Solutions to woes of mentally ill exist but aren't used

The USA could dramatically improve the lives of the 10 million Americans with serious mental illness if it would make wider use of proven programs.

"We know what to do," says Ron Honberg, national director of policy and legal affairs at the National Alliance on Mental Illness. "We just don't do it."

Most communities ignore mental health until there's a crisis, such as the school shootings in Newtown, Conn., two years ago. Though people are initially horrified by such acts of violence, Americans forget all too quickly – and move on.

"Six months later, it fades off the front pages," says Ron Manderscheid, executive director of the National Association of County Behavioral Health and Developmental Disability Directors. "It's hard to get anyone to pay attention until it happens again."

According to the National Institute of Mental Health, neglect of Americans with serious mental illness costs the nation $444 billion a year — mostly from lost earnings — and consigns millions to lives of suffering, addiction, homelessness or incarceration.

It doesn't have to be this way.

Studies show that supported housing, which provides a variety of services beyond low-cost apartments, not only reduces homelessness but also helps participants spend less time in shelters, hospitals and jail.

Supported employment programs, which provide one-on-one help to people with serious mental illness, have been proved effective in 20 high-quality studies. The programs can triple the employment rate of people with serious mental illness from 20% to 60%.

Yet only about 2% of people in the public mental health system receive either service, according to the Substance Abuse and Mental Health Services Agency.

Over the past seven months, USA TODAY has documented the consequences of the nation's failure to care about mental illness, examining the financial and human costs of apathy.

USA TODAY is devoting the final articles of this series to the stories of people helped by innovative approaches that have the potential to improve millions of lives.

This story shines a spotlight on programs aimed at helping people who suffered from a lack of treatment that led to repeated arrests and hospitalizations. The last piece in the series will examine what happens when people receive intensive help early in their lives, before mental illness has cost them their jobs, their families or their freedom.

Jessica duCille sank into a dark depression at age 13 after her mother's death from cancer. By 20, she was being bullied by voices in her head, which drove her to thoughts of suicide. Eventually, the voices grew into shadows of her dead mother.

The traditional approach to providing mental health care — in which profoundly disabled people are expected to find their way to the services they need — provided little help. DuCille suffers from a form of schizophrenia that includes periods of mania and depression, called schizoaffective disorder. She's been hospitalized dozens of times at facilities across her home state of North Carolina.

Though hospitals can help stabilize patients, they often provide no more than a temporary respite, releasing people such as duCille back into the community with no guidance about where to go next.

Like many women who suffer from serious mental illness, duCille fell into relationships that were physically and emotionally abusive. Twice, she was arrested for fighting her abuser.

The cycle was finally broken two years ago when she was transferred to the psychiatric unit of a hospital and referred to an innovative program called Assertive Community Treatment, or ACT. The program aims to provide the sort of intensive, round-the-clock help available in hospitals, except to do it in communities where people live, says Patricia Rutkowski, training direcgtor for the ACT program in Madison, Wis. That's where the program began in the early 1970s.

At the time she joined ACT, DuCille was hospitalized.

A social worker met duCille at the hospital. Unlike traditional caseworkers, who often manage many clients by themselves, ACT teams rely on a variety of mental health professionals working together, including counselors, nurses, a psychiatrist and employment and housing specialists.

DuCille was living with her father and afraid to leave her bedroom. There was no way she could have found her way to a clinic or social worker's office, let alone navigate a fragmented system to find help with food, housing and disability payments.

That's where programs such as ACT come in. They serve people with the most serious impairments, who have trouble living on their own and often have a history of multiple hospitalizations, arrests, periods of homelessness or addiction, Rutkowski says.

ACT teams address clients' immediate needs – food, clothing, shelter – before tackling anything else, says Tchernavia Montgomery, director of behavioral health for Carolinas HealthCare System.

Clients such as duCille know they're no longer on their own.

DuCille, 28, can call Montgomery or other team members 24 hours a day. If needed, a team member will come to her home, even several times a day. Having someone to call at 3 a.m. can keep people calm and stable – and out of emergency rooms. It also eases the burden on clients' families, Rutkowski says.

The ACT model, pioneered four decades ago, has had great success in helping people who aren't helped by other programs, Honberg says.

Without medication and support, 64% of people with schizophrenia are hospitalized again within a year, Montgomery says. In the Carolinas HealthCare System ACT program, only 4% return to the hospital in that time.

