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Mental health courts as a way to provide treatment to violent persons with severe mental illness.

WHILE THE GREAT MAJORITY OF PERSONS WITH severe mental illness (eg, schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, and other psychotic disorders) are not violent, there is a small minority who may become aggressive when stressed. For instance, in a US national study of persons with schizophrenia and violent behavior, the prevalence of serious violent behavior in the past 6 months was 3.6%. Many persons with severe mental illness and a history of violence reside in jails and prisons. As an example, a recent study in a large US metropolitan jail found that 72% of persons with severe mental illness had a history of arrests for a violent offense. In this Commentary we discuss how mental health courts could divert violent persons with severe mental illness from the criminal justice system to the mental health system and ensure that they receive needed treatment. Why does this minority of persons with severe mental illness become violent when under stress or pressure? Individuals with severe mental illness who are psychotic are more likely to become violent if they do not adhere to their treatment regimens. Substance abuse also has been shown to increase the risk of violent behavior in persons with severe mental illness. Moreover, some individuals with mental illness have anosognosia, a biologically based inability to recognize that one has a mental illness. In recent decades, there has been a growing literature on anosognosia in which researchers have identified various parts of the brain (such as the ventricles, frontal and temporal lobe subregions, medial temporal and inferior parietal regions, and subcortical structures) in which pathology is associated with anosognosia. This biologically based lack of insight of having a severe mental illness may be one of the predictors of violence in persons with schizophrenia; thus, demonstrating a relationship between poor insight and violent behavior. Criminalization and Mental Health Courts Since the latter part of the 20th century, there has been an increase in the number of persons with severe mental illness who have been placed in US jails and prisons. As of December 2006, using estimated percentages from the US National Commission on Correctional Health Care, at least 341 000 severely mentally ill persons were incarcerated representing a substantial proportion of the total jail and prison population of 2.3 million. These include many who have a history of violence. Despite this, there is a shortage of mental health treatment resources in jails and prisons. The large-scale criminalizationofpersonswithseveremental illness has stimulated a variety of modalities to reduce the risk of violence for individuals with severe mental illness. One approach is to divert these persons from jails and prisons into treatment inthementalhealthsystem.Ameansforaccomplishing this is through special courts called mental health courts. At first, these courts were established to hear cases of persons with mental illness who were typically charged with misdemeanors. In recent years, these courts extended their purview to serve persons with mental illness charged with nonviolent felonies. Some courts now consider cases of mentally ill persons who are charged with violent felonies. Ideally, in mental health courts all courtroom personnel (ie, judge, prosecutor, defense counsel, and other relevant professionals) have experience and training in mental health issues and available community resources. These courts are characterized by hearing specialized cases involving defendantswith mental illness, using a nonadversarial team of professionals (eg, judge, attorneys, mental health clinician), and using some way to monitor adherence that may involve sanctions by the court. In addition, mental health courts have links to the mental health system that can provide treatment as well as needed services and support after discharge from jail to help enable the persons to successfully reenter their communities. By diverting persons with serious mental illnesses charged with