The state has transitioned from housing people in state institutions to a system relying on community-based programs that allow individuals to live by themselves or with family. Dr. Gayle Jordan-Randolph, a deputy secretary at the state's Department of Health and Mental Hygiene, said the trend encourages recovery.

But Ria P. Rochvarg, an attorney who represents defendants with intellectual disabilities and mental health issues, said the state must provide more community health services if it expects people to count on them.

"They're not choosing to be this way, and they're not choosing to commit crimes," she said. "So how do we fix it?"

Smigiel said the closure of the state facility in his district created a new problem with homelessness because there weren't enough community programs to treat the mentally ill. "They sold us the promise of local community support and services, but people forgot about it."

Many of the untreated end up facing a crisis that lands them in the emergency room or locked up in jail, where workers aren't equipped to handle their needs. Others find that mental problems take over their lives, and they wind up in homeless shelters or living on the streets.

Local jails are trying to figure out how to deal with an increasing number of mentally ill inmates.

"All the detention centers are experiencing that," said Jack Kavanagh, director of the Howard County Department of Corrections. "A quarter of our population has mental health issues."

He added, "Jails are not mental hospitals."

Baltimore County Circuit Judge Nancy M. Purpura said she regularly sees defendants who should be in a mental facility rather than jail. While some defendants who face criminal charges can be released on bail, others must remain in jail until their trial.

"Often what drives their incarceration is the lack of services in the community," Purpura said.

Baltimore County Detention Center Director James P. O'Neill said mentally ill prisoners are waiting three to four weeks to get into Spring Grove Hospital Center to receive treatment.

A report last year by the Justice Policy Institute found that many individuals who were ruled incompetent to stand trial remained in jail even though they weren't convicted, because there were no mental hospital beds available in Maryland.

The most violent mentally ill patients accused of crimes end up at Clifton T. Perkins Hospital Center in Jessup, a maximum-security mental facility. But even there, two people were murdered within a month in 2011, leading to an overhaul of security at the facility, the hiring of a new CEO and other changes.

Conventional hospitals say they aren't equipped to treat mentally ill patients who end up in emergency rooms.

"Many of the people may not be in regular treatment, seeing a regular psychologist or taking the medication that research has found could help them," said Carmela Coyle of the Maryland Hospital Association. "The hospital emergency room becomes the immediate triage center."

State health officials acknowledge the system is not perfect.

"Even though we have good access and good support, there are still people that use emergency rooms and that are homeless. And that just means we have to work harder," said Dr. Brian M. Hepburn, executive director of the Maryland Hygiene Administration, which oversees the state's mental hospitals.

The solution is not increasing the capacity of places like Spring Grove, advocates say. Instead, they call for better ways of linking patients to the right programs and care.

"A person gets out with a referral and it takes weeks and weeks to get an appointment at a clinic" because of shortages of staff or facilities, said Laura Cain, managing attorney with the Maryland Disability Law Center.

Kate Farinholt, executive director of Maryland's chapter of the National Alliance on Mental Illness, said the state needs a greater variety of programs because mental illness affects everybody differently. She also noted that people have to feel comfortable accessing programs because of the stigma associated with mental illness.

She and other mental health advocates said that while the debate following the Connecticut shooting could lead to improvement in mental health care, they warn against broadly blaming mental illness for violent incidents.

"We need mental health treatment available," Cain said. "That's always been the case, but to link it to the shooting is misplaced. It increases stigma."

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