Big cities have always been a crucible for innovation, endowed as they are with the mixed blessings of diversity and density, so it should be no surprise that innovations in public sector psychiatry are being distilled in the Midwest’s largest city, Chicago.

Among those innovations are pilot programs designed to expand the use of outpatient commitment and to streamline the reentry of the jailed mentally ill back into the community. These were among the programs discussed at APA’s Institute on Psychiatric Services, held in New Orleans last fall.

The nation’s jails have become the repositories of last resort for untreated, severely mentally ill people, observed panelist Ronald Simmons, Psy.D., chief of adult forensic services in the Office of Mental Health, Illinois Department of Human Services. While the prevalence of "any severe disorder" in the U.S. general population is 1.8 percent, among male inmates it is 6.4 percent and among female inmates 15.0 percent, he noted. Deinstitutionalization, originally promoted as a civil liberties measure, has resulted in the de facto criminalization of the severely mentally ill, he observed.

In Chicago, as in other big cities, this translates into large numbers of mentally ill criminal inmates. Simmons and session chair Thomas Simpatico, M.D., codirect the Cook County Jail Project, a pilot program designed to help incarcerated mentally ill persons successfully reintegrate into the community upon their release. Simpatico, a psychiatrist, is chief of the Bureau of Chicago Network operations, which oversees mental health services for three hospitals and about 80 community mental health centers serving more than 12,000 people.

Although some mentally ill inmates get medication, "I’m convinced that real treatment cannot occur in the incarcerated setting," Simmons said. Of the approximately 300 new prisoners who enter the Cook County Jail every day, about 30 are found to need mental health services, said Simmons. The jail has more than 11,000 inmates.

Since January 1999, 19 men and 10 women have been referred to the Cook County Jail pilot program. Of the 29, 16 were diagnosed with schizophrenia, six with bipolar disorder, and the rest with other disorders.

"As far as we know, none of the 29 has been readmitted to an inpatient facility, and none has reoffended," he said. In addition, said Simmons, "their quality of life has improved because they are living in the community in semi-independent settings," he added.

The program involves meeting with community mental health workers and jail officials about three months prior to release. "Then the [community mental health workers] try to engage the inmates and develop some kind of relationship." They try to convince them that there is an alternative to a cycle of crime and reincarceration. "At some level the inmates acknowledge they are locked into the cycle and want some relief."

Simmons is optimistic that as the data come in, they will encourage an expansion of the funding for the program. There are hundreds of inmates who could benefit from the program at this time, said Simmons.

Outpatient commitment is an underused approach with great potential, according to panelist Mark Heyrman, J.D., clinical professor of law at the University of Chicago Law School. As of 1999, 40 states and the District of Columbia had some statutory provision for outpatient commitment, but few have pursued the use of outpatient commitment in any systematic way, he noted. Used correctly, outpatient commitment can reduce rehospitalization and enhance treatment adherence, said Heyrman.

The Illinois Department of Human Services recently created a pilot project on the north side of Chicago for persons involuntarily committed to the city’s Read Mental Health Center. The pilot project is directed by Simpatico.

Under the pilot program, some involuntarily committed patients have received an opportunity to agree to outpatient commitment contingent upon the approval of hospital officials and a judge. The system works as follows: if all parties agree, the judge enters an order committing the patient to the care and custody of an outpatient provider, explained Heyrman. The order details the obligations of the patient and the services to be provided. If the patient fails to comply, the outpatient provider may have the patient rehospitalized simply by completing a "certificate of need for rehospitalization," Heyrman said.

Although the pilot has been successful, it has been very limited in scope. In large part, this is because in Illinois, few patients are involuntarily committed each year, making the potential pool for outpatient commitment very small. Although thousands of involuntary commitment petitions are filed statewide each year, most of these result in an agreement by the patient for voluntary commitment. Heyrman would like to see the state code modified to allow anyone facing the possibility of involuntary commitment to opt for outpatient commitment in lieu of either voluntary admission or involuntary commitment.

One intangible obstacle to greater use of outpatient commitment is stigma. "To call yourself a mental health lawyer or a mental health judge is to put yourself at the bottom of the totem pole" in terms of professional prestige, Heyrman said. More tangibly, the commitment court in Chicago has become the site of "wholesale justice" with dozens of patients being run through the system quickly and impersonally, he added.

So far, none of the outpatient providers in the North Chicago pilot program has had to resort to the enforcement mechanism, a good sign that the approach is working, he said.—R.B.K.