The Incompetent to Stand Trial Crisis and Homelessness: Cause or Effect?

BACKGROUND: Homelessness is a pervasive societal problem for large numbers of people, leading to numerous negative outcomes. Research has shown that the prevalence of mental disorders among individuals experiencing homelessness is consistently higher than in the general population, in turn, being associated with a higher likelihood of incarceration. In California, this may relate to the rapidly increasing numbers of individuals found incompetent to stand trial since 2010. AIMS: We sought to explore relationships between homelessness, mental disorders and community mental health treatment in the 6 months before an index offence in a cohort of individuals found incompetent to stand trial. Our primary research questions were as follows: Among those found incompetent to stand trial, (1) are data collected at one state hospital representative of the entire system? and (2) how, if at all, are living situation, mental disorders and prior treatment related? METHODS: We gathered information from interviews and inpatient records about individuals found incompetent to stand trial and committed to at least one of four of the five hospitals operated by the California Department of State Hospitals over a 2-5-month period in 2016/2017. We also obtained data from the California state Medicaid system to access data on treatment in the community in the 6 months prior to the index charge. These datasets were then combined. RESULTS: Data were available on 396 individuals, approximately 60% of those found incompetent to stand trial and ordered to inpatient treatment in the study period; 333 of them were matched in the mental health treatment dataset. Almost half were homeless and unsheltered at the time of their arrest; a similar proportion had received no Medicaid-funded mental health community treatment in the 6 months prior to their arrest. Analyses revealed a relationship between housing status and receiving emergency treatment, with men particularly disadvantaged in regard to receiving any mental health treatment. CONCLUSIONS: Our data are consistent with many other studies to the extent that we found high rates of both psychosis and homelessness among individuals found incompetent to stand trial. Men are particularly disadvantaged in accessing necessary mental health treatment in these circumstances. Our study adds detail that may help recognise those in special need, on public safety and on personal grounds. California's fairly new Community Assistance, Recovery, and Empowerment Act 2024 may be a useful vehicle for improvement, but work may have to begin with building a clinically appropriate, integrated community mental health infrastructure that meets the complex needs of this population.