When Devin Davis was released from the Hamilton County Jail in September 2009, he had no idea where to go.
In and out of jails, prisons and mental hospitals since 2002, Davis - who has bipolar disorder - had no steady source of medication, no job opportunities and no home.
Without money or health insurance, there weren't many options for treatment. Though his manic episodes were escalating, Davis was not eligible for a bed at the state-run Moccasin Bend Regional Mental Health Institute because he was not deemed a danger to himself or others.
Up all day and night in a manic state after leaving the jail, he walked aimlessly till his feet bled. After about a week of living on the streets, he was arrested while trying to break into a pawn shop - and went straight back to jail.
"It was almost a relief, getting arrested," Davis said. "I was seven days off my meds, hungry, sleep deprived, on top of the manic episodes. When I went into custody I was thinking, 'At least this way I'll be getting some type of treatment. It may not be the best treatment, but it's better than this.'"
As health care costs climb and public mental health services continue to be weakened by budget cuts from states struggling to cope with economic fallout from the recession, cells in the Hamilton County Jail system are swelling with inmates diagnosed with mental disorders.
Today, about one in six inmates at the county jail deals with a mental illness such as bipolar disorder, schizophrenia, psychosis or depression, jail records show.
"Its increasing all the time," said Hamilton County Jail Chief Tim Gobble. "Frankly, we're not equipped to handle the scope of the issue. Some of them certainly need to be behind bars, but for many, jail is really not the place they should be."
Some are charged with violent crime, but most have been picked up for minor offenses - public disorder, trespassing or public intoxication - according to Chuck Courtright, a criminal justice liaison who works in the jail, counseling inmates with mental illnesses through a partnership with Johnson Mental Health Center.
"It's clogging our system with minor crimes and cycles of recidivism," Courtright said.
Each day, about $6,000 of the tax-funded Hamilton County Jail budget goes to house and feed inmates diagnosed with mental illness. That doesn't include the cost of medication or providing for mentally ill inmates at Silverdale Detention Center, which contracts with Hamilton County to hold female offenders and additional male offenders.
The problem is not unique to the county. Federal statistics from 2006 reveal that more than half of all prison and jail inmates nationwide were found to have a mental health problem, according the Department of Justice. Experts say that because of the recession, those numbers have mounted.
"Our jails and prisons are becoming the gateway service center for mental illness today," said Roger Thompson, University of Tennessee at Chattanooga associate professor of criminal justice. "What we know is that jails and prisons are not designed to offer the treatment needs of mental illness."
When mental health care providers say they worry about individuals "falling through the cracks," jail is at the center of that worry.
Law enforcement officials concur that the "arrest-release-relapse" cycle costs the county millions of dollars each year, stretches jail resources thin and usually only aggravates the conditions of mentally ill inmates.
And mental health care providers say they don't expect the situation to improve any time soon.
"We'll really only see recidivism reduced when there are a more long-term, holistic structures of support for the mentally ill," Courtright said.
JAILS FILLING UP
Of the 496 inmates at the Hamilton County Jail recorded during a census at the beginning of February, 86 had a diagnosis for a mental illness - about 17 percent, a figure jail officials say is about standard.
"I have started introducing myself at meetings as Moccasin Bend East because we house so many people with mental health issues," said jail Capt. John Swope. "The unfortunate thing is that we don't have the doctors or counselors."
Every two weeks, the jail has a nurse practitioner come in for eight hours to see inmates with mental illness and manage psychiatric prescriptions.
"Its not enough, but it's all we've got," said Beverly Cooper, nurse manager at the county jail. Cooper said the cost of psychotropic medication is $3,000 to $7,000 each month - about 45 percent of her total drug bill.
"The price of psych meds is just astronomical," she said.
Before 2010, the jail did not track its number of inmates diagnosed with mental illness, but Swope said the number has risen steadily over the past five years.
"You're always going to have people struggling with mental illness in jail. But lately its just gotten so much worse," Swope said.
The jail's capacity is 508 inmates per month, but recently it's been averaging about 520 inmates.
"The increase of mentally ill offenders does boost our population," Gobble said.
Records at Silverdale also show an increase in inmates with mental illnesses. In 2008, about 26 percent of inmates in the facility each month were diagnosed with a mental illness. By 2010, that number had grown to more than 33 percent of Silverdale's 900 inmates per month.
