As Georgia's county jails struggled to cope with a growing number of mentally ill inmates in the 1990s, a similar struggle was under way in state prisons.

The prison system's mentally ill population more than quadrupled, from 1,251 in 1991 to 5,737 in 2001.

During that same time, state spending on prison mental health services grew nearly tenfold.

But in the 1990s, when Georgia's population swelled by 26 percent and the state government budget nearly doubled, total state spending for mental health services in communities and hospitals remained flat.

"It's pretty clear that where the state is building its capacity to handle mental illness is in corrections," says Mary Sloan, director of NAMI-Georgia, the state branch of the National Alliance for the Mentally Ill.

Annual spending for mental health services in Georgia's prisons rose from $2.6 million in fiscal 1990 to $24.1 million in 2001. Mike Spradlin, administrator of health care for the state Department of Corrections, says Georgia's prison system will spend $6.6 million for psychiatric medications this year. That's nearly a third of the prison system's $23.2 million pharmaceutical bill.

"We currently have right at 6,000 inmates on the mental health caseload," Spradlin says.

The prison system's annual bill for mental health care represents more than $4,000 for every inmate on the mental health rolls. And that's on top of the more than $17,000 that the prison system estimates it costs to house an average inmate, minus mental health care.

The total bill comes to more than $125 million a year to house, guard and treat 6,000 mentally ill prison inmates. That's more than half of what Georgia spends on its entire community mental health system.

"It's shocking when you look at it," says Mike Light, executive assistant to Georgia's commissioner of the Department of Corrections. "Ever since the decentralization of the mental health system ... we became the catchment for the mentally ill."

He says the prison system is under court order to provide adequate medical care. The department had no choice but to invest in mental health services.

The prison system has its own shadow hospital, complete with services reminiscent of a conventional psychiatric hospital.

"It will range from an inmate living in the general population but being on the mental health caseload and receiving medication and seeing his counselor to an inmate who is housed in a special housing unit - a supportive living unit that is more of an inpatient type of setting," Spradlin says.

If an inmate has an acute psychotic episode, he says, "We have crisis stabilization units at institutions around the state."

The prison system now fields treatment teams that include psychiatrists, psychologists and clinical nurse specialists.

Spradlin says the percentage of mentally ill inmates has been growing at roughly 1 percentage point a year for the past five years.

Today, the 6,000 people on Spradlin's mental illness rolls represent 13 percent of the 46,000 state prison inmates. Some advocates think Georgia's prison statistics may be understating the problem. Based on a federal estimate, the number of people with mental illness in Georgia prisons could be as high as 7,500.

"Bear in mind, these inmates are not with us because they have a mental health problem. Somewhere along the line they broke the law," Spradlin says. "Whether they should be here as opposed to someplace else, that's for someone else to determine. But since we have them, we work to provide appropriate treatment for them."

Lagging treatment, more imprisonment

Sloan says she sees a direct link between the growing prison mental illness rolls and the state's lagging support of treatment services that could prevent people from being imprisoned in the first place.

Advocates for the mentally ill say that without treatment, mentally ill people on the streets often use illegal drugs as a substitute for legal medicines. Then they are liable to be arrested for felony drug offenses. For others, life on the streets can lead to violence.

"If you have someone who has a mental illness and becomes homeless, it doesn't take much to see there are going to be more situations where they get in fights and get victimized," says Sloan. "Perhaps they'll be committing violent crimes such as assault, and they're vulnerable."

Sloan and other advocates have watched with frustration as Georgia added mental health funds to the prison system while state support has failed to grow for mental health services in Georgia's communities and hospitals.

When state leaders speak about the mental health system, they tend to focus on a growing investment in the community mental health system.

In a statement released last week through his press office, Gov. Roy Barnes said funding for community-based mental health services has increased significantly during the past four years. What he did not mention is that hospital funds decreased during that same time.

Georgia's total spending on mental health is difficult to determine. The Department of Human Resources says it cannot break out mental health spending from the total budget, which also includes money for mental retardation and substance abuse services. But the sum of state and Medicaid spending on psychiatric hospitals and community mental health services hovered between approximately $550 million and $600 million every year between 1993 and 2001.

By that rough measure, the overall state investment in mental health services remained virtually unchanged.

