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.
1. Ridgely MS, Engberg J, Greenberg MD, et al. Justice, treatment, and cost--an evaluation of the fiscal impact of Allegheny County Mental Health Court. RAND Technical Report. Available at: http://www.rand.org/pubs/technical_reports/TR439. Accessed June 1, 2007.
2. Council of State Governments. Mental health courts:a national snapshot. Available at: http://www.ojp.usdoj.gov/BJA/pdf/MHC_National_Snapshot.pdf. Accessed June 1, 2007.
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4. James DJ, Glaze LE. Mental health problems of prison and jail inmates. September, 2006. US Bureau of Justice Statistics, NCJ 213600. Available at: http://www.ojp.gov/bjs/abstract/mhppji.htm. Accessed June 1, 2007.
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