RAND Study First to Document Costs and Fiscal Impact of a Mental Health Court
Special courts that sentence people with mental illness who are convicted of misdemeanors and low-level felonies to treatment instead of jail have the potential to save taxpayers money, according to a RAND Corporation study. The study examined costs incurred by participants in the Allegheny County Mental Health Court in Pittsburgh. There are about 120 such courts in the United States, and the findings are likely applicable to many of them, according to M. Susan Ridgely, J.D., the lead researcher on the RAND study team.
The Council of State Governments, sponsor of the study, cites evidence that many people with mental illnesses cycle through the criminal justice system. Nearly a quarter of jail inmates who reported having a mental health problem had served three or more prior jail terms, according to 2006 figures from the U.S. Bureau of Justice Statistics. About 16% of people in jails and prisons have a serious mental illness, compared with about 5% of the U.S. population. Millions of dollars are spent each year incarcerating people with mental illness, many of whom engage in relatively minor offenses, such as trespassing and disorderly conduct.
Mental health courts offer defendants the opportunity to participate in court-supervised, community-based treatment in lieu of typical criminal sanctions—the intervention is essentially probation with close supervision and mandated treatment. Because such courts are relatively new—in 1997 there were only four in the United States—only a handful of studies have measured their performance, and no published study has systematically examined the costs of mental health courts or, more specifically, their fiscal impact on criminal justice, mental health, and welfare systems.
The sample for the RAND study included all 365 individuals who participated in the Allegheny County Mental Health Court between its inception in June 2001 and the end of September 2004. Cost analyses were conducted for subsamples for which comparison conditions could be constructed. To determine the fiscal impact, RAND researchers gathered information on treatment costs and costs incurred by the criminal justice, behavioral health, and welfare systems from six state and county public agencies. These costs were compared with costs that would have been incurred by the participants had they gone through the normal criminal court system and with their costs before and after an arrest in the years before entry into the mental health court.
Most participants were men (62%). They ranged in age from 18 to 72 years old; half were between the ages of 29 and 44. The sample was split between white, non-Hispanic (55%) and African-American (41%) individuals. On average, participants were arrested twice in the two years before they entered the mental health court and had spent almost half of the two years (an average of 345 days) in jail.
Diagnoses were missing for almost one-third of the sample, but for the remainder, severe mental illnesses dominated—schizophrenia, schizoaffective, and other psychotic disorders (22%); bipolar disorder (21%); and major depression (6%). Half of the sample had evidence of alcohol or drug abuse. Although Global Assessment of Functioning scores were missing for a quarter of the participants, most had a score of less than 50, indicating a group of individuals with serious psychiatric impairment.
The findings show that entry into the mental health court program led to an increase in the use of mental treatment services in the first year as well as a decrease in jail time. The decrease in jail expenditures mostly offset the cost of the treatment services. When federal cost-sharing under Medicaid is factored in, there was a complete offset of costs for the state and county. An analysis that followed a subsample of participants for a longer period showed a dramatic decrease in jail costs in the second year of participation. The treatment costs returned to pre-mental health court levels in the second year. The drop in jail costs more than offset the treatment costs, suggesting that the program may help decrease total taxpayer costs over time.
Although the overall cost savings for the two years was not statistically significant, the leveling off of mental health treatment costs and the dramatic drop in jail costs yielded a large cost savings at the end of the observation period. The lower cost associated with the program in the final two quarters of observation was more than $1,000 per quarter per person and statistically significant in both quarters. The study also found that more seriously distressed subgroups had larger estimated cost savings, although none of the savings was statistically significant in the first year of participation. Consistent with previous studies of mental health courts, no evidence was found that diverting these individuals from the criminal justice system posed any higher risk to public safety.
The 48-page report, Justice, Treatment, and Cost: An Evaluation of the Fiscal Impact of Allegheny County Mental Health Court, can be found at www.rand.org and at www.justicecen ter.csg.org.
Nada Stotland Chosen APA President-Elect, Carolyn Robinowitz to Succeed Pedro Ruiz as APA President
Nada L. Stotland, M.D., M.P.H., a Chicago psychiatrist, was chosen president-elect of the American Psychiatric Association (APA) in 2007 balloting by APA members. Dr. Stotland will serve as president-elect for one year and assume the post of president in May 2008. The current president-elect, Carolyn B. Robinowitz, M.D., of Bethesda, Maryland, will become APA president next month. She will succeed Pedro Ruiz, M.D., of Houston, Texas.