Scott Frederking of the Governor's Office of Planning and Budget said he questions whether that total is accurate. However, neither he nor officials at DHR could offer a better one.

Mental health advocates say Georgia is falling behind.

One in five Americans experiences a mental illness in the course of a year, according to a 1999 report by the U.S. Surgeon General. Authorities estimate that at any given time, 2.8 percent of the American population has a severe mental illness. In Georgia, in 1990, that represented 181,000 people. Today it's 230,000.

"You've got more people, the same dollars, a little inflation. It doesn't take too much to realize the dollars are actually declining," says Sloan. "You look at the population of a large state like Georgia, and you see an awful lot of people who need help and not enough money to provide that help."

Per capita spending figures support Sloan's contention that Georgia is lagging.

In 1990, Georgia ranked 26th among states for per-capita mental health spending. In 1997, the most recent year for which a comparison is available, it ranked 33rd. The per-capita figures are not an exact match, because states organize their mental health systems differently. But mental health officials say they do provide a rough basis for comparison.

"Georgia is clearly below the average," says Dr. E. Fuller Torrey, a nationally recognized authority on public mental health policy. He says the chances are "marginal" at best that Georgia can deliver good mental health services with that level of investment.

Department of Human Resources Commissioner Jim Martin acknowledged that his agency has less to work with now than a decade ago.

"I do think the primary public policy focus in this state over the past decade has been education and corrections," Martin says. "That's where a lot of the new state dollars have gone. That's a public policy issue for the governor and the Legislature to address. The consequence has been that we have not had as much money in human services as we would like."

Cost effectiveness

There are reasons to believe that community mental health treatment is more cost effective than imprisoning or hospitalizing mentally ill people.

The hospital is the most expensive option. Karl Schwarzkopf, director of the DHR's Division of Mental Health, Mental Retardation and Substance Abuse, says it costs an average of $300 a day - $109,500 per year - to treat someone in a state psychiatric hospital.

"We can get a lot of community services for less than $300 a day," he says.

Many observers say that in Georgia, DeKalb County provides some of the most complete community services. DeKalb Community Service Board Director Derril Gay says the average cost of treating an adult mental health client in DeKalb is $3,076 a year. That figure could be higher if the state provided more in the way of housing and outreach, two of the services that advocates say are most needed.

But even with those added costs, most advocates believe a full array of community-based treatment and support services would be more cost-effective than jail.

On average it costs more than $21,000 to keep a mentally ill person in prison for a year.

Macon psychiatrist Richard Elliott, former medical director of Georgia's mental health system, says numerous studies have shown that good community mental health services are no more costly than locking sick people in jail and provide more benefit to society.

"Jails are really quite expensive," Elliott says. "And you have to look at other costs such as transporting people out to Central State. That's very expensive for the sheriffs to do that."

But treating people and helping them live useful lives have hidden benefits, Elliott says.

"For example," he says, "if you can get somebody back into sheltered employment or full employment, then they're not on the welfare rolls. You save money there. Once they get into full employment, they're paying taxes. When you look at the range of the different kinds of money going back and forth, there's a net savings."

Providing those services would require the state to begin investing more money in its community mental health system. Officials say it's hard to say how much more.

Laura Ciprotti, a mental health advocate in Atlanta, estimates it would take $167.5 million to bring Georgia's mental health spending in line with the growing needs.

But new state dollars for Georgia's mental health system will be hard to find in the 2002 legislative session. The post-Sept. 11 economic slowdown prompted Barnes to order his department heads to cut budgets.

The governor recently told lawmakers that this year's budget is tight and next year's will be even tighter.

The call for cuts to human services dismayed NAMI's Sloan.

"Mental health funding has been flat for the past 11 years," she said in a recent letter to NAMI supporters. "Population has been increasing. One in five persons has a mental illness. More people, more illness. Same dollars. What can we cut? In good conscience, we have to say, 'nothing.'"

But cutting "nothing" isn't an option for DHR Commissioner Martin. He says the Division of Mental Health, Mental Retardation and Substance Abuse staff has tried to identify cuts that "at least wouldn't be a step backwards."

"That's our plan to get through the immediate crisis: To try to maintain our position," he says. "And in the long run, as the economy comes back, to be more aggressive in making our case to the governor about the need for additional resources in this area."