BILLINGS — Montana’s legal system is dealing with the impacts of untreated mental health symptoms in the community, including in Yellowstone County’s District Court. Criminal and civil cases are being impacted by the crisis in different ways.
District Court Judge Jessica Fehr says systemic issues with mental health in the criminal justice system worsened due to the COVID pandemic.
“Its a huge issue. It backs up our dockets, it backs up our courtrooms, it fills up our jail, so its just kind of a ripple effect of what it does,” said Fehr.
She said mental health issues now seem to permeate every aspect of her caseload, including in the two treatment courts she oversees, Family Treatment Court and the Seize Opportunity and Recover (SOAR) court, which is a program for first-time felony drug offenders.
She said before COVID, there were more local mental health professionals and shorter wait times to send people to the state hospital.
“I think we all feel it and see it. After being locked in for two years, we’re seeing an uptick in mental health issues. We’re seeing an uptick in domestic violence related to mental health issues. There is not, I can say, there is not a single drug case, that I see in either of my treatment courts, and I think in most of my criminal cases, where there isn’t an underlying mental health issue that maybe went untreated, that maybe, they’re self-medicating,” Fehr said.
There are multiple factors contributing to long wait times for cases to be resolved across the board, including large caseloads for district court judges.
Cases where people with severe mental illness commit crimes have an additional step that extends their case. If a judge decides someone needs to be evaluated for mental fitness before proceeding with their criminal case in Yellowstone County, that person will sit in jail, waiting in some cases for over a year.
Judges have to make a determination if the individual is a flight risk, or a risk to themselves or others. Fehr said in limited cases, the defendant's family can support care in the community to keep them out of custody.
The Montana State Hospital’s Forensic Mental Health Facility conducts these evaluations and is experiencing high demands on its facility.
“We have some really, significantly sick people, and we have few options,” Fehr said.
Fehr said she observes defendants worsening while waiting in the jail, in part due to isolation and in part due to the defendant's need for more mental health treatment than the jail can provide.
The Yellowstone County jail brings in psychiatric care and telehealth appointments for defendants. The jail is currently operating with almost two dozen open detention officer positions and about 150 inmates over capacity.
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“The downside is, people get worse. The initial symptoms that led me to issue an order for evaluation simply get worse as they sit longer and longer,” Judge Fehr said.
The state hospital’s Forensic Mental Health Facility (FMHF) in Galen conducts court-ordered mental fitness evaluations.
According to Department of Public Health officials, there are 54 beds for inpatient evaluation services. In Mid-April, there were 40 men and 27 women on the facility waiting list.
Montana Department of Public Health and Human Services officials said there is no average wait time for people in need of an evaluation for mental fitness.
Once an individual is admitted to the facility, they may need to stabilize from psychiatric, medical, and chemical dependency issues before an evaluation can be conducted.
Officials said there is an insufficient number of beds and psychiatrists at the mental health facility to handle the demand for court-ordered inpatient evaluation from courts across Montana.
COVID-19 quarantine procedures exacerbated the historic bed shortages at Warm Springs and at the more recently established facility in Galen, which opened in 2016, according to agency officials.
A lack of local mental fitness evaluators in communities across Montana also contributes to the high demands on the state hospital to do the work.
Fehr said there is one psychiatrist in Billings who does initial evaluations for the Yellowstone County courts, and that provider is retiring soon.
“Our only option will be the state hospital,” Fehr said.
A variety of factors contribute to the lack of local providers and a lack of providers willing to do court-ordered evaluations, which are often paid for by Medicaid.
Medicaid reimbursements for mental and behavioral health care were cut significantly during the 2017 legislative session, which may have contributed to a decreasing number of providers willing to provide Medicaid-paid services.
Fehr said she thinks there are fewer providers in the community taking Medicaid due to the reduced provider rates, and that during COVID, providers scaled back their practices.
“Times for admission have also been affected by situations where FMFH restored a defendant to fitness to stand trial, but the defendant was then not timely tried in court, discontinued prescribed medications, was again jailed, and decompensated (and, as a result, became mentally unfit to proceed to trial). This required FMHF staff to re-admit the defendant and restore their fitness to proceed for the same criminal charge,” DPHHS communications director Jon Ebelt said in a statement.
He said Montana State Hospital leadership continues to work on addressing waiting list issues.
District Court Judge Ashley Harada says she volunteers to handle a lot of civil commitment cases because she cares about the individuals in need of intensive mental health treatment.
She often goes to Billings Clinic or St. Vincent Healthcare where people being held due to severe mental health symptoms are evaluated for treatment or possible civil commitment.
The Montana State Hospital in Warm Springs primarily serves people who are civilly committed.
People with severe, disabling mental illness who cannot feed, clothe, or house themselves, among other factors, can be sent to the state hospital for stabilization by a judge’s order.
“Lots of times we see people repeatedly coming into the hospital and then going to the state hospital, and then coming back to our community and then going back to the state hospital. So I’m repeatedly committing people and they are not coming back and getting services in our community because lots of times there’s no services available,” Harada said.
She said short stays at the Montana State Hospital aren’t enough sometimes to stabilize an individual before they are sent back to their community.
“Let’s just say, if somebody goes to the state hospital for two or three days and then they come right back here with a new medication to try, they’re not stabilized. We don’t know that they have been able to understand that they have to take this medication, this medication will make them feel better, that they know the side effects for the medication,” Harada said.
Harada said repeatedly committing people is traumatic for the individuals and their families.
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She said she sees people in need of evaluation for civil commitment come to Yellowstone County from rural parts of the state due to a lack of resources in their communities, which adds to the Yellowstone County caseload.
Harada said she wants to see more local treatment options and case management support so that fewer people decompensate to the point of needing to be committed.
These are the number of commitments, which could be the same individual multiple times, from Yellowstone County to Warm Springs in recent years:
2018 (122)
2019 (109)
2020 (144)
2021 (98)
2022 (87)
2023 (25)
= 585 commitments (2018-2023)
There are some possible solutions on the horizon to address the mental health crisis in Montana.
Gov. Greg Gianforte recently signed a measure passed with bipartisan support from the legislature to create a commission that will work on rebuilding the state's behavioral health system with $300 million dollars in appropriations from the 2023 legislative session.
RELATED: Montana lawmakers seek to fix damage to mental health care from 2017 budget cuts
Fehr said she hopes the commission establishes care managers to support people with severe mental illness in Montana communities that law enforcement and courts can work with.
The legislature boosted Medicaid reimbursement rates across the board.
“I’m optimistic that perhaps we’re going to see more people open up their Medicaid rolls to who they will accept and what they will be willing to take. It is a significantly reduced rate from what a private pay will be able to cover,” Fehr said.
One of the challenging systemic issues for people with severe mental health issues is that there’s almost no case management in Montana communities.
This means when people return from the state hospital after being committed, they may have no support to remain stabilized.
Stays are typically less than a month at the hospital.
"We got to figure out a better way once someone comes back to the community, to do a solid hand off to the team here. to say, you have an appointment at the mental health center, this is the person who is going to make sure you get there, this is where you're going to stay,” Fehr said.
She said people returning on a bus from the state hospital do not get connected to local support as part of the discharge process.
Fehr said she is looking forward to a new Substance Abuse Connect program that is expected to roll out in the next few months in Billings.
A new mobile response unit will help support the initial calls for service for people experiencing mental health symptoms in the community.
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