KALISPELL, Mont. — Inside the white-brick hallways of the Flathead County Detention Center, Jail Commander Jen Root walked up to a steel door with a small window and pointed inside.

“She’s been here almost a year, just laying on her bed,” she said.

Inside the cell, dimly lit by a single window, a woman was curled up under a fleece blanket, only her bright-pink fingernails sticking out.

This woman was charged with burglary in September 2022, Root said. An evaluation after her arrest determined that mental illness prevented her from standing trial and that she required treatment at the Montana State Hospital, the state-run inpatient psychiatric hospital.

Like many inmates deemed unfit for trial due to a mental health condition, she has been stuck on a waiting list for the Montana State Hospital’s 54-bed forensic unit, which stabilizes inmates through medication and treatment so they are competent to stand trial. The woman in the Kalispell jail was No. 2 on the unit’s waiting list of 70 people as of June 30. Meanwhile, the northwestern Montana jail where she’s waiting isn’t equipped to treat mental illness, and the jail staff can’t force her to take medication.

“So, they just deteriorate within our facility,” Root said of her and other inmates with mental health conditions.

Before their legal case can proceed, people charged with crimes in Montana must understand the charges they face and participate in their own defense. But because of bottlenecks in services across the country, people in jail with serious mental illness are waiting months to receive the care needed to “restore” their competency to stand trial.

The Montana State Hospital for years has struggled to keep up with the number of people who are criminally committed to the facility, but Root said the number of such people at the Flathead County jail has grown since the pandemic and as Montana’s recent population boom has pushed up housing costs.

This year, state lawmakers began to address the woes of the troubled state hospital, which lost its federal funding and accreditation in 2022 amid a rash of patient deaths, by creating a $300 million fund to improve behavioral health care in the state and passing bills to increase transparency.

Now, state health officials are asking lawmakers to change criminal commitment laws so the Montana Department of Public Health and Human Services has a say before a judge orders a patient committed to the Montana State Hospital or another state-run facility.

“That is something we would like to address with you,” Chad Parker, an attorney for the health department, told the Children, Families, Health, and Human Services Interim Committee in July. “That is something we’d like to look at to try and change, to give the department some more control, to at least give us a place at the table.”

But Republican Rep. Jennifer Carlson, a member of the interim committee, said that there is nowhere else to send patients facing criminal charges for evaluation and treatment, and that the health department should focus on improving patient care instead of denying patients access.

Parker said judges rarely order patients to be committed at community care facilities as an alternative to the state hospital system, though he acknowledged that community service options have dwindled, in part due to low Medicaid reimbursement rates. Lawmakers raised those rates by about 20% this year, but it will take time to determine whether that increase is enough to rebuild mental health services that have shuttered.

In the meantime, patients are funneled to the state hospital as it’s the only option for many inmates who need mental health care.

“When there are no available patient beds or they are not available for some time, the department can be held in contempt or receive another sanction,” Parker told the legislative committee. “And we need to address that, as well.”

In an emailed statement, health department spokesperson Jon Ebelt said that state law doesn’t require courts to consider wait times before committing inmates to the state hospital for mental health care. Neither Ebelt nor Parker pointed to specific community services or other mental health facilities that could treat inmates in the criminal justice system to become fit to stand criminal trial.

Interim legislative committees study issues during the Montana Legislature’s off years (it is in session only in odd-numbered years), and can draft bills for the next session, scheduled to start in January 2025. During their July meeting, lawmakers on the Children, Families, Health, and Human Services Interim Committee decided to explore what community mental health services are available but did not commit to drafting the legislation sought by the health department. The committee next meets on Sept. 12.

In an interview with KFF Health News and Montana Public Radio, Kalispell District Court Judge Amy Eddy did not address the health department’s proposal to give the state a say on involuntary commitments. But she noted that the state hospital is currently the only facility in the state that can take patients charged with crimes and involuntarily medicate them.

Involuntarily medicating inmates found to be mentally unfit is often the only way to stabilize them so they can stand trial and then be transferred to community services to help them maintain the mental stability that the medications can provide, according to experts in Montana’s judicial and mental health systems.

“It’s not realistic to change the commitment laws and keep people out of Montana State Hospital” unless other tools are developed, said National Alliance on Mental Illness of Montana executive director Matt Kuntz, who has worked in the past with lawmakers on changes to commitment laws.

However, Republican Rep. Bob Keenan said Montana’s commitment laws do need to be reexamined if the state is to rebuild its struggling behavioral health treatment system and reduce wait times for services in the state hospital.

Keenan requested that another committee, the Law and Justice Interim Committee, also study the commitment laws. But Keenan did not request any specific changes, and that committee had not responded to his letter as of Aug. 30.

“Montana has strictness when it comes to forced medication in mental health situations,” Keenan said. “That is something that needs to be looked at.”

Montana guarantees the right to a court hearing before people can be forced to take medication. That could be a hurdle to expanding the types of mental health facilities that can involuntarily medicate patients, particularly among those that can hold patients for only a few days, said Keenan.

The $300 million state lawmakers appropriated this year aims to fund both community-based mental health services and regional mental health facilities that could take on patients who need a lower level of care than what’s offered at the state hospital. But it will take years for any of those initiatives to come to fruition.

While additional mental health services are needed, the state also needs to work on improving care at the state hospital for the patients it does serve, said Eddy, the Kalispell judge.

Eddy said once inmates make it to the state hospital for treatment, they’re typically there for two weeks, instead of the allotted 90 days, before being sent back to the county jails. That makes it difficult to truly stabilize them, she said.

Many inmates refuse to take medication once they return to jail to await their legal proceedings, then they mentally deteriorate, according to Eddy and Root, the jail official. The jails also might be unaware of an inmate’s diagnosis or whether they’re on medication, Eddy said.

“That makes it very difficult, having gone through all this effort to restore this person’s fitness, to then keep them fit to proceed in the criminal stuff,” she said.

Some inmates are left waiting once again in jail only to go back through the process to get treatment at the state hospital.

“Then sometimes they’ve been here for so long, I think nobody knows what to do, and then they get released,” said Root.

With limited community mental health resources, those who are released typically end up back in jail, only to repeat the cycle.

“Probably my biggest frustration with our system is the mentally ill and having people in here that should not be criminally charged,” Root said. “Yes, they’re not safe to be out in the public, but being in jail is not the answer either.”

By Aaron Bolton
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.