Forensic Patients in State Hospitals:

Forensic Patients in State Hospitals: 1999-2016 Vera Hollen, M.A. Senior Director of Research & Consulting Director, Mental Health/Criminal Justice Research Center National Association of State Mental Health Program Directors Research Institute 1

Authors and Contributors Authors of the paper Forensic Patients in State Psychiatric Hospitals: 1999-2016 Amanda Wik, M.A. NRI Research Associate Vera Hollen, M.A. NRI Senior Director of Research and Consulting William H. Fisher, Ph.D. NRI Senior Consultant Contributors Debra A. Pinals, M.D Medical Director of Behavioral Health and Forensic Programs Michigan Department of Health W. Lawrence Fitch, J.D. Adjunct Professor, University of Maryland Law School and Medical School Katherine Warburton, D.O. Acting Medical Director/Deputy Director of Clinical Operations California Department of State Hospitals And the Forensic Directors in each State Behavioral Health Agency 2

Background Recent concern has arisen over the proportional increase in state hospitals forensic patients Inpatient bed availability has been a pervasive theme among policy makers, advocates, family members, and the media At least twenty states have been threatened with, or have been, held In Contempt over wait times for admission 3

4 States that Responded to Survey Washington New Hampshire Oregon Montana North Dakota Minnesota Vermont Maine Idaho Wyoming South Dakota Wisconsin Michigan New York Massachusetts Rhode Island Non-Responding States California Nevada Alaska Arizona Utah Colorado New Mexico Nebraska Kansas Oklahoma Texas Iowa Pennsylvania Ohio Illinois Indiana West Virginia Virginia Missouri Kentucky North Carolina Tennessee Arkansas South Carolina Georgia Mississippi Alabama Louisiana Connecticut New Jersey Delaware Maryland States that Responded with Numerical Values for all Years States that Responded but had Missing Data for some Statuses States that Responded and had Data Missing for One or Several Year(s) Florida Hawaii Note: The District of Columbia also responded to the survey. Source: 2017 NRI Inpatient Forensic Services Study

Total Forensic Patients In State Hospitals 5

One Day Census Per State of Adult Forensic Patients 600 One Day Census Per State of Adult Forensic Patients at State Psychiatric Hospitals, 1999-2014 Based on all 51 States 500 400 300 Average Median 200 100 0 1999 2002 2004 2005 2006 2009 2011 2014 Sources: 2017 NRI Inpatient Forensic Services Study, and 1995-2015 6

One Day Census Per State of Adult Forensic Patients 7 7000 One Day Census Per State of Adult Forensic Patients at State Psychiatric Hospitals, 1999-2014 Based on 28 States with Numerical Values for All 8 Years 6000 5000 4000 3000 2000 1000 0 1999 2002 2004 2005 2006 2009 2011 2014 Sources: 2017 NRI Inpatient Forensic Services Study, and 1995-2015

One Day Census Per State of Adult Forensic Patients 2500 One Day Census Per State of Adult Forensic Patients at State Psychiatric Hospitals, 1999-2014 Based on 28 States with Numerical Values for All 8 Years 2000 1500 1000 500 0 1999 2002 2004 2005 2006 2009 2011 2014 Sources: 2017 NRI Inpatient Forensic Services Study, and 1995-2015 8

All States Percent Change Percent Change in Inpatient Forensic Population Based on the 35 States with Numerical Data for 1999, 2005, and 2014 350% 300% 1999 to 2005 2005 to 2014 1999 to 2014 250% 200% 150% 100% 50% 0% -50% -100% State names have been removed Sources: 2017 NRI Inpatient Forensic Services Study, and 1995-2015 9

One Day Census Per State of Adult Forensic Patients Per 100,000 Adult Civilians 25 One Day Census Per State of Adult Forensic Patients at State Psychiatric Hospitals Per 100,000 Adult Civilians, 1999-2014 Based on 28 States with Numerical Values for All 8 Years 20 15 10 5 0 1999 2002 2004 2005 2006 2009 2011 2014 Year Sources: 2017 NRI Inpatient Forensic Services Study, and 1995-2015 10

Change in Forensic Composition Between 2002 and 2014 11 80.00% 70.00% Change in the Forensic Composition of State Psychiatric Hospitals, 2002-2014 Based on 28 States with Numerical Data for All 7 Years 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 2002 Versus 2014 0.00% -10.00% -20.00% -30.00% State names have been removed Sources: 2017 NRI Inpatient Forensic Services Study, the Uniform Reporting System. and the 1995-2015

