“There is nothing, nothing worse than seeing someone in jail for a misdemeanor nonviolent offense who has a mental illness,” said Vicki Maca, director of criminal justice/behavioral health initiatives for a region that encompasses northeast Nebraska.

They’re not in a therapeutic, trauma-informed environment,” she added .

And staff shortages are making things worse.

As Nebraska wrestles with shortages in psychiatric providers, officials are concerned that individuals struggling with mental illness are becoming increasingly entangled in the criminal justice system, frequently winding up in county jails.

And those jails, particularly in more rural communities, face unique challenges in meeting the complex needs of mentally ill inmates, according to mental health providers, jail administrators, county officials and criminal defense attorneys.

At these jails, there is no full-time staff devoted to mental health needs, as there is in the state prison system—which, while facing its own challenges with crowding, has a mental health unit.

The restrictive jail environment isn’t conducive to individuals struggling with mental illness, officials say. Yet those individuals face greater challenges moving through their criminal proceedings—such as long waitlists at the state’s Regional Centers, which conduct court-ordered competency restorations—which lengthen their stays.

Officials worry that challenges in providing continuous care out in the community increase the likelihood that mentally ill individuals may find themselves back in jails multiple times.

At the Saunders and Washington County jails, officials believe that mental illness is playing a far larger role in inmate populations than in the past.

“I’ve been doing this for 37 years, and I don’t ever remember the number of people with mental health issues being as dramatic, or significant, as large as it is right now,” said Captain Rob Bellamy, head of corrections in Washington County.

A 2006 report from the Bureau of Justice Statistics found that 64 percent of inmates in local jails across the country had some sort of mental health problem. The Virginia-based Treatment Advocacy Center estimates that 16 percent of inmates in jails and prisons have a severe mental health illness, such as schizophrenia or bipolar disorder.

More recent, localized data on mentally ill inmates is hard to come by. But generally, rising jail populations are becoming a greater concern for area counties.

The average daily population of Dodge County inmates at the Saunders County jail, which holds inmates from Saunders, Dodge and Sarpy counties, has increased from 61 to 81 since 2012, growing to encompass more than two-thirds of the total jail population, according to Jail Administrator Brian Styskal.

Washington County, meanwhile, is constructing a new, $24.5 million justice center—complete with a 120-bed jail—to accommodate a growing population that routinely exceeds its 17-bed capacity, and requires housing inmates in other counties.

Officials attribute jail growth to a number of factors, such as changes in sentencing laws and rising drug use, which is often coupled with mental illness, especially when individuals face obstacles in receiving proper medication or treatment.

“A lot of crimes are committed are when folks that I know, because I’ve dealt with them over the years, I know they have mental health issues, and doctors and psychiatrists have told me that,” said Dodge County Attorney Oliver Glass.

“I can tell you from my experience that a lot of [mentally ill individuals’] criminal activity occurs when they are self-medicating with alcohol or illegal street drugs.”

A rising population also leads to rising costs. To house its inmates in Saunders County, Dodge County pays a baseline cost of $64.50 per inmate per day, Styskal said, and that doesn’t include additional expenses, such as medical costs, which have been rising. This past year, the county spent $346,569.58 on inmate medical costs, more than double the original budgeted amount of $140,000.

That expense has increased every year since the 2013-2014 fiscal year, when it was just below $30,000. Medical costs have increased in Washington County as well, Bellamy says.

Mental health can play a big role in driving those costs.

A 2017 suicide in the Dodge County jail accounted for $114,000 after the inmate was flown to Lincoln for emergency medical treatment.

But even more alarming than the burden on counties’ budgets is the concern that jails are not an appropriate environment for the mentally ill.

“They’re in a jail, they’re having limited contact with other people, they may or may not be on their meds, they’re not getting support from family and friends like they may need, they’re not maybe seeing the mental health people as frequently as we would all like, ” said Maca who coordinates mental health services for Behavioral Region 6, which covers five Nebraska counties, including Dodge and Washington.

The jails also lack re-entry planning services, Maca said, which are available in the prison system or in larger jails, like in Douglas County. Those services could help line up mentally ill inmates with the resources they need out in the community to stay out of jail: counseling, substance abuse treatment, housing, vocational training and more.

