Already this month, Georgia officials have settled one federal case alleging civil rights violations of state psychiatric hospital patients. They have until the end of July to respond to another.

Together, the two cases could force a doubling of Georgia's mental health budget, adding $480 million a year, or more.

Even then, Georgia would only reach the national average in per-person spending on mental health, an analysis by The Atlanta Journal-Constitution shows. Matching the top states would cost as much as $1 billion a year.

Such spending once would have seemed unfathomable in a state hardly known for generous social services. But Tuesday, in response to federal regulators, Georgia officials vowed to create substantial community-based programs outside state psychiatric hospitals for people with a mental illness or developmental disability.

Meanwhile, the U.S. Justice Department is demanding intensive improvements in care at the seven state-run hospitals, and could use the power of the federal courts to mandate compliance.

Federal authorities have not put a price tag on the improvements. It is clear, however, that merely lifting Georgia up to average would require more than a two-fold increase over the $465 million the state spends now.

Officials at the Georgia Department of Human Resources, which operates the state's mental health system, did not respond to requests for an interview.

In recent days, they have issued statements expressing a commitment to improving care in the psychiatric hospitals and in community-based programs.

The statements did not address the potential cost or offer details of planned improvements.

The Journal-Constitution calculated the shortfalls in Georgia's mental health spending with figures from the National Association of State Mental Health Program Directors. Georgia is one of the group's members.

Most spending on mental health goes to one of two areas: the state hospitals, or alternative services available closer to where patients live. The hospitals have about 2,700 beds — half dedicated to people with developmental disabilities — and serve more than 15,000 people a year. Mental health advocates and state officials alike acknowledge that far too few community-based programs exist to fill the need.

Georgia fell 26 percent shy of the national average on spending for state mental hospitals in 2005, the most recent year for which statistics are available.

Georgia is nearly three times more likely than the national average to treat people with mental illness in a state hospital rather than in the community, which suggests its budget for those facilities actually lags even further behind the average.

Greater spending for the state hospitals, mental health advocates say, could relieve chronic overcrowding and understaffing. Both contributed to the neglect, abuse and poor medical care found in the suspicious deaths of 136 patients from 2002 through late 2007, the Journal-Constitution has reported.

A larger shortfall exists in community services such as group homes, outpatient clinics and other programs intended to prevent hospitalizations. On average, other states spend 2.5 times more than Georgia on treating and managing mental illnesses outside hospitals.

Those services often are expensive but tend to be more effective, advocates say.

"If you want to move your system toward health, it's going to cost more on the front end," said Angela Kimball, director of state policy for the National Alliance on Mental Illness. "But long-term, it will save money."

Georgia spends millions of dollars a year repeatedly treating many of the same patients in its state hospitals. In its letter outlining its findings, the Justice Department cited one patient who had been admitted 107 times.

Instead, said David Shern, president and chief executive of Mental Health America, the goal should be to provide "a continuum of services to keep people healthy."

Those include housing, access to medication, case managers who check on clients in their homes, more group homes, detoxification facilities and transportation to medical and psychiatric appointments.

"There are a lot of approaches out there," Kimball said, "and they cost a lot. But if you compare it to hospitalizations, it's a bargain."

Shern said community-based services are "unevenly available across the country." Such disparities, he said, "would be intolerable for cardiac care."

Georgia's agreement to provide more outpatient services settled a 7-year-old complaint alleging it was not complying with a landmark court decision requiring states to provide services that allow people to live outside institutions. The U.S. Supreme Court's so-called Olmstead opinion in 1999 came in a case from Georgia, but the state took almost a decade to agree to implement its mandates.

The state said it would improve hospital discharge planning to determine who can live in group homes or other community settings.

The state says it has addressed hospital deficiencies by hiring more nurses and technicians.

It has focused on Georgia Regional Hospital/Atlanta, where federal investigators described "critically deficient" conditions that have contributed to preventable deaths, injuries and illnesses.

After reports in the Journal-Constitution, state officials last year set aside $3.4 million for what they called a "turnaround" effort at the Atlanta facility.

This May, according to DHR statistics, the hospitals employed 28 percent more registered nurses, 12 percent more licensed practical nurses and 4 percent more health technicians than they did a year earlier.

Still, employee turnover continues at a rapid rate, and many positions remain vacant.

In the state's psychiatric hospitals, more than four in 10 registered nursing positions were vacant in May, state data show. At Central State Hospital in Milledgeville, nearly three-fourths of those jobs were open.

One-fourth of all licensed practical nurse jobs and 12 percent of technician positions also were vacant in May, the state says.

In a statement, DHR said it has made "continuous, aggressive recruitment efforts." The agency has used events such as hiring fairs to attract employees to jobs that generally pay less and offer tougher working conditions than those in the private sector.

The statement attributed the high vacancy rates among nurses to "market factors and intense competition." The hospitals use temporary employees to fill gaps.

"In summary," the statement said, "the data illustrates that the trend is in the right direction."

In early June, as news broke on the Justice Department's findings, the Atlanta hospital again experienced a familiar conundrum: too many patients, not enough staff.

The hospital's West Unit had 53 residents on

June 8, seven more than capacity, according to documents obtained by the Journal-Constitution.

The extra patients had to sleep on cots or rollaway beds, some in hallways or other common areas.

Hospital administrators assigned two registered nurses to the overnight shift: one for every 26 patients.

Eight technicians also worked that shift, but they had to watch over three patients requiring one-on-one supervision, three others who were supposed to remain in their sight at all times and 18 more who had to be checked at least every 15 minutes.

Whatever challenges this presented, the nurse in charge of the unit reduced them to a terse summary in her report on the shift: "Very busy tour."

LOW IN SERVICES

In 2005, Georgia ranked 42nd among the states and the District of Columbia in per-person spending on community-based mental health services:

1. Alaska, $232.10

2. District of Columbia, $228.82

3. Pennsylvania, $163.90

4. Vermont, $145.59

5. New York, $141.72

Average: $70

42. Georgia, $26.67

43. South Dakota, $26.19

44. Louisiana, $23.68

45. Kentucky, $22.97

46. Arkansas, $22.92

47. Nebraska, $22.84

48. Texas, $22.07

49. Idaho, $21.70

50. Florida, $19.66

51. New Mexico, $12.90

LOW IN HOSPITALS

Georgia ranked 35th among the states and the District of Columbia in per-person spending on state psychiatric hospitals:

1. District of Columbia, $138.82

2. Mississippi, $57.82

3. New York, $55.62

4. New Jersey, $49.63

5. Connecticut, $47.98

Average: $30.32

35. Georgia, $22.31

46. Texas, $13.81

47. Oklahoma, $12.86

48. New Mexico, $11.33

49. Arizona, $10.55

50. Arkansas, $10.19

51. Iowa, $9.22

Source: National Association

of State Mental Health Program Directors Research Institute Inc.