PORTLAND, Ore. _ In the midst of a harrowing psychotic episode in summer 2009, Annie broke into her ex-husband's house and used a hammer and scissors to lay waste to plates, knickknacks, clothing, "and honestly, I don't know what else."
Had the mother of four, a retired captain in the National Guard, chosen to plead guilty, as a first offender she might have gotten off with the six months she'd already spent in jail.
Instead, she chose to accept the verdict of "guilty except for insanity" _ Oregon's version of the insanity defense. For Annie, who asked that her real name not be used because she fears being stigmatized, that meant accepting state supervision until 2029, when she will be 68.
She has no doubt she made the right choice.
"If I had been released with the hallucinations I had then ... I wouldn't be alive today," said Annie, an outgoing redhead who during a recent interview wore a black blouse festooned with ladybugs.
About 14 percent of state and federal prisoners (about 200,000) and 26 percent of jailed inmates (about 190,000) have serious mental illnesses, according to a report last year by the U.S. Department of Justice. Prison and jail officials don't have the resources to treat them, and many deteriorate behind bars.
By contrast, in some states those judged to be criminally insane receive better mental health treatment than practically anybody else _ including people who have never committed a crime.
This is especially true in Oregon, according to the Treatment Advocacy Center, an Arlington, Va., nonprofit that advocates for those with severe mental illness.
Oregon's Psychiatric Security Review Board oversees the care of the criminally insane from the time they receive the verdict until they are discharged from state care. During that period, which can go on indefinitely for someone serving a life sentence, the board supervises the treatment plan and determines when a person is ready for a less secure facility and, eventually, conditional release.
In Oregon, that final stage includes not just clinical treatment but supportive housing and help with job hunting, transportation, budgeting and grocery shopping.
"The amount of contact they have with clinicians and support staff is much, much higher than anyone in community mental health would get," said Katrina Bennett, clinical director of criminally insane patients at Cascadia Behavioral Healthcare.
Cascadia provides outpatient mental health care to about 18,000 people a year in the Portland area. Among them are about 70 people found guilty except for insanity, mostly from the Oregon State Hospital in Salem.
Not many states match Oregon in caring for the criminally insane, according to the Treatment Advocacy Center. Only three states _ Arizona, Connecticut and Washington _ have a centralized authority comparable to Oregon's Psychiatric Security Review Board.
Four states _ Idaho, Kansas, Montana and Utah _ don't allow an insanity defense, so defendants with extreme mental illness usually are sent to prison instead of being hospitalized and treated. Others, including Idaho, Indiana, Massachusetts, New Mexico, North Carolina, Pennsylvania and Texas, do not have conditional release laws.
Oregon's model of intense care and supervision is not cheap: Caring for a patient at the Oregon State Hospital costs between $383,000 and $437,000 annually, according to the Oregon Health Authority. Conditional release supervision costs between $30,000 and $157,000 a year.
It has, however, yielded impressive results. Over the past five years, the rate of recidivism for those on conditional release in Oregon after a verdict of criminal insanity is 0.47 percent. By comparison, one report put the recidivism rate among all Oregon ex-inmates, whether mentally ill or not, at about 18 percent.
The irony of intensive care for the criminally insane is not lost on those who study the subject. "You shouldn't have to be found guilty except for insanity to get high-quality care," said Lisa Dailey, the legislative and policy counsel at the Treatment Advocacy Center.
