at one of my state’s Superior Courts and left with the strong impression that a high proportion of those in court were insane to varying degrees [including some of the prosecutors]. I can readily believe that up to a third or even half of the people held in our prisons have mental illness. And if they didn’t have mental illness before they were incarcerated my impressions of jail and prison life lead me to believe many will have mental illness before they are released from jail or prison. Without regard to the stress of incarceration, the shear enforced boredom, lack of meaningful activity, and lack of contact with friends and family, spread over years would be adequate to break all but the strongest psyches.
I am skeptical that many of the drugs used to treat mental illness are truly effective as treatment and even when they are they often have serious side effects. And the amounts charged for the drugs are all out of proportion to their costs to discover, test, manufacture, and market. In my state some of the better drugs are still made available to anyone fortunate enough to end up in the state’s shriveling mental health system. I suspect — but don’t know for sure — that the jails and prisons more often use the less expensive alternatives which more often come with the less pleasant side effects.
I sometimes wonder whether mental illness arises due to an imbalance in the brain’s chemistry as we are told. I think the concept of mental illness in part describes an inability to fit into society and then I wonder whether the problem is that so many individuals have trouble fitting into society or our society so poorly fits so many.
We all know our country closed down most psychiatric wards decades ago which has been replaced by prisons ever since.
But that would not be grounds for any recent changes alluded to in the article, Therefore I concur this sounds suspect.
Here’s an addendum from the point of view of a psychiatrist, albeit from a decade back:
Briefly, psychiatric evaluation provides an excuse for the indefinite incarceration of inmates who can’t afford bail. If you’re not competent to stand trial, then you can hardly expect the 6th Amendment to apply. (Not that it’s otherwise held in high regard.) Bonus points if the resulting time served happens to exceed the length of the typical sentence for your crime.
It’s not just inmates, it’s everyone. Everyone’s on meds, and half of them are self medicating on top of it. Ok maybe that’s an exaggeration, but look around you. I think it’s a plausible explanation for the American public’s apathy, lack of memory and general foolishness.
OK I’m going to out myself as a former “mental patient”. I won’t go into details, but from my point of view, I and people like me who survived the “mental health” system are the real experts who’s voices ought to be heard on issues of so called “mental health”. I don’t give a fig what the psychiatrists and psychologists say, and if you sense a little anger behind my words, you are not mistaken.
Yes, people do have problems and yes they do need help, and no, not everyone experiences a “mental breakdown” just because society is rigid, demanding and uncompromising. But the psychiatric establishment is a mountain of lies and distortions. We were told that closing the psych wards was the “humane” thing to do and that people would receive the “treatment” they need in the community. That “treatment” amounted to forced drugging…. and make no mistake about the coercion involved. To claim that “patients” take drugs “voluntarily” is analogous to claiming that workers accept their wages voluntarily and that there is nothing at all wrong with the labor contract view of capitalism. It is to ignore the consequences of refusing the proffered deal and the amount of effort that goes into convincing people to accept the role demanded of them.
I suppose that people no longer read Szasz and Foucault, or Breggin these days, but it comes as no surprise to me that the “humane” alternative of treating people with chemical straight-jackets and releasing them into neighborhoods, has morphed into locking them up in jails. I’m sure the penal system psychologists are filled with good intentions, just as the families of psychiatric patients are, when they speak in (y)our behalf, but as long as “the mentally ill” are cast as the other, no amount of good intentions will serve to produce accurate descriptions or acceptable treatment for people stigmatized as “mentally ill”. We are not the other, we are you in different circumstances.
I admit to having been diagnosed and incarcerated, so it is only fair that I also admit to having received my B.S. in psychology. I know how to read a scientific journal and a clinical trial. I have also worked as a counselor. I have seen the system from both sides. You will not convince me that the best we, as a society, can do for people, whether suffering from life’s circumstances or suffering from faulty brain wiring is to give them mind numbing chemicals, even when they cry out for those very chemicals and take them “voluntarily”. The trends in psychiatry and in the penal industry are the same… that is to continually expand the population “served”. That those expansions especially target vulnerable populations, women, people of color, children and the elderly ought to tell you something. How could we be surprised if another vulnerable population, that of prisoners, became a target? The fact that so many find it so easy and natural to assume a huge overlap between the prison population and the crazy population also ought to tell you something.
I emphasize we, as a society. It may indeed be the case that we, as individuals, do not have the time or resources to actually help people, as indicated by the lead response and others telling stories about how their efforts to help were futile and underappreciated. There is no reason to think that a condition years in the making can be easily reversed, especially when the actual causes are completely unknown, go unrecognized or are deliberately obfuscated.