DuCille's ACT program costs $1,700 a month, compared with the $20,000 cost of an eight-day psychiatric hospital stay, Montgomery says.

"You can do a pretty decent program for someone just by saving the cost of one hospital stay," Rutkowski says.

A 2004 study that focused on ACT programs for people with a history of arrests cut the number of hospital days by 85% and the number of jail days by 83%. Studies show ACT participants are more likely to have stable housing and have a better quality of life.

The programs are cost-effective and may even save money. A Georgia ACT program, for example, saved more than $1 million in its first year, according to a 2004-05 study.

In Wisconsin, 40% to 60% of ACT participants are working. That's two to three times higher than the national average for people with serious mental illness, Rutkowski says.

"There is a huge body of evidence showing that ACT works," Honberg says. "We don't need more research."

ACT was endorsed by a U.S. surgeon general's report in 1999. Although ACT programs are available in 40 states, only Washington, D.C., and six states — Delaware, Florida, Michigan, New Jersey, Rhode Island and Texas — offer it statewide, Honberg says.

Although many community programs say they follow the ACT model, many fall far short, offering services only from 9 a.m. to 5 p.m., rather than the "wraparound" services that make ACT distinct, Honberg says.

ACT works in Wisconsin because local boards pay for all public mental health services out of the same budget, Rutkowski says. That gives them an incentive to keep people healthy and out of the hospital.

Today, duCille sees a therapist and a doctor. Clients can attend weekly substance-abuse programs or classes that help manage stress, from group therapy to yoga to art therapy, which resonates with duCille, who expresses herself through her drawings. In the darkest times of her life, those drawings were black and white. When she's optimistic, color returns.

DuCille is still looking for a job. Thanks to the ACT team, she and her 3-year-old daughter were able to leave her father's home last month, moving into an apartment of their own.

DuCille hasn't been hospitalized since beginning the program two years ago. Although she remains fragile and soft-spoken, duCille says she feels hopeful about her future.

"There are times when I don't feel like doing anything," duCille says. "My daughter pushes me to take better care of myself."

By age 40, Julie Reed had fallen as far as she could.

She was addicted to crack. She sold her body and stole from her family and stores to support her habit. Her two daughters moved in with relatives because she was unable to take care of them. "I was slowly killing myself," says Reed, who has suffered from mental illness since she was a teenager.

Arrested for assault with a deadly weapon, Reed found herself in the Miami-Dade County jail, one cell away from a woman accused of murder.

"It was a life or death situation for me," Reed says. "Part of me wanted to give up. I had to decide, 'Am I going to fight for my life or am I going to die?' "

Reed found help through an innovative program started by Judge Steven Leifman, which aims to provide treatment, rather than jail time, for people with mental illness or addiction.

Although she could have left jail on a year's probation, Reed asked for help instead. She was transferred to a residential treatment facility for four months of drug rehabilitation. Thanks to Leifman's program, Reed got treatment for the bipolar disorder that had led her to "self-medicate" with drugs. She reported to the court once a month for a year before completing the program.

"It's unfortunate that you have to go to jail to get any type of help," says Reed, 45. "I'm so grateful to that man."

Leifman says he's seen too many wasted lives.

People with mental illness have long filled both his courtroom and the Miami-Dade County jail, which has become the largest psychiatric institution in Florida.

About 20,000 of the 114,000 bookings there last year involved people who needed intensive psychiatric treatment while incarcerated, says Leifman, an associate administrative judge for the Miami-Dade County Court's criminal division.

Nationally, 2 million people with mental illness go to jail every year, according to a 2013 study in Psychiatric Services in Advance.

Many people with mental illness are arrested for relatively minor crimes – such as loitering or causing a public disturbance – more related to their illness or addiction, rather than an intent to do harm, Leifman says.

Locking up people with mental illness is not just inhumane, Leifman says. It's also expensive.

In Florida, one of every three mental health dollars is spent on "competency restoration" — treating mentally ill people who've been accused of felonies, so they are competent to stand trial, Leifman says. That money doesn't pay for continuing mental health services after trial, so people typically leave jail no better than before, often getting rearrested within weeks or months.

As states have closed psychiatric hospitals and scaled back mental health services, more people with mental illness wind up in jail, Leifman says. People with serious mental illness are actually more likely to be incarcerated than hospitalized, a 2007 study found.

