Treating Illness in Justice System Comes at High Cost
Abstract
If more effort was expended on alternatives to the criminal justice system for people with serious mental illness, state budgets would take a far smaller hit.
The total costs for people with mental illness who are also involved with the criminal justice system are nearly double the costs for those without such involvement, according to a study of state mental health records in Connecticut.
The justice-involved individuals each incurred total costs of $48,980 on average, compared with $24,728 per person for those not involved with the criminal justice system, said Jeffery Swanson, Ph.D., and colleagues in Psychiatric Services in Advance March 15.
The researchers added up costs from the Connecticut Department of Mental Health and Addiction Services (DMHAS), Medicaid, the state judiciary, and the Department of Correction and Public Safety.
Of the 25,133 adults served by the DMHAS in 2006 and 2007, 6,904 had been arrested and convicted of a crime or were in prison, on parole or probation, in a jail-diversion program, or spent time in a forensic psychiatry setting. Common diagnoses were schizophrenia (37 percent), bipolar disorder (63 percent), and a substance use disorder (65 percent).
Patients with a psychiatric illness not involved in the criminal justice system had a different pattern of diagnoses. About 47 percent had schizophrenia, 54 percent had bipolar disorder, and 28 percent had a co-occurring substance use disorder.
Such clinical differences may account for higher numbers of short-duration, acute hospital admissions, suggested Swanson and colleagues.
Overall, individuals in the justice system accounted for mental health and substance abuse service costs of more than $215 million, with an average of $31,196, said the researchers. When an average of an additional $17,784 of other criminal justice costs were added, the total average cost per person was $48,980.
The DMHAS covered about 49 percent of the costs for the justice-involved group and about 69 percent of the same costs for those outside the justice system.
“[F]orensic hospitalization was responsible for a large share of the difference in costs,” said Swanson. Costs averaged $287,062 per person involved in the justice system, largely due to lengthy hospitalizations to restore competency or because defendants were found not guilty by reason of insanity.
Among hospitalized patients, those outside the justice system had 124.7 days paid for by the DMHAS, compared with 249 days for forensic patients.
There are probably two reasons why forensic inpatients had such extended lengths of stay, suggested forensic psychiatrist James Reynolds, M.D., medical director at the state-run Northwest Missouri Psychiatric Rehabilitation Center in St. Joseph, Mo.
“As in other states, patients found incompetent to proceed to trial are often quite sick and thought disordered and take correspondingly longer to stabilize,” said Reynolds, in an interview with Psychiatric News. “Also, they can’t just be released when they are less acutely ill, as in civilian settings. They usually must be kept as inpatients until ready for trial, and those who are permanently incompetent usually can’t just be let go either.”
One potential area of cost saving might be the use of nonhospital crisis-intervention programs, said Erik Roskes, M.D., director of forensic services at Springfield Hospital Center in Sykesville, Md, in an interview. “This could be used as a cost offset by avoiding use of expensive inpatient resources, [although] there is also a risk that forensic patients might be excluded from consideration due to their histories.”
One aspect of care for prisoners or arrestees was not included in the study, said Roskes. “There is no mention of the general medical costs of these populations, which we know is very high,” he said. “In some cases, the medical problems relate directly to both the mental health and the criminal justice costs, as with traumatic brain injuries, for example.”
Roskes also noted that one group not cited in the research and that can be very costly to treat are people with comorbid cognitive/developmental disabilities.
The study might serve as a model to analyze similar costs in other states, and its findings should help Connecticut health officials better plan, coordinate, and deliver services to these populations, concluded Swanson. ■
An abstract of “Costs of Criminal Justice Involvement Among Persons With Serious Mental Illness in Connecticut” is posted at http://ps.psychiatryonline.org/article.aspx?articleID=1668301.
“To be competent to defend yourself in court, you can’t just be good enough, you must really be pretty stable,” James Reynolds, M.D., medical director of the Northwest Missouri Psychiatric Rehabilitation Center in St. Joseph, Mo., told Psychiatric News. “Many defendants may refuse treatment for lengthy periods of time or only partially comply with treatment, thus lengthening their inpatient course.”
Missouri uses a strict conditional-release protocol to follow forensic outpatients, most of whom are law-abiding, free of substance abuse, and fully compliant with their medication and day-treatment programs, said Reynolds.
“It significantly affects the revolving door of civil mental health treatment that so tragically leads to patients eventually becoming involved in the criminal justice system, often to a victim’s, not to mention their own, grief,” he said. “And it reflects our goal to treat them to the point of remission, or at least meaningful stability.”
“We must find a way to respectfully and ethically ensure that the most severely ill individuals who are not mentally responsible for their conduct stay in meaningful treatment so they have the maximal chance of leading a life as free as possible in the community while not posing a risk of harm to themselves or others.”
