Hampton Roads Regional Jail in Portsmouth houses hundreds of mentally ill from the peninsula. The special units sometimes hold mentally ill in solitary. There are anywhere from 6 to 12 inmates on suicide watch at any given time at the jail.

Worlds apart in their treatment of mental illness, the Hampton Roads Regional Jail in Portsmouth and Eastern State Hospital in James City County have overlapping populations. Some even go back and forth between the two institutions.

Both house men and women diagnosed with schizophrenia, bipolar disorder, and delusional and depressive disorders. Both serve those awaiting trial on misdemeanor and felony charges and both conduct "restoration to competency" for court.

Beyond that, some go on to serve their sentences at the jail, where they receive minimal mental health treatment in harsh conditions, while others found Not Guilty by Reason of Insanity, NGRIs, receive intensive long-term psychiatric treatment at the hospital before being released to the community.

Everyone agrees — from the jail superintendent to community service boards personnel to mental health advocates — that jail is not the place for mental health treatment, yet as many with serious mental illnesses are incarcerated as receive treatment at the state hospital.

Costs versus care

"It's a hard environment. It's not therapeutic," said David L. Simons, jail superintendent. "It's a huge strain on our resources to deal with this population. The resources to take over mental health care ought to come through the state. We really are a medical mental health facility."

The relative costs are a major factor, according to Meghan McGuire, spokeswoman for the Virginia Department of Behavioral Health. The per diem cost for ESH inpatient care is $660, compared to $65 for a jail inmate. "Even by assuming the additional cost of medication and treatment for a person with mental illness … the comparative cost of hospitalization is prohibitive for all but those with the most intensive clinical needs," she wrote in an email.

Simons, however, estimates those inmate costs balloon to $500 per day for those with a mental illness, a cost that falls to localities.

At the jail

Local jails filter their most problematic inmates to the regional jail for both medical and mental health needs. "There's some resentment. They know they don't belong in jail. There's nothing we can do, but give them the care we can with the resources we have," said Eugene Taylor III, assistant jail superintendent.

Those resources primarily involve security and medications. "We're not qualified mental health professionals," said Major Taunya Hatchett, chief of security, noting that the jail's become a safety net from the street for some.

Unlike at a hospital, the U.S. Department of Justice does not establish psychiatric staffing levels for the incarcerated. HRRJ employs a part-time psychiatrist, a couple of full-time counselors and a psychiatric nurse practitioner. And, while almost half of close to 400 inmates diagnosed with mental illness at HRRJ are prescribed psychotropic drugs, which cost the jail — and local taxpayers — more than $100,000 annually, they cannot be forced to take them. Last year, 97 at the jail refused their medications, according to the annual Virginia Compensation Board report. By contrast, at Eastern State Hospital, court orders to force compliance are routine. Non-compliance creates additional problems for the jail staff and a cycle of destructive behavior for patient inmates.

Mental health treatment

There are three mental health units within the concrete walls of the HRRJ, a maze of highly polished stone floors and scrubbed-clean, bare walls interrupted by a series of remotely controlled locked doors. Jail uniforms are color-coded — green for the general population, red for segregation, and pale blue for the mentally ill. The initial intake screening by a registered nurse and a social worker determines where an inmate is housed.

Those with mental illnesses are less likely to be granted bond and their need for pre-trial mental health evaluations results in longer delays in jail, according to the Department of Behavioral Health. For those already sentenced, the average length of stay is 18 months.

There's a lot of teasing of the mentally ill by other inmates, and staff tries to protect them as much as possible from taunts and contact.

Apart from substance abuse groups conducted by community service board counselors, there's no regularly scheduled individual or group therapy, though inmates and jail staff can request a mental health sick call, according to Giovanni Montague-Sneed, health services administrator. Medications are dispensed nine times a day at "pill passes," delivered in a mobile cart to each housing "pod."

While some share cells and mingle in a common area, others are confined to small, concrete windowless enclosures, alone, with no activity or distractions for 23 out of 24 hours. There's no natural light, a metal pass-through tray in the door is used for meal delivery, and the square metal "window" to the common area is closed, except when an inmate is on suicide watch.

There are up to a dozen at any given time who are under constant observation or 15-minute checks, their clothes removed and replaced by a "suicide" blanket that they can use to cover up, or a "suicide smock," quilted fabric fastened with Velcro that functions as a soft restraint. Many have had all their personal possessions removed. They have a mat on the floor, a metal sink and a toilet. In some, the water's been turned off to prevent them flooding the cells.

'Special Management Unit'