Crisis in the Treatment of Incompetence to Proceed to Trial: Harbinger of a Systemic Illness Hal Wortzel, MD, Ingrid A. Binswanger, MD, MPH, Richard Martinez, MD, MH, Christopher M. Filley, MD, and C. Alan Anderson, MD Across the nation, a growing number of defendants judged incompetent to proceed (ITP) to trial are unable to access needed mental health care because of critical shortages of state hospital psychiatric beds and funding. Many of these patients languish in jails and prisons that lack the resources to provide adequate care during their prolonged wait for treatment. The crisis is yielding results that are medically, legally, and ethically unacceptable. The problem is presented as the latest symptom of an overwhelmed mental health system. Deficits across multiple domains are responsible for the current ITP logjam, creating an emergency that has been receiving increasing attention by medical and legal professionals, the media, and the public. Achieving meaningful and long-term solutions will necessitate recognizing the deficiencies in mental health capabilities within jails and prisons, courts of law, and communities, and addressing the dire need for the integration of these sectors. J Am Acad Psychiatry Law 35:357– 63, 2007 The lack of adequate mental health resources across the nation is hardly a recent development. Like most problems left unaddressed, the difficulties related to insufficient psychiatric services continue to mount and to manifest in new and troubling ways. Recently, the latest symptom of this lack of resources has gen- erated front-page news, 1,2 with increasing attention from medical and legal professionals, the media, and the public. The crisis in treatment of persons judged incompetent to proceed (ITP) to trial is emblematic of an overwhelmed mental health system, represent- ing the downstream logjam resulting from insuffi- ciencies at multiple levels. As a result, hundreds of patients with severe mental illness deemed incompe- tent to proceed are languishing in jails around the nation, unable to access meaningful psychiatric care and not moving forward in the legal process as they await admission to grossly undersized and under- staffed state hospitals. It is not surprising that the combination of inadequate psychiatric care, the stress of incarceration, and the long waits involved have yielded nightmarish results for many of the in- dividuals, including needless exacerbation of mental illness, bodily harm, and at least two reported deaths. 3,4 Physicians, advocates for the mentally ill, proponents of constitutional law, legal and correc- tional authorities, and champions of basic human rights recognize the unacceptable situation that has resulted from the ITP crisis. The Crisis The ITP crisis is a national concern. Mossman 5 reported recent estimates suggesting that 50,000 to 60,000 defendants are evaluated for competency to stand trial each year, and that nearly 20 percent of these defendants are found incompetent by courts. At any given time, defendants hospitalized for resto- ration to competency occupy nearly 4,000 psychiat- ric hospital beds in the United States, or more than 10 percent of the nation’s state psychiatric hospital beds. The ITP crisis garnered particular attention recently in the states of Colorado and Florida. Dr. Wortzel is Instructor-Fellow with the Veterans Integrated Service Network (VISN) 19 Mental Illness Research, Education, and Clinical Center (MIRECC), Denver VA, and the Department of Psychiatry, University of Colorado, Denver, CO. Dr. Binswanger is Assistant Professor, Division of General Internal Medicine, University of Colo- rado, Denver, CO. Dr. Martinez is Director, Program in Forensic Psychiatry, University of Colorado, and Director of Psychiatric Emer- gency and Forensic Services, Denver Health Medical Center, Denver, CO. Dr. Filley and Dr. Anderson are Associate Professors, Depart- ments of Neurology and Psychiatry, University of Colorado and Den- ver VA, Denver, CO. Address correspondence to: Hal Wortzel, MD, Department of Psychiatry, CPH Room 2508, 4200 East 9th Ave- nue, C268-25, Denver, CO 80262. E-mail: hal.wortzel@uchsc.edu 357 Volume 35, Number 3, 2007 ANALYSIS AND COMMENTARY