"It's obvious to me that I have more mentally ill people all the time," said Edna Shepherd, Silverdale's health services administrator.
Shepherd estimates Silverdale spends $10,000 to $12,000 on psychiatric drugs per month. And because of budget restrictions, the medications Silverdale gets are usually older and cheaper brands, typically not as effective.
Davis said the inconsistencies of medication in the prison system exacerbated his condition.
"Between the jails and prisons and mental hospitals and everything, my medication was always getting ying-yanged," he said. "Most jails and prisons take the cheapest way out, because they have to."
NATIONAL SCOPE and BUDGET CUTS
Courtright said the increased number of mentally ill inmates is partly because of better recognition and diagnosis of mental disorders, but it's also a direct consequence of state budget cuts to mental health services.
Major cuts to Tennessee's state mental hospitals began in 2008, according to Tennessee Department of Mental Health spokeswoman Sarah Lingo.
Since then, state discretionary funds for mental health care have been reduced by $21.5 million from about $172 million.
One result has been fewer beds at state mental health hospitals such as Moccasin Bend, which has cut 25 beds since 2008. According to Lingo, there are still beds available throughout the state, and the reduction was a "right-sizing move," conducted with the goal of directing more people to less-restrictive, community-based care.
But Courtright said most of the mentally ill who end up incarcerated lack stable families or active community support. Many are homeless.
"On top of that, the funding for community health services just hasn't followed," he said.
Slashes to state mental health budgets span the nation. From 2009 to 2011, cuts to non-Medicaid state mental health spending nationwide totaled more than $1.8 billion, according to the National Alliance on Mental Illness. Medicaid funding - the prime source of money for public health services - will be reduced when the federal stimulus package expires in June.
In his proposed budget for the coming year, Tennessee Gov. Bill Haslam proposed $1.5 million in cuts to the state's mental health and alcohol and drug abuse services. If passed, those cuts could mean more than $300,000 will be docked from community mental health services already reeling from three years of budget cuts.
But mental health care providers say they will be forced to give up significantly more resources if Haslam and state lawmakers slash TennCare payments by 8.5 percent, as the governor has proposed.
In a letter to Haslam, Bob Benning, chairman of the Tennessee Coalition for Mental Health and Substance Abuse Services, said providers initially thought mental health services in general came out favorably in Haslam's budget.
"Now that we understand that community providers of outpatient mental health services stand to see a potential rate reduction that could total up to $25 million," the letter stated.
Meanwhile, the demand for community mental health services has grown.
"There has been more effort over the last several years to establish community services for the mentally ill. They're woefully underfunded, and woefully inadequate compared to the need," said Donna Maddox, director of the Johnson Mental Health Center in Chattanooga.
In 2007, the center scheduled 2,483 first-time appointments. In 2010, it scheduled 4,666. Maddox said the spike in numbers means people have become more willing to seek help for mental illness, but it's also a consequence of the floundering economy: More people need subsidized health care, and more people are suffering anxiety and depression.
Like many community health centers, the Johnson Center depends on funding from a variety of funding sources, including state grants.
"We're still waiting to see how the budget settles to see which grants will be renewed next year, which programs will be safe," Maddox said.
In Georgia, Gov. Nathan Deal's proposed budget for fiscal year 2012 recommends an increase of about $35.6 million in general fund dollars for mental health services. The infusion of money is a response to a U.S. Department of Justice lawsuit against the state's mental health department over poor conditions in state psychiatric hospitals, according to the National Alliance on Mental Illness.
Jane Elmore, president of National Alliance on Mental Illness' Chattanooga chapter, said state and county agencies will be forced to shell out money to meet mental health needs one way or another.
"You cut mental health funding, you have to increase funding for criminal justice, ERs, family services," Elmore said. "Really, it's a pay-me-now-or-pay-me-later situation. Do you want to pay a jail guard or a mental health therapist?"
BREAKING THE CYCLE
Davis' entanglement with the justice system began in 2002 when he was arrested for burglarizIng a pharmacy in East Ridge. Since then, he has spent 71 months either in jail or state prison.