Through Region 6, Washington and Saunders are currently exploring the possibility of adding those services, though there are challenges at the jail level. In prisons, release dates are based on fixed sentences that are easy to predict. For jail inmates whose cases are being processed at varying lengths, preparing such services can be more difficult, Maca said.

Both jails have access to mental health crisis intervention services, which can respond in emergency situations. But those services are provided from outside the jails by local community-based programs, such as Blue Valley Behavioral Health and Lutheran Family Services.

Managing psychotropic medications in the correctional setting is also a challenge, as the medical practitioners from Advanced Correctional work to verify that prescriptions are accurate and that medical and mental health needs are legitimate.

Area defense attorneys are often concerned about how medications are doled out, especially at the larger Saunders County jail. They grow concerned that their clients are being forced off stabilizing medication “cold turkey.”

“That kind of confinement, and that kind of treatment of them really exacerbates some of their mental illness, especially when you restrict them on their access to meds going in,” said Fremont attorney Richard Register, who also sits on the county mental health board, which determines whether mentally ill individuals should be committed to state hospitals.

Generally, getting incarcerated poses frustrations for individuals who are on medications, especially if those medications have withdrawal symptoms, said Lindsay Kroll, Crisis Response Supervisor at Lutheran Family Services in Omaha.

Even in the period of time it takes to verify prescriptions, those symptoms can begin to manifest, she said.

Jail administrators, meanwhile, have to ensure that they are meeting inmates’ medical and medicinal needs while guarding against the potential that medications may be abused. With substance abuse becoming increasingly prevalent, jails need to ensure that prescriptions are legitimate, that needs are real and that inmates struggling with addiction aren’t seeking to compensate for lack of access to street drugs, Styskal argued.

“It makes it a problem for our contract medical provider where, their license is on the line for whatever they prescribe, so they have to be definitely cautious and make sure there is a medical need versus a medical want,” Styskal said.

And often, at the request of attorneys, judges will intervene, signing orders compelling the jails to prescribe those medications, Styskal said, though he believes that those decisions are often made without considering the full history of the inmate and the possibility that they may seek to abuse those medications.

Additionally, inmates with mental health issues often spend longer times in jails than other inmates. Among other contributing factors here in Nebraska is the lack of available inpatient beds at the state Regional Centers—inpatient psychiatric institutions that also provide court-ordered competency evaluations and restorations, when a defendant appears incompetent to stand trial.

Meanwhile, wait times for admissions at the still fully operational Lincoln Regional Center have increased. Mentally ill defendants ordered to receive competency evaluations can be put on long waitlists, awaiting court-ordered resources that must occur before their case can proceed.

The average wait time for a bed at the Regional Center in 2018, through Sept. 30, is 85 days—more than double what it was in 2014. Dodge County inmates have waited for anywhere between 30 to 100 days, said County Attorney Glass. In Washington County this year, one inmate spent more than 10 months waiting for a competency evaluation.

“That’s frustrating from the jail and the jail administrators’ perspective because apparently, the system recognizes that he has a problem that needs to be treated, but yet he continues to be warehoused in a jail because there’s, obviously and apparently, there’s nowhere else for them to go,” Bellamy said.

The Regional Center conducts competency evaluations both inpatient and outpatient, according to the state’s Department of Health and Human Services. The number of those evaluations are up: in 2018, through Sept. 30, there were 223 competency evaluations compared to 138 in 2016. Most of those were conducted in an outpatient setting.

But the higher number of calls means more individuals found to be incompetent to stand trial, which puts them on the waitlist for an inpatient bed for competency restoration, which can only be conducted at the Lincoln Regional Center, DHHS said.

Still, officials and attorneys say that the biggest frustration is the barriers to care outside of jail, like expensive medication or a shortage in psychiatrists. And for those who face those barriers, the criminal justice system may be their first exposure to treatment. Fremont-based attorney Leta Fornoff has seen that firsthand.

“I can say that there have been people that I have represented before that have wished to be incarcerated so that they can get the help they need,” Fornoff said.

“Now that’s few and far between, but it has happened.”

James Farrell is a John Jay Rural Justice Reporting Fellow. This is an edited version of a story published this weekend in the Fremont Tribune, first in a two-part series exploring the intersection of mental health and the local criminal justice system. The full version is available here.