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T h e N EW ENGL A N D JOU R NA L o f M EDICI N E

May 5, 2016

n engl j med 374;18 nejm.org May 5, 2016 1701

U.S. correctional institutions, local courts, and police officers frequently encounter people with untreated or undertreated serious
mental illnesses, often coupled with substance-use

disorders. These encounters usual-
ly stem from the alleged commis-
sion of a misdemeanor — tres-
passing, panhandling, petty theft
— or a minor, nonviolent felony.
Each year, about 11.4 million
people are booked into local U.S.
jails, where on any given day,
745,000 of them are held. An esti-
mated 16.9% of jail detainees have
a serious mental illness,1 which
means that nearly 2 million peo-
ple with such illnesses are arrest-
ed each year.

Florida’s Miami-Dade County
faces a particular challenge be-
cause, among large U.S. commu-
nities, it has the highest percent-
age of residents with serious mental

illnesses, but Florida ranks 48th
nationally in state funding for
community mental health ser-
vices. According to county judge
Steven Leifman, approximately
9.1% of the county’s population
(192,000 adults and 50,000 chil-
dren) — two to three times the
national average — has serious
mental illness, but only about 1%
receives services in the public
mental health system. Moreover,
roughly one third of the county’s
under-65 population lacks health
care coverage.2 In general, indi-
gent people receive treatment
only when they’re in extreme cri-
sis and present an imminent risk
of harm to themselves or others,

or when they enter the criminal
justice system.

Many communities have devel-
oped strategies to redirect people
with mental illnesses away from
the criminal justice system.
Though these approaches reduce
inappropriate arrests and incar-
cerations, their effect on commu-
nities’ public health and safety is
often limited because they reside
primarily within the legal system.
What sets Miami-Dade County
apart is its 15-year effort to de-
velop a comprehensive, coordinat-
ed response to what’s recognized
as a shared community problem
requiring a shared community
solution. This effort leverages di-
verse expertise and resources to
divert people with mental illness-
es from the criminal justice sys-
tem to community-based mental
health services, aiming to improve
community outcomes.

Decriminalizing Mental Illness — The Miami Model
John K. Iglehart

P E R S P E C T I V E

1702

decriminalizing mental illness

n engl j med 374;18 nejm.org May 5, 2016

In addition to grappling with
inadequate funding, the local
mental health system is ham-
pered by fragmented service de-
livery and poor coordination,
which make it difficult to navi-
gate. Some additional funding
has been secured from govern-
mental and private sources, but
the initiative’s success is largely
attributable to an effort to struc-
ture patterns of service delivery
and deploy existing resources in
ways that are better aligned with
the needs of people coming out
of the justice system.

These efforts have helped to
reduce the size of the county’s
jailed population and the number
of police officers injured in the

line of duty and to improve pub-
lic safety. Now, Miami-Dade plans
to open a facility that it says
“will expand the capacity to di-
vert individuals from the county
jail into a seamless continuum of
comprehensive, community-based
treatment programs that lever-
age local, state and federal re-
sources.”3

Miami-Dade’s initiative was
launched in 2000, when Judge
Leifman, frustrated by the fact
that people with mental disor-
ders were cycling through his
court repeatedly, created the
Eleventh Judicial Circuit Criminal
Mental Health Project (CMHP).
As Leifman explained, “When I
became a judge . . . I had no

idea I would become the gate-
keeper to the largest psychiatric
facility in the State of Florida. . .
. Of the roughly 100,000 book-
ings into the [county] jail every
year, nearly 20,000 involve people
with serious mental illnesses re-
quiring intensive psychiatric
treatment while incarcerated. . . .
Because community-based deliv-
ery systems are often fragment-
ed, difficult to navigate, and
slow to respond to critical needs,
many individuals with the most
severe and disabling forms of
mental illnesses . . . fall through
the cracks and land in the crimi-
nal justice or state hospital sys-
tems” that emphasize crisis reso-
lution rather than “promoting

ongoing stable recovery and com-
munity integration.” 4

The CMHP includes pre-book-
ing and post-booking jail-diver-
sion programs. The pre-booking
part follows the Crisis Interven-
tion Team model, in which mental-
ly ill people who may otherwise
be arrested for minor offenses
are diverted to crisis units to re-
ceive treatment. Law-enforcement
officers undergo 40 hours of
training in recognizing signs of
mental illness in distressed per-
sons and deescalating potentially
violent situations. Some 4600 of-
ficers serving in Miami-Dade’s
36 municipalities and in county
public schools have been trained.
In 5 years, officers from the two

largest police departments have
responded to about 50,000 men-
tal health crisis calls that result-
ed in 9000 diversions to crisis
units and only 109 arrests. The
average daily census in the coun-
ty jail system has dropped from
7200 to 4000, one jail facility has
been closed, and fatal shootings
and injuries of mentally ill peo-
ple by police officers have been
dramatically reduced.

Participation in treatment for
persons diverted pre-booking is
based on the state’s civil com-
mitment laws and the person’s
desire to receive treatment. If
someone appears to meet crite-
ria for civil commitment, the treat-
ment provider may petition the
court for authorization for invol-
untary outpatient or inpatient
placement. More often, however,
diverted people do not meet
these criteria and are simply pro-
vided referrals and linkages for
follow-up care.

