In Linn and Johnson counties, the largest mental health care providers - at least, by number of beds - aren't mental health care centers or the hospitals.
It's the jails.
Linn County Sheriff Brian Gardner reports that three-fourths of the jail population - currently more than 300 inmates - at any given time is on some sort of psychotropic medication. In fiscal year 2013, approximately 16 percent of all inmates booked at the Johnson County Jail - or 873 people - self-reported being on psychiatric medication, according to Jessica Peckover, the county's jail alternatives coordinator. That doesn't count those who decline or fail to report any mental health issues at the time of booking.
The problem of jails providing care for people with mental health issues isn't new, but it isn't going anyway, either. Sheriff Lonny Pulkrabek said a lack of funding for mental health providers means the status quo of jails taking on some offenders who would be better served in a health care setting won't change soon.
"It's problematic for jails being the number one mental health giver, not only in the state of Iowa, but on a national basis," Pulkrabek said. "What happens to people is the lack of services on the outside men people come to the inside of the jail. They may get stabilized. But, there's not enough funds once they go to the outside...to make sure they're staying stabilized and staying on their medications."
Pulkrabek said the problem dates back to the 1980s when mental hospitals around the state started closing. The people served by those facilities still needed a place to go, however.
"They were kept stable and they were kept on meds," he said. "What has replaced those is jails."
Changes to the state's mental health care system continue to this day. Iowa is implementing a regional mental health system and funding for that system remains in question. Locally, concerns about funding and the future of residential care facilities in Iowa led The Abbe Center for Community Care, Inc. to close the doors and move 70-some patients.
Gardner said the closing of the Abbe Center did not directly impact the jail because those treated at the Abbe Center were generally not those out committing crimes.
"The bigger issue is those who should not be incarcerated in the jail because we are not set up to provide the services they need," Gardner said.
He said it's one thing to provide patients with medication, which his staff is prepared to do.
"It's another thing to need aggressive treatment that we're certainly not set up to provide," he said. "That's a concern we have across the state. We have a smaller number of mental health beds available in treatment centers."
Both the Linn and Johnson county jails providing psychiatric medications, when appropriate, to their inmates. In accordance with Iowa code, all law enforcement officers also undergo an initial four hours of mental training in Mental Health First Aid or Crisis Intervention. Officers are also required to complete one hour of training each year or four hours of training every four years. Both jail staffs are also equipped to take patients who are having a severe psychotic episode or are a threat to themselves or others to a hospital for emergency intervention.
"As long as the inmate is not self-destructive and as long as they are not a security issue to the rest of the facility, we can deal with that in house," Gardner said.
From there, however, the two jail staffs take different approaches to their population with mental health issues.
In addition to the Linn County Jail's full-time nursing staff, the sheriff's office also contracts with the Abbe Center to receive weekly visits from a psychiatric nurse. Every other week, a psychiatric doctor will visit the jail. Jail nurses will make recommendations on which inmates would benefit from a visit from the psychiatric nurse, who, in turn, will make recommendations to the doctor.
"The reality is, for some of these folks, we are the only time they receive medication and receive treatment," Gardner said.
Johnson County employees a two-person jail alternatives team, led by licensed social worker Jessica Peckover. The jail alternatives programs aims to identify inmates who could be better served outside of the jail and try to connect them with a variety of services including substance abuse counseling, medication assistance, crisis intervention, residential care facilities, transitional housing or mental health services.
That does not mean every inmate booked at the jail who reports having a mental health problem automatically receives assistance from the jail alternatives program.
"We try to do something in the way of identifying people who have mental illness and getting them linked up with mental services," Peckover said. "We can get them on their medications if they're not on it. If somebody is grossly de-compensated to the point it's a jail management issue...then we can coordinate with the university hospitals to get some brief intervention. We do some crisis intervention sort of stuff if someone is suicidal or emotionally intense."
"It's pretty minimal in terms of what's being offered in the jail," she added.
Organizations like the National Alliance on Mental Illness advocate for those with mental illnesses and work with families whose relatives are incarcerated. Mary Issah, executive director of NAMI Johnson County, said Sheriff Pulkrabek and Johnson County Attorney Janet Lyness advocate for those with mental illnesses, but that isn't always enough.
"Is everyone getting their needs met?" Issah said. "Probably not."
So, how do you get the inmates the help they need? For Pulkrabek, that's "the million dollar question."
"I don't know that I have the answer for that," he said.
Peckover said the solution may lie in the establishment of a "comprehensive and integrated" system of crisis response services able to offer care to a wide spectrum of people, from the man feeling desperate after losing his wife and his job to the woman who may be suffering from a serious mental illness.
Each community, Peckover said, needs three things: diversion services to help keep people out of jail in the first place, institutional services within the jails and prisons so inmates can get the treatment they need, and re-entry services to help get former inmates back on their feet.
"What would be very helpful is a comprehensive continuum of services that are well-funded and well-implemented," she said.