Jonathan M. Meyer
California has the largest population of mentally ill defendants nationwide, and on June 27, 2018, the governor signed into law Assembly Bill 1810 that offered every county the opportunity to establish diversion program procedures (Section 15), and opened program access to all mental health diagnoses excluding antisocial personality disorder, borderline personality disorder, and pedophilia.1 This measure thus reflects the increasing nationwide interest in channeling seriously mentally ill individuals away from traditional legal processes into pre-trial diversion programs.2 On an individual level the goal is to provide treatment for mental health conditions, decrease the legal burden and consequences of arrest, and facilitate integration with community support structures. Despite the expense of jail diversion, a fiscal benefit is realized immediately through reduced costs of custodial care, especially for defendants deemed incompetent to stand trial who may have faced lengthy detours through jail and state hospital competency restoration programs.3 The longer-term fiscal benefit is derived from those who successfully complete mental health court treatment, as diversion program completers experience fewer post-treatment arrests and days incarcerated.4,5
While the use of community-based resources allows appropriate diversion clients to be managed as outpatients, provision of care outside controlled settings (e.g. jail and hospital) presents a set of challenges for monitoring treatment fidelity. Schizophrenia patients benefit from mental health court participation, and schizophrenia spectrum disorders remain the core group targeted by many diversion programs across the nation.6 For schizophrenia spectrum disorders antipsychotic medication is the foundation of treatment, and medication nonadherence not only increases illness relapse risk but is also associated with higher recidivism rates in forensic patients. Among a cohort of 63 prison parolees with a schizophrenia diagnosis previously found not guilty by reason of insanity, poor adherence to treatment increased the odds of reoffense by 10-fold (OR = 10.42; p = 0.001).7 Importantly, in a large (n = 11,462) Canadian study of offenders with schizophrenia and a mean follow-up of 10 years, lower antipsychotic adherence levels were significantly associated with increased adjusted risk ratios (ARR) of violent (ARR = 1.58; 95% CI = 1.46–1.71) and nonviolent (ARR = 1.41; 95% CI = 1.33–1.50) offenses compared to those with high adherence rates (≥ 80%).8 Although jail diversion programs must provide a comprehensive array of services, including supported housing, case management, substance use treatment, and appropriate rehabilitative options (i.e. cognitive, psychosocial, vocational), maintenance of participant psychiatric stability is key to the successful completion of mental health court dictates. Because antipsychotic nonadherence looms as one of the biggest factors in psychiatric relapse and recidivism, measures to track and mitigate nonadherence must be incorporated into the treatment protocols of all diversion programs.9 The purpose of this focused review is to provide a description of how evidence-based strategies, including pill counts, plasma antipsychotic levels, and long-acting injectable (LAI) antipsychotics, can be implemented in outpatient diversion programs with the goal of minimizing risks of treatment failure related to inadequate antipsychotic treatment.