Mental Health Courts Reduce Incarceration, Save Money

Figures from the US Department of Justice indicate that more than half of prison and jail inmates have a mental health problem. Mental health courts (MHCs) were designed to divert mentally ill persons convicted of nonviolent crimes to supervised treatment instead of incarceration, but while the number of MHCs has grown substantially over the past decade, limited information has been available about outcomes and costs.

Now a study from the RAND Corporation has demonstrated that an MHC in Pennsylvania was successful in increasing mental health services and reducing jail time for participants while reducing costs to taxpayers.¹ The study, sponsored by the Council of State Governments Justice Center, was the first to evaluate the fiscal impact of an MHC anywhere in the United States, according to economist John Engberg, PhD, one of the authors. It found that the court saved taxpayers $3.5 million over a 2-year period, Engberg told Psychiatric Times.

While the study focused on the Allegheny County MHC in Pittsburgh, the findings are applicable to many other MHCs in the United States, the study's director, M. Susan Ridgely, explained in a press statement.

Based on drug court models, an MHC is a special docket of a criminal court. "Essentially, mental health courts offer participants an opportunity to avoid incarceration if they agree to comply with community supervision and mandated treatment. Compliance is monitored through a series of reinforcement hearings before a dedicated jurist," the RAND research team wrote.

To determine the fiscal impact of the Allegheny County MHC, 1 of 4 such courts in Pennsylvania, the RAND researchers gathered information on the treatment, criminal justice, and entitlement program costs from 6 state and county public agencies. These costs were compared with the costs government would have incurred during a comparable period had MHC participants gone through the traditional criminal court system and the costs before and after an arrest in the years prior to their entry into the MHC program. From the study population of 352, the researchers extracted data on 3 subsamples to develop their analyses.

The MHC participants were predominantly male (62%), and half were between the ages of 29 and 44. Slightly more than half (54.6%) were white (non-Hispanic) and 41.2% were black.

When the participants entered the MHC program, diagnoses were missing for nearly one third. Among the remainder, 20.5% had bipolar disorder; 21.6% had schizophrenia, schizoaffective disorder, or other psychotic disorders; 6.3% had major depression; and 13.1% had depressive disorder, not otherwise specified. About half of the population showed evidence of alcohol or drug abuse. Although Global Assessment of Functioning scores were missing for one quarter of the participants, the majority scored below 50, indicating that they had severe symptoms and impairment.

In their report conclusions, the RAND researchers determined that the Allegheny County MHC program "is a success in achieving its mission to divert nonviolent offenders with serious mental illnesses out of the penal system and into community-based health treatment and other services"; that the diversion of seriously mentally ill individuals into the MHC program did not pose any increased risk to public safety; and that the MHC program "did not result in substantial incremental costs, at least in the short term," over the status quo.

In the short run, Engberg elaborated, Allegheny County broke even financially. The MHC program resulted in an increase in the use of mental health treatment services, but a reduction in jail time. The decrease in jail expenditures mostly offset the cost of the treatment services, he explained.

In the second year of study, both the average mental health services and jail costs were reduced, the latter dramatically, suggesting that the MHC program may help decrease total taxpayer costs over time, Engberg said. Allegheny County and the state, he added, also benefited because Medicaid, which is jointly funded by the state and federal government, primarily pays for mental health costs.

Engberg went on to point out that cost savings achieved during year 2 may actually be greater with the most severely affected subpopulations. The RAND analysis revealed that cost savings derived from participation in the MHC program were greater for those charged with felonies, those suffering from psychotic disorders, and those with scores indicating severe psychiatric illness and low functioning.

Court growth and roadblocks

In 1997, only 4 MHCs existed in the United States. As of June 2005, there were 125 courts in 36 states.² In an online survey of 90 MHCs, 56% said they accepted both misdemeanor and felony cases, and 60% reported that they accept only those referrals that have a serious and persistent mental illness or an illness that meets Axis I criteria.³

MHCs are "blooming everywhere," according to Engberg, because they provide a coordinated approach for persons in the criminal justice system who have a severe mental illness.

In the Allegheny County system, an MHC judge, the assistant district attorney, the public defender, the MHC monitor, the MHC forensics support specialist, and the probation liaison meet and discuss the circumstances surrounding the charges, the diagnosis, the need for treatment, the service plan, and the need for supervision in the community. The MHC participant is then given help obtaining treatment, housing, and public assistance and returns to court for periodic reinforcement hearings.

