Imagine being jailed and charged with trespassing after having a spirited conversation with a friend while in line for stamps. The district attorney wants to prosecute and is offering probation to avoid jail time, in exchange for pleading guilty to a misdemeanor. Though she had no criminal history, my mother did have a history of schizophrenia; she was psychotic when the police were called to the post office.

As mental health budgets around the country are continuously targeted for cuts, the severely ill who suffer from conditions such as schizophrenia and bipolar disorder are increasingly entering the criminal justice system rather than mental health centers. In fact, the number of Americans who receive mental health care in prisons and jails has surpassed the number of those who receive services in hospitals or clinics. Despite increased media attention, government leaders and mental health systems are doing little to reverse this shameful trend.

It has now become commonplace to imprison seriously mentally ill individuals for crimes that they often commit as a direct result of untreated illness. Those who work in law enforcement and in the public mental health system confront this reality on a daily basis. The victims of this criminalization are frequently uninsured, marginalized and the most indigent members of society. Given paltry state and federal reimbursement rates for mental health services, and the fact that affected individuals generally lack the social support or financial resources to pay out-of-pocket, treatment of the mentally disordered is often a money-losing venture for those who provide care for this population.

To complicate matters, approximately 40 percent to 50 percent of the seriously ill have deficits in their brains that impair their self-awareness. This lack of insight leads to an inability to recognize their illness and often results in the refusal of offered services. With strict laws governing involuntary treatment, a significant percentage of the severely ill do not receive treatment until it is too late. While the majority of the seriously ill are not dangerous, studies have clearly shown that a small subset of the severely ill are at increased risk of violence, either toward themselves or others. The result of this neglect is a costly revolving door to emergency room visits and hospitalizations, incarcerations, homelessness and preventable tragedies. These poor outcomes are wasteful in terms of financial and human resources, unnecessarily risks public safety and perpetuate the stigma of mental illness.

Following the money, it is clear that incarcerating the seriously ill is often an easier alternative for underfunded mental health systems. Mental health treatment provided in jails and prisons is not funded by anemic mental health budgets, but instead paid for with more robust criminal justice dollars. While we are increasingly training law enforcement to better manage the severely mentally ill, we are simultaneously reducing mental health resources. This shifting of responsibility for the care of the mentally ill toward law enforcement and away from mental health systems is inappropriate, unjust and promotes the criminalization of this susceptible population.

What can be done? Mental health programs need to be protected from further cuts, and more resources need to focus on intervening before the severely mentally ill are incarcerated. People can and do recover, provided they are given the necessary support and resources. We need to take a more preventive approach toward mental health, mirroring the preventive focus in other areas of medicine. Importantly, this involves proactively engaging the seriously ill, particularly those who are most at-risk for clinical deterioration and who are the highest users of services. Doing so may require an upfront investment, but will undoubtedly save lives and taxpayer money by maximizing the limited resources that are available, and preventing unnecessary hospitalizations and lengthy criminal court proceedings.

Health systems are in a period of transition as a result of health care reform. Now is the time for our leaders to help safeguard the most vulnerable members of society and to seize this tremendous opportunity for improving our mental health systems. Until this happens, prisons and jails will remain the primary mental health providers in the United States.

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Gary Tsai, a UC Davis medical school graduate, is a resident psychiatrist living in the Bay Area.

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