The post-booking program in-
volves identifying people in acute
psychiatric distress who’ve been
booked into the county jail. After
screening them for eligibility,
judges can approve defendants’
transfer from jail to a crisis unit,
where they receive treatment
while the court monitors their
progress and case managers em-
ployed by the courts and the
South Florida Behavioral Health
Network work with community-
based service providers to arrange
ongoing treatment and housing.
All participants are assessed for
criminogenic risk factors and
treatment needs using evidence-
based tools. Once participants
return to the community, case
managers continue to monitor
them and their treatment provid-
ers for 1 year. Participants who
are eligible to apply for federal

Over the past decade, the CMHP
has facilitated about 4000 diversions

of defendants with mental illness
from the county jail into community-based

treatment and support services.

P E R S P E C T I V E

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decriminalizing mental illness

n engl j med 374;18 nejm.org May 5, 2016

entitlement benefits are assisted
in preparing and submitting ap-
plications.

People referred to the post-
booking diversion program who
appear to meet criteria for exam-
ination under Florida’s civil com-
mitment laws may initially enter
treatment on an involuntary ba-
sis. Once stabilized, they are
asked for consent to continue
participation; 80% of them agree
because participation may mean
more favorable disposition of
their legal cases, and it provides
access to resources and supports
that may otherwise be out of
reach. The cases of those who re-
fuse treatment or participation
follow the normal criminal jus-
tice process.

Initially, the CMHP served
only people charged with misde-
meanors. In 2008, the post-
booking program was expanded
to include defendants arrested
for less serious, nonviolent felo-
nies, who are screened by the
state attorney’s office before en-
rollment to ensure that they have
no significant history of violence
and are unlikely to threaten pub-
lic safety. Over the past decade,
the CMHP has facilitated about
4000 diversions of defendants
with mental illness from the
county jail into community-based
treatment and support services.
The annual recidivism rate has
been about 20% among partici-
pants who committed a misde-
meanor, as compared with
roughly 75% among defendants
not in the program. Participants

charged with minor felonies have
75% fewer jail bookings and jail
days after enrollment in the pro-
gram than they had beforehand,
and their recidivism rate is much
lower than that of their counter-
parts outside the program.

Like most mental health pro-
grams, the CMHP relies on mul-
tiple sources of support, and no
program is more important than
Medicaid. Unfortunately, Florida
is one of 19 states that have de-
clined to expand their Medicaid
programs under the Affordable
Care Act, leaving some 3 million
adults with incomes at or below
138% of the federal poverty level
without insurance coverage. About
567,000 Floridians fall into this
coverage gap and remain unin-
sured. “Expanding Medicaid would
have had a profound impact on
keeping people with a serious
mental illness out of both the
criminal justice system and the
acute mental health system,” Leif-
man told me. Although Florida
provides little funding for com-
munity mental health services, it
“spends exorbitantly to house
people with mental illnesses in
criminal-justice settings.”5

Miami-Dade County stakehold-
ers actively support the initia-
tive’s replication in other com-
munities. In 2015, the Council of
State Governments Justice Cen-
ter, the National Association of
Counties, and the American Psy-
chiatric Association Foundation
launched “Stepping Up: A Nation-
al Initiative to Reduce the Num-
ber of People with Mental Ill-

nesses in Jails.” Miami-Dade,
chosen as one of four launch
sites, has been helping with
planning and development. More
than 240 counties in 41 states
have passed resolutions to ad-
vance the goal of reducing the
prevalence of people with mental
illnesses in their jails, and repre-
sentatives of 50 jurisdictions in
37 states recently attended a Step-
ping Up Summit meant to help
them achieve that aim.

Disclosure forms provided by the author
are available with the full text of this article
at NEJM.org.

Mr. Iglehart is a national correspondent for
the Journal.

1. Steadman HJ, Osher FC, Robbins PC,
Case B, Samuels S. Prevalence of serious
mental illness among jail inmates. Psychiatr
Serv 2009; 60: 761-5.
2. Robert Wood Johnson Foundation, Uni-
versity of Wisconsin Population Health In-
stitute. County health rankings & roadmaps
(http://www .countyhealthrankings .org/ sites/
default/ files/ 2016CountyHealthRankings
Data .xls).
3. Eleventh Judicial Circuit, Miami Dade
County, Florida. Eleventh Judicial Criminal
Mental Health Project: program summary.
2016 (http://fmhac .net/ Assets/ Documents/
2015/ Handouts/ Leifman CMHP Program
Description 102714 .pdf ).
4. Where have all the patients gone? Exam-
ining the psychiatric bed shortage. Testi-
mony before the House Energy and Com-
merce Subcommittee on Oversight and
Investigation, March 26, 2014 (https:/ / energy
commerce .house .gov/ hearings-and-votes/
hearings/ where-have-all-patients-gone
-examining-psychiatric-bed-shortage).
5. Leifman S. Give people with mental ill-
ness treatment, not a jail cell. Miami Herald.
May 29, 2014 (http://www .patrickjkennedy
.net/ articles/ give-people-mental-illness
-treatment-not-jail-cell).

DOI: 10.1056/NEJMp1602959
Copyright © 2016 Massachusetts Medical Society.

Reproduced with permission of copyright owner. Further reproduction
prohibited without permission.