Dr. Stotland, who will complete a term as APA vice-president in May 2007, has held a wide range of leadership positions within APA, including speaker of its Assembly. In addition Dr. Stotland serves on the board of Mental Health America, a consumer and family advocacy group, and is a noted authority on women's mental health, among other topics.
Carol Bernstein, M.D., won election to a two-year term as APA vice-president. Dr. Bernstein, who has served on the editorial board of Psychiatric Services for the past seven years, was APA treasurer from 2000 to 2004. At New York University School of Medicine, Dr. Bernstein is the associate dean for graduate medical education, vice-chair for education in the Department of Psychiatry, and associate professor of psychiatry.
Roger Peele, M.D., of Rockville, Maryland, was elected to a three-year term as trustee-at-large. Dr. Peele, who currently serves as an APA area 3 trustee, is chief psychiatrist for Montgomery County, Maryland, and clinical professor of psychiatry at George Washington University.
Baltimore psychiatrist John C. Urbaitis, M.D., was elected to a three-year term as area 3 trustee, representing the Mid-Atlantic states. Dr. Urbaitis is assistant professor of psychiatry at Johns Hopkins University School of Medicine and clinical associate professor of psychiatry at the University of Maryland.
For area 6 trustee, representing California, Santa Monica-based psychiatrist Thomas K. Ciesla, M.D., won another term; he has served as area 6 trustee since 2004. Dr. Ciesla is in private practice and is associate clinical professor of psychiatry at the University of California, Los Angeles.
APA's members in training elected Lauren M. Sitzer, M.D., Ed.M., member-in-training trustee-elect. Dr. Sitzer is in the psychiatry residency training program at Harvard-Longwood.
About 9,200 APA members voted in this year's election—or 29% of those eligible to cast ballots. That total is down from 32% of eligible members last year. Thirty-two percent of voters chose online balloting in 2007—compared with 28% of voters in 2006. The winning candidates will take office at the conclusion of the association's annual meeting in San Diego, May 19–24.
News Briefs
Guide on workplace mental health: The Partnership for Workplace Mental Health, a program of the American Psychiatric Foundation, has published A Mentally Healthy Workforce—It's Good for Business. The 23-page guide, illustrated with colorful charts and sidebars, is designed to help businesses initiate effective mental health programs for their employees and assess the quality of existing ones. The document presents the latest research findings on the high costs of ignoring mental illness in the workplace and provides employers with specific questions to ask insurers about the availability of a range of services. The document outlines a three-phase approach to evaluating, constructing, and strengthening employee mental health programs. The guide is available at www.workplacementalhealth.org/businesscase.aspx.
Legislative roundup: State governments across the country are engaged in a range of efforts to improve the response to individuals with mental illnesses who are in contact with—or who are at risk of contact with—the criminal justice system. The Justice Center of the Council of State Governments has identified a sampling of diverse state-level approaches to addressing criminal justice-mental health issues that have been signed into law over the past two years. Currently, six states are featured in the round-up. For example, the California Department of Corrections and Rehabilitation Corrections Standards Authority has awarded 44 grants totaling $44.6 million to 28 counties as part of its Mentally Ill Offender Crime Reduction grant program. The roundup, which provides links to relevant legislation, granting agencies, and program recipients, is part of the Criminal Justice-Mental Health Consensus Project and is available at http://consensusproject.org/updates/features/leg-roundup.
Primers on Medicaid and Medicare: The Kaiser Family Foundation has issued a new primer on the Medicare program and an updated version of its Medicaid primer. The 19-page Medicare primer explains key elements of the program that provides health coverage to nearly 44 million people—about 37 million adults age 65 and older and seven million younger adults with permanent disabilities. It looks at the characteristics of the Medicare population, what benefits are covered, how much people with Medicare pay for benefits, and the program's overall costs and financing challenges. The 30-page Medicaid primer provides an overview of the basic components of the nation's largest health coverage program, which covers 55 million low-income individuals (including families, people with disabilities, and elderly people) and is the dominant source of the country's long-term-care financing. Tables examining state variation in eligibility, enrollment, and spending for Medicaid enrollees are included. The primers are available on the Kaiser Web site at www.kff.org.