Conclusions State psychiatric hospitals have seen an increase in the number of adult forensic patients from 1999 to 2014 But the degree of increase varies among states A larger proportion of the state psychiatric hospitals population is comprised of forensic patients and is increasing 12

Pre-Trial Evaluations 13

One Day Census Per State of Pre-Trial Evaluation Patients 14 30 One Day Census Per State of Pre-Trial Evaluation Patients at State Psychiatric Hospitals, 1999-2014 Based on all 51 States 25 Median Average 20 15 10 5 0 1999 2002 2004 2005 2006 2009 2011 2014 Sources: 2017 NRI Inpatient Forensic Services Study, and 1995-2015

All States Percent Change 350% 300% Percent Change in the Inpatient Pre-Trial Evaluation Population, 1999-2014 Based on the 17 States with Numerical Data for 1999, 2005, and 2014 1999 to 2005 2005 to 2014 1999 to 2014 250% 200% 150% 100% 50% 0% -50% -100% -150% State names have been removed Sources: 2017 NRI Inpatient Forensic Services Study, and 1995-2015 15

Incompetent to Stand Trial (IST) Restoration Services 16

One Day Census per State of Incompetent to Stand Trial (IST) Patients 17 One Day Census Per State of Incompetent to Stand Trial (IST) Patients at State Psychiatric Hospitals, 1999-2014 Based on all 51 States 160 140 120 100 Median Average 80 60 40 20 0 1999 2002 2004 2005 2006 2009 2011 2014 Sources: 2017 NRI Inpatient Forensic Services Study, and 1995-2015

One Day Census Per State of Incompetent to Stand Trial (IST) Patients 1400 One Day Census Per State of Incompetent to Stand Trial (IST) Patients at State Psychiatric Hospitals, 1999-2014 Based on 23 States with Numerical Values for All 8 Years 1200 1000 800 600 400 200 0 1999 2002 2004 2005 2006 2009 2011 2014 Sources: 2017 NRI Inpatient Forensic Services Study, and 1995-2015 18

All States Percent Change 300% Percent Change in Inpatient Incompetent to Stand Trial Population, 1999-2014 Based on the 26 States with Numerical Data for 1999, 2005, and 2014 1999 to 2005 2005 to 2014 1999 to 2014 250% 200% 150% 100% 50% 0% -50% -100% State names have been removed -150% Sources: 2017 NRI Inpatient Forensic Services Study, and 1995-2015 19

All Forensic Statuses 20

Median Number for One Day Census Per State 90 80 70 60 50 40 30 20 10 0 The National Median for the One Day Census Per State of Forensic Patients in State Psychiatric Hospitals from 1999-2014 by Forensic Category Based on Data from All 51 States 1999 2002 2004 2005 2006 2009 2011 2014 Year IST Not Guilty By Reason of Insanity Pre-Trial Civilly Committed Sex Offenders State Prisoners Jail Detainees Other Forensic Note: A higher number of states reported in 2002 than in 1999 and 2004. The median for 2002 was 142. The median for 2002 was dramatically higher than the medians for all other years. As a result, the median from 1999 was used for 2002 in this graph. Therefore, the median for 2002 should be interpreted with caution. Sources: 2017 NRI Inpatient Forensic Services Study, and 1995-2015 21

22 Conclusions An increasing proportion of state psychiatric hospitals forensic population is composed of Incompetent to Stand Trial patients NGRI patients and civilly committed persons with a history of sex offenses also account for a proportion of the forensic population that occupy beds for a long period of time The rise in the proportion of beds occupied by the forensic population has led to increased expenditures for this group The rise in the forensic population in state hospitals may be attributed to an increased number of referrals from the judiciary In some states, litigation and threat of litigation has occurred related to the amount of time taken to admit forensic patients Each state faces their own unique challenges related to forensic patients. The issues are highly complex States are implementing a broad diversity of approaches to help address the demand for forensic services within the state psychiatric hospitals The demand for inpatient services is directly related to the array of services available in the community

Contact: Vera Hollen, M.A. Senior Director of Research and Consulting Vera.Hollen@nri-inc.org 703-738-8165 Amanda Wik, M.A. Research Associate Amanda. Wik@nri-inc.org 703-738-8178 23