Fiscal Fallout: Patients in the Criminal Justice System

APA's far-reaching white paper titled "A Vision for a Mental Heath System" loudly rings the alarm bell, warning that our mental health system is crumbling (Psychiatric News, May 16). This is further echoed in the message from the President's New Freedom Commission that the "mental health system is in shambles." As a consequence of this, an increasing social and financial toll is exacted, with more and more of the seriously mentally ill entering into the criminal justice system. These developments are largely due to the lack of treatment resources in the community. When mental health dollars disappear, the shift of patients from necessary and appropriate care and from hospital beds to prison beds is not a new phenomenon. Penrose described this dynamic in 1939 in his comparative study of European statistics of mental disease and crime, published in the British Journal of Medical Psychology (volume XVIII, pages 1-15) in the article "Disease and Crime: Outline of a Comparative Study of European Statistics." Unhappily for our society, fiscal planners have not learned from history.

The move to deinstitutionalization that took place about 40 years ago was powered by federal legislation. A shift from public psychiatric hospitals to the community, with the states and counties providing major resources for overarching social services, vocational rehabilitation, and treatment services, was responsive to concerns that psychiatric patients were being "warehoused" and denied the best available treatment. The introduction of new antipsy- chotic medications also drove the deinstitutionalization engine. The states and counties were obligated to put into place community resources to monitor medication treatment, assure rehabilitation, and provide adequate housing for people with impaired autonomy.

What went wrong? A number of things went wrong. Most importantly, the necessary community resources didn't materialize in anywhere near the capacity that was needed. Also, antipsychotic medications, although powerful treatments, don't work in isolation. Patients need a relationship with a psychiatrist, clinic, or other stabilizing force to ensure ongoing adherence. Acutely ill patients often need to spend time in a psychiatric hospital to become stabilized. For some, the disorder is so debilitating that longtime bed availability in a protected treatment center is necessary.

While deinstitutionalization has succeeded in decreasing the number of hospital beds, an unforeseen consequence has been the proportional increase in the number of mentally ill people housed in the criminal justice system. Following deinstitutionalization, the number of state hospital beds decreased from 339 per 100,000 population to fewer than 20 in a little more than 40 years. Meanwhile, the number of mentally ill persons in jail has geometrically increased. Take for example the situation in Los Angeles County. In 2002 there were 38,600 psychiatric evaluations at the inmate reception center of the Twin Towers Jail. Of these, 23,190 (60 percent) were found to be in need of mental health treatment. A reasonable person could not fail to see the correlation among decreased funding for mental health resources, the closure of hospital beds, and homelessness and criminalization. Untreated and without access to long-term care, a large number of mentally ill patients end up with symptoms and behaviors that result in jail time.

With the predicted loss of Medicaid financing for mental health services, you can anticipate an accelerated shift from mental health to criminal justice settings. It is tragic that Medicaid cuts will further reduce already strained services in community mental health centers, drug treatment programs, and private offices that would otherwise significantly reduce the institutionalization and reinstitutionalization of the mentally ill.

This shift in funding not only is a blight on our society, but it also costs money-it costs a lot of money. The cost of corrections staff, mental health staff, medication, amortization of buildings, and time spent by the police and sheriffs in court all amount to very large sums of money compared with the costs incurred to treat patients properly in the community. This doesn't make long-term financial sense, much less humanitarian sense.

State appropriations committees and political decision makers haven't learned from history, but at APA we intend to press for change. APA is developing a blueprint for our members to help them to advocate for a more rational deployment of resources. APA's Corresponding Committee on Jails and Prisons is currently gathering and analyzing the data that will sharpen our presentations to political decision makers. Research from studies across the country, including a multisite study looking at the differential costs between prebooking evaluation and the absence of such evaluations, should prove invaluable. If you have more information in this area, please contact Henry Weinstein, M.D., chair of APA's Corresponding Committee on Jails and Prisons, at [email protected].

In this day and age of budget shortfalls, we cannot present only the moral, medical, and psychiatric rationale for appropriate care. We must simultaneously present the "business case" for reversing the current lack of appropriate funding. This effort by APA and you, its members, will make it happen -replacing misguided criminal justice with social justice. ▪