MHCs, when implemented with necessary and quality resources, provide a way of reducing use of the "revolving door," Engberg said.

That high recidivism was documented in a 2006 report by the US Bureau of Justice Statistics, which found that nearly one quarter of state prisoners and jail inmates who had a mental health problem had served 3 or more incarcerations; only one fifth of those with no mental health problem had a similar rate of incarceration.⁴ One contributing factor to the recidivism may be that mentally ill individuals often receive only minimal treatment in jail, Engberg added.

In the Allegheny study, researchers found that most people who went through the MHC "tended not to return . . . to jail," Engberg said. A corollary benefit of MHC programs, he added, may be that they reduce jail/prison overcrowding and free jail space for more violent offenders.

Despite the promise of MHCs, Engberg noted that several factors can limit their growth. There are upfront costs to establishing MHCs. Already overloaded district attorneys' offices and the courts must find time to coordinate with community-based mental health treatment providers to create an MHC. In addition, he pointed out, establishing an MHC can be politically risky. If an MHC participant were to commit a terrible crime, there could be a high price to pay politically by government officials, politicians, and others who supported the court's establishment.

Daniel W. Shuman, M. D. Anderson Foundation Endowed Professor of Health Law at Southern Methodist University, noted that many of the judges on the ground floor of the MHC movement wrote chapters for Judging in a Therapeutic Key: Therapeutic Jurisprudence and the Courts.⁵ The book describes the newly emerging problem-solving courts (drug treatment courts, domestic violence courts, MHCs) and the principles of therapeutic jurisprudence that ap-pear to be at work in successful judicial approaches.

"My limited first-hand experience is that these courts are a function of the judge's style; no 2 are quite the same," Shuman added.

Other studies and approaches

Since MHCs are relatively new, studies on their effectiveness are still emerging.^6-8 Engberg noted that studies are under way that examine participant characteristics and outcomes. Allison Redlich, PhD, a senior research associate with Policy Research Associates, said that organization is conducting 2 studies, the MacArthur Mental Health Court study and the National Science Foundation (NSF) Mental Health Court Study.

The NSF study seeks to examine MHC defendants' perceptions and comprehension of court processes and requirements using pilot data from the Bronx, NY, MHC to validate newly developed instruments; they are also using 200 interviews with MHC defendants from the Brooklyn, NY, MHC and Washoe County, Nevada, MHC coupled with standardized assessments; and 1-year outcome data derived from record reviews and court charts.

The MacArthur study seeks to determine whether participation in MHCs (as compared with treatment as usual) leads to better access to mental health and substance abuse treatment in the community, and in turn, whether increased access leads to more favorable outcomes, such as improved quality of life and lowered recidivism. Self-report data will come from 140 MHC clients and 140 jail inmates at sites in California, Minnesota, and Indiana.

Phase 2 of the NSF study (interviews) is complete, and preliminary results from both studies should be available in a year or so, Redlich told Psychiatric Times.

In addition to MHCs, researchers, along with federal, state, and local officials, are looking at multiple points at which mentally ill individuals can be intercepted and diverted from the criminal justice system: crisis intervention teams; prebooking jail diversion programs; specialty courts; reentry from jails, prisons, and forensic hospitalization; and community corrections and community support.⁹ Last year, the Substance Abuse and Mental Health Services Administration awarded $7.2 million for jail diversion grant programs in 6 states.¹⁰

This November 14 to 16, the Allegheny County Department of Human Services' Office of Behavioral Health and the University of Pittsburgh's Center on Race and Social Problems, along with other agencies and organizations, are sponsoring the national conference, "Which Way Out? Applying the Sequential Intercept Model as a Framework for Decriminalizing Mental Illness," in Pittsburgh. Speakers will include the developers of the sequential intercept model Patricia Griffin, PhD, senior consultant for the National GAINS Center for People with Co-occurring Disorders in the Justice System and the Philadelphia Department of Behavioral Health, and Mark Munetz, MD, chair of the department of psychiatry at Northeastern Ohio Universities College of Medicine and chief clinical officer of the Summit County Alcohol, Drug Addiction, and Mental Health Services Board. Another speaker will be Pete Earley, author of Crazy: A Father's Search Through America's Mental Health Madness.¹¹ For more information, contact Sue Martone, assistant deputy director of the Office of Behavioral Health for Allegheny County Department of Human Services, at: smartone@dhs.county.allegheny.pa.us.

References:

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