Thank you for your enlightening and enlightened post. I agree with you that much of what ails us as a society is our individual disconnection from society. All the “hustling” to survive that we are forced into (or have chosen) does not permit us to take the time to help neighbors in need. Hannah Arendt described this “atomisation” of society in her “Origins of Totalitarianism” as well as in correspondence with Karl Jaspers in the 1940s.
Can a revival of enlightened individual participation in the public sphere save American society; a modern-day Agora to look after the health and well-being of the Polis?
Hayek said no…. otherwise totalitarianism takes root.
…or perhaps New England style town-hall democracy.
According to the aforementioned camp democracy is a gateway drug to totalitarianism.
You are correct. Plato warned of it long before Hayek, but I like to believe that an engaged citizenry can avoid the descent into tyranny. The capture of the reins of government by oligarchy and the resulting populist backlash is well documented, but it need not be the destiny of modern democratic states. I could well be wrong.
Really cheap housing would solve half the problem. When I moved to SF in the early 80s, I had a housemate who was schizophrenic. My rent was $104/month; hers was a little more; we were renting rooms in a house. She could afford that, by babysitting (as far as I can tell she didn’t have any problems in that position). Even when she had periods of time when she couldn’t work because she was having visions, which happened since she didn’t like the meds and did like the visions since they were often religious, she could still manage the rent. So she was functional. She still seems to be in SF (I checked intellius), but there is no way that she could presently be housed, given the costs now. Having a home you can afford on your own work, even if it is intermittent and badly paid, is very stabilizing.
I would make an educated guess, having witnessed decades of how insidously California operates, that it’s indiscriminate, lawless, inhumane prison population control.
California nursing homes have the same problem. From a February 8, 2018 article, Study Finds California Has Highest Elder Abuse Rate in Nation:
The piece fails to mention that a person has to be able to afford that California Attorney. One might counter that pro bono services would be available, but pro bono legal services in California from my observation over the decades are severely limited. Currently, in Silicon Valley, pro bono legal services appear to be devoting all of their services to immigration issues, I know this because I tried to acquire some assistance regarding renters, as I can no longer afford an attorney. For example, if one goes to the Santa Clara County Legal Aid Society – Housing/Fair Housing page (the 3rd of three categories of its pro bono legal services), it notes : Unit is Currently Closed, despite the Rampant Homelessness in Silicon Valley/Santa Clara County. Ditto for the 2nd of the three Legal Services Categories, the Family Law page: Unit is Currently Closed.. There is no page for Elder abuse, and certainly none for those prison/jail/and faux mental health issue incarcerated which – incarceration – California has always specialized in. The only active page is for immigration services, none for anyone with voting status. (Complex Immigration issues – particularly surrounding voteless, underpaid legal immigrant renters, which California and the Federal Government deliberately allow to gut lifelong voting citizen renters – are a huge, horrid and insidious example of the Republic of California pitting its inhabitants against one another.)
I always bleakly snicker when California is spoken of as meritocratic and looked to as a template for Progressive Policies. Right along with that 5th Largest Economy status, it has – for years now – the highest Poverty/Inequality in the Nation, when measured by the US Census Bureau.
Given that 10 percent of U.S. schoolchildren are medicated, I don’t find the stats for prisoners at all surprising. That NIMH article has some interesting details on the ‘why?’ and ‘who is responsible?’ aspects:
“What I hear from families in crisis is lack of access, poor quality care, and a desperate need for answers. In the media reports on over-medicating children, this perspective is missing. The possibility that there is a real increase in the number of children suffering with severe emotional problems, just as there is a real increase in the number of children with diabetes and food allergies, is not even considered. Shouldn’t we be asking why so many children, at younger ages, are being seen for emotional and behavioral problems?”
So perhaps it is no accident that this is occurring at the same time as a raging opiod and deaths-of-despair epidemic.
When I worked in state hospitals and psych hospitals many of our patients cycled in and out of jail. Some were sent to us as they were too violent for the jails to cope with. State hospitals began closing in the 1970s. I worked with patients from both
Elwyn and Pennhurst, two local Hell holes near Philadelphia. Elwyn was reformed and still exists as an institution for “special needs” folks. Pennhurst is used as a Halloween horror house.
I’d be willing to bet most of them are on Seroquel. An atypical antipsychotic that can also be prescribed for bipolar and depression. It also tends to make you sleep for like 12 hours and be really chill all day. I could easily see it as being frontline treatment for people in jail.