Most of his subsequent charges stemmed from burglaries, attempted burglaries and probation violations. The majority of the burglaries were of pharmacies as he tried to satisfy a long-term addiction to prescription painkillers and psychoactive drugs. For Davis, the cycle of release and relapse furthered a spiral into addiction and crime.
"I kept getting worse. I can't understate how psychologically damaging it can be, going in and out of the system. Especially when you don't have consistent, proper treatment," he said.
In mid-2010, Davis was again in jail, awaiting sentencing, "basically at rock bottom," he said.
But this time, he met people who weren't going to let him stay there. Davis was approached by a member of the Hamilton County Public Defender's Office who told him he was eligible to take part in a new initiative that might help him break the pattern of recidivism. It was called the Bridge Project.
Developed in March 2010 by the public defenders' office, the Bridge Project was a post-booking conditional release program developed for offenders struggling with mental illnesses. Once approved, candidates were assigned a case manager and a release plan, filing goals and stipulations with a judge.
"The idea behind the Bridge Project was taking these individuals and meeting their needs under the court rather than incarcerating them," Courtright said.
To Davis, the Bridge Project was a lifeline.
"Not to be thrust into the same destructive environment that got me caught up in the legal system in the first place? It didn't seem possible," he said.
Davis applied and was approved. But a few weeks later he received bad news: The Bridge Project had lost its funding and was defunct.
Because Davis already had been promised help, those who had been involved in his initiative pooled their resources to ensure he still would receive assistance after his release. He found a case manager in Chia Zellermayer, who helps manage the Homelessness Prevention and Rapid Re-Housing Program with the AIM Center, a local psychiatric rehabilitation center.
Zellermayer picked him up from Silverdale in August 2010 and took him to a group home.
"Chia kept checking up on me, making sure I was doing what I was supposed to do," Davis said. "People were helping me make sure I didn't waste this chance."
He completed an intensive detox program for over nine weeks, learning coping skills and how to avoid triggers that could spark an urge for drugs.
He became a member of the AIM Center, where his week gained structure. He now works for a local restaurant in a transitional employment position set up through the AIM Center. That stint ends in April, but the restaurant wants to keep him on permanently.
Last December, he moved into a duplex in Brainerd through AIM Center Housing - something he thought he'd never be able to do with a felony record. Old friends he reconnected with have helped him furnish it. He's playing guitar, his longtime passion, and has adopted a tabby cat named Miss Putty- from the old Tweety Bird catchphrase "I t'ought I saw a putty tat."
"I couldn't explain how wonderful it is - people that care," he says again and again. "I don't think I'll ever make anyone understand just how grateful I feel."
Stories like Davis' give Courtright hope, but he says systems are not in place for other inmates to follow suit. His own state-funded grant that he used to help pay for housing and treatment for inmates like Devin is spent, and he doesn't anticipate seeing that kind of a money again.
"When everything falls together in place, we can make a difference for someone like Devin," Courtright said. "But we have no comprehensive plan we can offer the mentally ill leaving jail," he said.
He said the reinstatement of a program like the Bridge Project would make a world of difference among the people he counsels.
Another model for such a system lies in the mental health court system, which traditionally provides offenders with mental disorders alternatives to prison sentences, intensive case management and help finding medication and housing.
On March 14, Georgia's state Senate voted 50-0 for a bill to create mental health courts across the state.
"We're looking for better ways to spend our correctional dollars and this looks like a smarter way," said Sen. Johnny Grant, R-Milledgeville, sponsor of the bill. Milledgeville is home to Central State Hospital, the state's largest mental health facility.
"Mental health courts are proven to reduce recidivism and reduce the amount of time someone spends in jail. They help get treatment to people whose major issue is not criminality. Their issue is illness," Grant said.
Researchers say states that set up special facilities and programs that help offenders find treatment, housing and jobs pay off in the long run.
A study of Baltimore courts that handle drug cases and emphasize treatment found that they not only significantly reduce recidivism, the courts save the city up to $1.46 for every $1 they cost, The Associated Press reported. Another study in Washington state found that sustained mental health treatment cut repeat offenses up to 20 percent, according to the AP.
The idea of such a system is attractive to Courtright.
"If you could have more monitoring and intensive case management of these people under the authority of the court, you would see much greater success and less recidivism," he said. "If mentally ill people keep going to jail, getting out, and going right back in - then something is obviously wrong with the system."