The Judicial Criminal Mental Health Project, which Leifman founded in 2000, aims to redesign the system at every level, to keep people with serious mental illness out of jail.

"It's taken us 14 years, but we have educated a whole community," Leifman says.

More than 4,400 police officers have been trained to approach calls for service in a different way. Following a model pioneered in Memphis police officers in the Miami metro area are trained to calm people down and refer them to help.

Last year, crisis intervention teams in Miami-Dade County and the city of Miami responded to more than 10,000 mental illness-related calls, yet made only nine arrests. Police referred one-third of the people involved in these calls to crisis stabilization units, free-standing emergency psychiatric facilities for short-term stays.

For those who are arrested, jail psychiatrists screen inmates for mental illness and refer those who appear ill to social workers. Judges can arrange for inmates to be transferred out of jail into a crisis stabilization unit, where inmates can be treated for up to two weeks, Leifman says.

Once they are stabilized, about 80% of defendants agree to treatment, Leifman says. That's partly because of the influence of peer specialists – graduates of the program who explain the advantages of opting for treatment rather than jail. State attorneys can drop charges, reduce charges or give inmates credit for time served, allowing people to avoid jail and a criminal record.

Because inmates with mental illness are often homeless, program staffers help them get stable housing and apply for Medicaid and disability payments. Many inmates have benefits arranged by the time they leave jail.

Since Leifman's program began, the fraction of people with a serious mental illness who are rearrested for a misdemeanor within a year has fallen from 72% to 20%, Leifman says.

Altogether, Leifman's programs have helped reduce the jail census from 7,800 inmates at a time to 4,800, allowing Miami-Dade County to close one of its jails, at a savings of $12 million a year, he says. The county has funneled some of the money back into Leifman's program.

Leifman's next project is a 187,000-square-foot "forensic diversion center," which will provide one-stop shopping for many of his participants, with a courtroom; a crisis stabilization unit; a facility to provide up to 90 days of residential mental health treatment; a rehabilitation center, where people can attend daytime programs; and a commercial kitchen where people can prepare for jobs in food service.

Eventually, Leifman hopes to open a supportive housing program on the site.

Mental health advocates such as Honberg see the Miami-Dade program as a national model.

"Judge Leifman deserves a lot of credit for persistence," says Fred Osher of the Council of State Governments' Justice Center, a non-profit research and policy center.

The Miami-Dade project stands out because it tackles some of the greatest problems facing people with mental illness – lack of treatment, drug addiction, homelessness, incarceration – at many levels, bringing together people from across the community, Osher says.

"We're spending a lot of money already" to incarcerate people with mental illness, Osher says. "We're not getting any return on our investment. Let's get smarter about how we use these scarce resources."

Though Osher says he'd like to see Miami's success replicated around the country, he says judges can't do it alone. Communities and state lawmakers have to fund services — from mental health clinics to drug rehab and therapy — so inmates have a real alternative to jail. "You can't force someone to get treatment if there aren't any services to refer them to," Osher says.

When Reed completed the program, Leifman offered her a part-time job as a peer specialist. She works with other people who've been recently arrested, guiding them through the process of getting help and changing their lives. "I sit next to them in court," Reed said. "I try to give them hope."

Reed was first hospitalized for cutting herself when she was 13 and cycled through hospitals and jails on charges of cocaine possession and driving under the influence. She hasn't been hospitalized or arrested since entering Leifman's program. She has worked to rebuild her relationship with her mother, her daughters — ages 22 and 26 — and her grandchildren, ages 4 and 7. "I spend every day trying to pay it forward."

Leifman says Reed has lived up to his expectations.

"She really wanted to get better," Leifman says. "To let people with mental illness work, it's such great therapy. When they can give back, it's even better. When you are working and making a contribution, it gives them a reason to get up every day."

Her life isn't easy.

Reed is in treatment for HIV, which she contracted from her first husband, an IV drug user who committed suicide. Neither of her daughters has HIV. Reed worries that she may never find a full-time job because of her felony conviction.

Reed is going to school to earn a bachelor's degree. She takes nature photographs and dreams of opening her own photography business. She hikes. She kayaks. She appreciates the second chance she's been given.

"I would never have been referred over to a residential treatment center and have gotten my life put back together if I hadn't gotten arrested," Reed says. Although she's not a religious person, she describes landing in Leifman's court as "a divine intervention."