The Department of Corrections is the largest provider of institutional mental health services in Alaska. This has happened over the last decade as a result of a number of system changes, some of which are mirrored in other states and some of which are more "Alaskan." Alaska came to deinstitutionalization of its hospitalized mentally ill patients later than most other states in the U.S. In the mid-1980's, the Alaska Psychiatric Institute began the process of decreasing its bed capacity, a process still underway. Funding decreases and the patient advocacy movement triggered this trend, but deinstitutionalization has had its own momentum. The net effect has been that API has gone from a facility with a 200+ bed capacity to a proposed facility that will have 54 beds. This has reduced both the number of patients that can be treated at a time, and the length of stay. Community services have not kept pace or been adequate to assist people who could no longer receive treatment in API. This has caused an increase in the number of mentally ill people in homeless shelters and, especially, in correctional facilities. Many chronically mentally ill people whose disability had previously placed them in hospital settings for extended periods were displaced into relatively unsupervised settings in the community. Without adequate monitoring, structure and the means to ensure treatment compliance, a portion of these consumers suffered a decompensation in mental status, often resulting in their arrest on misdemeanor or felony charges.

At about the same time deinstitutionalization was gaining momentum, a process of reinstitutionalization was occurring. In 1982, the Alaska Legislature effectively eliminated the Not Guilty by Reason of Insanity defense in Alaska, by passing restrictive amendments. Instead, they substituted a new designation, the Guilty But Mentally Ill verdict, which is seldom used. Those found Guilty But Mentally Ill are committed to the custody of the Department of Corrections and serve their entire sentences in correctional facilities while undergoing psychiatric treatment. In actual fact, "guilty but mentally ill" offenders serve more time in correctional facilities than individuals found guilty of the same offense, due to specific statutory language prohibiting furlough and parole eligibility. Consequently, increasing numbers of severely mentally ill offenders who might otherwise have been in hospital settings in other states have become reinstitutionalized in Alaska's prisons for lengthy periods of incarceration.

Other states have recently passed statutes which require the commitment and treatment of persons defined as highly dangerous sexual offenders following completion of their original sentence. If enacted in Alaska, such a law could increase the number of individuals civilly committed for treatment in locked facilities. Housing and treatment for such persons could impact bed space and resources available to treat the mentally ill, and potentially divert resources to a population that has not been considered mentally ill by Alaska's mental health treatment agencies.

Arrest and incarceration have become a common form of emergency respite care and long-term reinstitutionalization for chronically mentally ill Alaskans. Unfortunately, this is an expensive moral and financial price to pay for public protection and individual treatment.

The documented burden placed on the correctional system is enormous. In 1996, Department of Corrections mental health clinicians saw 1,741 unduplicated mentally ill individuals in Alaska's correctional facilities. According to a recently completed mental health needs assessment, on one snapshot day (1/15/97), 883 individuals, or 29% of the 3091 individuals incarcerated in Department of Corrections correctional facilities, were identified as having some mental illness as defined by AS 47.30.056, and suffering from conditions which require some special care from mental health staff. Of these, 373 individuals (337 males and 36 females), 12% of the total incarcerated population, were suffering from a major mental illness. Seventy-eight individuals, or 38% of the 203 incarcerated females, were identified as mentally ill. (Data is taken from the 1997 report by Care Systems North entitled a Mental Health Needs Assessment for Offenders in Custody and Under Supervision of the Alaska Department of Corrections.)

Intensive community treatment for mentally ill individuals is more humane, effective, and often less expensive than incarceration or hospitalization at Alaska Psychiatric Institute. For example, continued care in community settings averaged $6,650 in FY 96. Actual costs depend on the level of services required by the mentally ill individual, based on the severity of the person's illness and amount of supervision or enhanced services needed. The average total cost for housing and clinical services combined is $9,984 per year. Actual community housing costs ranged from $4,020 per year for rental assistance only, to $4,332 per year for individuals living in adult assisted living homes. Clinical and rehabilitation services for adult assisted living clients averaged $5,652 per year. Mentally ill individuals living in permanent supported housing with daily intensive clinical and rehabilitation services on average range from $20,000 to $30,000 per year. The highest cost can range up to $70,000 or more for a severely disturbed individual who requires 24 hour intensive individual services. API cost $758.48 per day in FY 98 (which if an individual stayed for a year would be $274,000 per year). The average statewide daily rate for a Department of Corrections bed in FY 97 was $105.27 per day ($38,520 per year); court costs and other costs involved in prosecution are not included. All incarceration costs are borne by the State of Alaska. Fifty percent of API costs are borne by the State of Alaska while the rest are covered by the federal government or other third party payers. Mentally ill individuals in community care may receive Medicaid and other federal funds to support their care in the community. When we use a system approach to costing out alternatives, clearly, the community and the individual are better served by intensive and appropriate treatment in a community setting. Clinical and legal recidivism rates for people in intensive community treatment settings are lower than for those without adequate community supports.

In the long term, ways need to be found to divert mentally ill offenders whose crimes result from their illness, especially misdemeanants, from the criminal justice system and correctional facilities to effective community care. In large communities, a "single point of entry," one place where police can bring people experiencing mental difficulties, may be a solution. In all communities, coordination between the criminal justice system and mental health providers and advocates is important.

Mentally ill offenders are required by law and simple humanity to receive treatment while incarcerated. In addition, care for these individuals and public safety concerns require attention to relapse prevention. What needs to be done to meet these twin needs?

The Mentally Ill Offenders Action Team recommends several objectives which seek to implement the goal of expanding and improving the continuum of care for mentally ill offenders. These objectives encompass prevention of imprisonment by enhancing community supports, promoting adequate care for those who are incarcerated, and emphasizing relapse prevention after release.