Georgia faces years of federal oversight, as well as expensive remedies, after an eviscerating investigation of the state psychiatric hospital in Atlanta.

State officials declined to say Thursday whether they plan to contest findings by the U.S. Department of Justice that a lack of "generally accepted professional standards" contributed to patients' deaths at Georgia Regional Hospital/Atlanta.

"We take the recommendations of the DOJ very seriously, and we will be developing a response," said Dena Smith, a spokeswoman for the Department of Human Resources, which operates Georgia Regional and the six other state-owned psychiatric hospitals. The state has until late July to agree to sweeping reform or face a possible lawsuit.

Regardless, Georgia may have little choice but to overhaul its mental health care system. Since 2003, the Justice Department has found violations of civil rights and other laws in 10 hospitals in five states and the District of Columbia. Only two states fought the findings in court, but they ultimately gave in.

When such serious problems are found, court-appointed monitors have been assigned to supervise the hospitals in those states; the Justice Department oversaw Hawaii's mental health system for more than a dozen years. Monitors generally have free rein to examine the hospitals. Should they find a state isn't living up to a settlement agreement, judges may order even tougher sanctions.

Moreover, settlements have forced the states to spend heavily — nearly half a billion dollars in North Carolina alone.

No estimates were immediately available on the cost to bring Georgia's hospitals up to standards. But experts in mental health care said the Justice Department's 65-page letter to Gov. Sonny Perdue detailed an unusually high number of deficiencies in a surprisingly accusatory tone.

"It reads almost like a criminal indictment," said Ron Honberg, legal director for the National Alliance on Mental Illness. The Arlington, Va.-based advocacy group requested the investigation last year in response to articles in The Atlanta Journal-Constitution. The newspaper has reported at least 136 patients died under suspicious circumstances from 2002 through late 2007. In addition, officials substantiated almost 200 cases of patient abuse during that period.

Justice Department investigators have inspected three of the hospitals and plan to visit another, Central State in Milledgeville, next week.

In reporting on Georgia Regional in Atlanta, they described conditions as "critically deficient" and as needing immediate reform. They also said that an "unabated" failure to respond to deaths and other serious events caused similar fatalities to multiply and left patients vulnerable to sexual assaults and other attacks. The investigators concluded that hospital conditions violate the civil rights of patients.

State officials have said they were not surprised by the findings and said they were trying to improve the hospitals before the investigation began. Officials made a similar contention in late 2006 when Journal-Constitution reporters questioned them about the newspaper's findings of suspicious deaths.

Gwen Skinner, director of the state's mental health division, said Georgia Regional has assembled a "better complement" of medical staff members, appointed new administrators and hired additional nurses. Retaining employees, particularly nurses, has been a recurrent challenge for the state hospitals, which offer lower pay and more difficult working conditions than most private facilities. By tolerating a chronic nursing shortage, federal investigators found, Georgia Regional "routinely compromises" patient care.

For now, Skinner said, "our goal is to continue to track and monitor improvements until every issue is addressed."

In other states, federal authorities set firm deadlines for specific changes.

In Vermont, for instance, a settlement agreement gave state hospital officials six months to ensure that physicians assess every patient who has been physically restrained and 24 months to revamp their restraint policies. The agreement called for Vermont to prohibit face-down restraints, which often are fatal (as has been the case at least twice in Georgia mental hospitals since 2002).

Other states that have faced Justice Department scrutiny include California, Oregon and Connecticut.

The Justice Department's letter to Perdue contained a 13-page list of needed remedies. The letter said Georgia Regional should improve its procedure for investigating and reporting patients' deaths and other serious incidents. It said hospital employees should give out psychotropic drugs only as prescribed and should stop using sedatives to restrain patients. It said the hospital should figure out how to protect patients at risk of choking or aspirating their food — which caused three deaths in rapid succession.

The letter called for no new buildings or renovations. In North Carolina, the Justice Department's involvement forced the replacement of two aging hospitals with three new facilities.

In Georgia, the investigation will lead to a better mental health system, said Dr. Peter Buckley, chairman of psychiatry and health behavior at the Medical College of Georgia.

"When the DOJ comes in, it's a very serious event, and they come in with the expectation that the state will work with them," said Buckley, who assembled a team of consultants who studied the state hospitals last year.

Substantial change, he said, "will take an infusion of money, and a systemwide commitment, and time. ... It's a commitment over time."