There seems to be a growing number of cases in which the defendant is, at least initially, incompetent to stand trial. In the absence of places for long-term civil commitment (meaning holding anyone for more than a few days), defendants seem to be getting their treatment through the criminal justice system.

I find this frustrating, because much of this stuff is preventable. I have a growing number of mental health officers coming to my office for criminal justice solutions because they can't get the state to hold patients long enough to protect the public.

Anyone seeing anything similar?

What would you think of the availability of a civil commitment solution that permitted a judge to require long-term outpatient court supervision, making sure that the defendant took meds and stayed in therapy? What about assigning a mental health official to that person as we do with a probation officer?

Our servicing state mental hospital has a program called "outpatient commitment" where the patient is actually committed by court order to an outpatient treatment regimen. It's monitored by the MHMR people and not the probation people. We were not able to use it because the state hosp eventually caved in and agreed to an inpatient commitment. You might check into that program if your state hosp has it.

Many psychotics are incapable of managing their meds on an out-patient basis. They can be medicated to the point they are on an even keel, but unless there is someone watching while they take their meds (and sometimes checking under their tongue) they will sooner or later go off the meds, and swiftly go into a spiril downward. They cannot be managed like a probationer.

The problem is that the state hospital does everything they can to dump these people on local mental health programs on an out-patient basis. Since such programs can't insure the patient is taking his meds, its not long before they're off their meds and they've gone off the deep end again. Many of these people end up as homeless people, and many more end up in jail or prison.

This is a nation-wide problem, and is the result of "reforms" that took hold in the early 1960s, which preached that insane people should be handled on an out-patient basis except for the most extreme of cases. It's my impression that the psychiatric community has largely bought into this crazy idea, so getting back to a rational mental health policy will be extremely difficult.

Terry hit the nail on the head. I have a good friend who is an RN; she worked for a few years for MHMR. According to my friend, the biggest problem with these patients is after being stabilized on meds in the hospital, they are released into the outpatient programs where it becomes far more problematic to ensure that the patients take the required meds. As a result, many don't and end up in a yo-yo situation. The patient feels fine and says "I'm ok; I don't need x medication anymore." Patient stops taking the med and decompensates. The result--back in the hospital if MHMR can find the patient, or on the streets or in jail, if not.

The idea behind these reforms was wonderful; but the resources allocated are insufficient to carry out the idea.

Janette Ansolabhere

The problem is the $'s, as y'all have noted. Could we make the argument that it would actually pay for itself? I mean, if a valid system is set up to ensure they take the pills at the stated intervals, won't it actually decrease the number of inpatient commitments (and criminal offenses)? We're in belt tightening times, but if someone with knowledge ran the numbers, it seems like it is simply a more rational use of existing funds rather than a requirement for new funding.

There is probably a class of mental patients that can be properly managed on an out patient basis where the patient has to come to the clinic to take his meds, but there are many others who will not comply with such a program. The only place for them is a mental hospital.

The problem is not the same as managing probationers. With probationers you are trying to keep them from using illegal drugs. A P/O can do random urine tests and tell whether a probationer has used illegal drugs in the last several days. He can't tell how much of an illegal drug the probationer has taken, or exactly when he took it, just that he's ingested it in the last several days. That inexactude is good enough to keep most probationers off drugs, and its good enought to revoke, for those that don't.

Managing a mental patient presents the opposite problem: you must insure that he has taken the proper dose of drugs at least daily, and sometimes 2 or 3 times daily and at certain times. The only way to monitor compliance is to have someone watch them take their meds, and if they refuse, force them to take their meds. Moreover, many of these people have a tendency to go off their meds as well as to self-medicate with alcohol & illegal narcotics, which may interfere with their meds. The result is that they simply can't be managed except in a mental hospital.

TDC and the county jails house a large number of serious mental patients, who in an earlier day were housed in the state hospital. If we brought back the state hospitals, this cost would be shifted from the criminal justice system to the mental health system, but I have no idea which would cost the taxpayers less. Chances are, however, that a proper mental health system would cost more, because such a system would end up housing more people over a longer period of time. For example, we have a homeless mental patient who periodically shoplifts at the HEB in order to go to jail. He may stay there a few months before he is released, and then he lives on the streets & under bridges for a few months until he gets arrested again, and goes to jail for a month or 2. Under a proper mental health system he would be permanently housed in a hospital.