Hawaii has seen a dramatic increase in the number of criminal defendants being ordered by state courts to stay at the Hawaii State Hospital during the past two decades, a trend that has put an enormous strain on the Kaneohe facility.

According to the Hawaii Department of Health, the courts committed 331 defendants to the State Hospital in 2016, accounting for every admission to Hawaii’s only state-run psychiatric facility.

That’s more than a threefold increase from 1997, when 100 patients were committed under court order.

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The number of forensic patients at the State Hospital has been under the spotlight since acquitted killer Randall Saito escaped last month and fled to California, triggering an investigation that has so far resulted in a number of suspensions among employees.

But only a handful of defendants end up at the State Hospital each year in the same way as Saito — automatically committed there after being acquitted of their charges “on the grounds of physical or mental disease, disorder or defect.”

In fiscal year 2016, 16 patients were committed that way.

Meanwhile, a vast majority of forensic patients end up at the State Hospital for reasons relating to their mental fitness to stand trial: Nearly 70 percent of all patients were committed either for being “unfit to proceed” in their cases or to be evaluated for their fitness.

Those who were recommitted after violating the terms of their conditional release made up an additional 26 percent of the admissions at the State Hospital.

Marvin Acklin, a Honolulu forensic psychologist, says “multiple interlocking factors” are likely playing a role in the increase in forensic patients.

Acklin says one factor is that the courts are increasingly aware of how a defendant’s mental illness can affect the ability to receive a fair trial — and how failing to consider competency can become grounds for appeals.

A defense attorney, judge or prosecutor can request a competency evaluation if a defendant exhibits signs of mental illness. A defendant found unfit is required to go through treatment until he or she is “restored” to competency.

But Acklin, who has evaluated more than 600 forensic patients — including Randall Saito, who escaped the State Hospital last month — says the biggest driver of the increase in forensic patients is likely homelessness among the mentally ill.

According to the latest “point in time” count, nearly 1,100 homeless people in Hawaii were suffering from a “serious mental illness” during the week of Jan. 23, when the annual survey was conducted. That’s an increase of more than 30 percent from 2013.

“If people don’t have a place to live, are they more likely to be mentally ill or to commit a crime? The answer to that is likely yes,” Acklin said. “So is this a reflection of what’s happening in terms of being able to provide mental health services to people who are un-housed? I’m sure that there’s a connection.”

Jack Tonaki, the state public defender, concurs, saying that he sees an uptick in mentally ill defendants whenever a homeless sweep takes place.

Tonaki says the increase in forensic patients “is a symptom of more people living out on the sidewalks in the streets, and that in turn is leading to more police action, which in turn leads to an overload in the various social service areas.”

In Hawaii, 18 provisions in the Hawaii Revised Statutes spell out the circumstances in which a defendant can end up in the custody of the Department of Health, which operates the State Hospital.

By and large, the provisions outline two broad scenarios: One is when a defendant might be unfit to stand trial, while the other is when he or she is acquitted of a crime by reason of insanity.

Such scenarios have played out in some of Hawaii’s biggest murder cases, including one in which Adam Mau-Goffredo was accused of fatally shooting three people at Tantalus Lookout in 2006. Diagnosed with paranoid schizophrenia, Mau-Goffredo was eventually found unfit to stand trial and has since been committed to the State Hospital.

But most forensic patients at the State Hospital are involved in less severe crimes. Nearly 80 percent of forensic patients committed in fiscal year 2016 were charged with the lowest-level felonies or misdemeanors — about 45 percent of which involved “offense against another.”

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Neil Gowensmith, former chief of forensic science at the Adult Mental Health Division, says the increase in forensic patients in Hawaii mirrors national trends.

Gowensmith, who now leads the Denver Forensic Institute for Research Service and Training at the University of Denver, has been studying the increasing number of competency evaluations across the country — including in Colorado, which saw a 206 percent jump from 2005 to 2014.

“Those requests for competency evaluations are skyrocketing all over the place, and more people are being found incompetent,” Gowensmith said. “It’s gone up consistently year after year, but within the past seven to 10 years there’s been an explosion.”

Ultimately, Gowensmith says, the increase in forensic patients at the State Hospital highlights a lack of preventive treatment for the mentally ill.

In 2008, the Adult Mental Health Division suffered significant funding cuts — about $25 million in all. That led to the elimination of 58 staff positions and reduction in resources for the community-based mental health services, such as case management and homeless outreach.

Janice Okubo, a department spokeswoman, says the Adult Mental Health Division began rebuilding the community-based services in 2014. Still, they’re yet to be back up to the pre-2008 level.

“Folks are falling through the cracks and then wind up getting usually low-level misdemeanor, nonviolent charges because they’re not getting their mental health needs met,” Gowensmith said. “I think the number of forensic patients will continue to rise unless that’s changed.”