Health officials call them outliers - rare, unpredictably violent people who don't respond to medication or other treatment. Advocates call them victims of a system that has lost patience and creativity in caring for those who are most difficult to treat.
Loopholes in federal and state laws and impotent oversight allow hospitals to lock some patients away for the safety of staff and other patients. Some cases involving seclusion and restraints have resulted in costly lawsuits, yet they are so rare that many advocates had no idea there were similar situations in other states until The Associated Press inquired about it.
No one tracks such cases. However, through interviews and records from advocacy groups and state and federal agencies, the AP found at least a dozen patients who were held in seclusion for months or years at a time.
"I think it's just a wink and a nod and some people are looking the other way," said Charlie McCarthy, an advocate with Disability Rights Montana, who nevertheless said he understands what drives hospitals to work around the law.
"Everybody's frustrated with what do you do with somebody like this? The patient has rights, but the other patients have rights to be safe and free from abuse."
In Virginia, one man was locked in a three-room suite for 15 years and another patient was held in a similar setup for five years. Connecticut and Florida have paid millions over allegations that they tethered patients to furniture for years.
Federal law requires that seclusion or restraints - including drugs - be used on patients covered by Medicare or Medicaid only in emergencies to protect other patients and staff. Such measures can be used for more than 24 hours only if a physician deems it necessary, and only if a doctor updates that assessment daily.
Moreover, the U.S. Supreme Court has ruled it unconstitutional to restrain or isolate patients for extended periods.
The laws and court rulings don't cap the consecutive days a patient can be isolated or restrained, though, so hospitals can hold a patient indefinitely by simply signing off on it every 24 hours.
The Supreme Court also has ruled that hospitals must treat people who are involuntarily committed. So Stuart Grassian, a psychiatrist who has studied the effects of solitary confinement on prisoners, and others question whether outliers are being held legally.
"Once a person is locked up, the state has to provide them with adequate and appropriate treatment, otherwise they lose any authority and any legitimacy to keeping the people locked up against their will," Grassian said.
Seclusion, he said, can intensify patients' paranoia, agitation and delusions.
Advocates insist that with proper training and sufficient staffing, hospitals can eliminate the need for seclusion and restraints in nearly all cases, not just outliers.
In 1997, Pennsylvania enacted stricter policies against those techniques, trained staff in crisis management and established minimum staffing levels for its psychiatric facilities. Today, the state does not seclude or restrain patients for extended periods and rarely uses either method at all, according to the state mental health agency.
Such efforts can be costly, but proponents cite them as proof that with the right support, any mentally ill person can improve enough to safely interact with others.
"People can make progress and they do get to a point where they can be reintegrated into the community," said Deborah Dorfman, deputy director of the Los Angeles-based Disability Rights Legal Center. "You just need the right treatment and the right expertise."
A spokesman for the Justice Department's Civil Rights Division, which investigates complaints concerning institutionalized individuals, would not comment on the use of seclusion and restraint. According to its Web site, the division wrapped up two probes this year that found improper use of seclusion and restraint in Oregon and Georgia and recommended policy changes to the governors of those states.
At Oregon State Hospital, investigators found four patients who had lived in prolonged seclusion, some for at least a year. In a report, the Justice Department called the practice "unrefined and unlawful" and said it had never "encountered the use of continuous seclusion as a planned treatment strategy."
Since 2006, the Justice Department has entered into settlements with California, Vermont and the District of Columbia over violations that include improper seclusion and restraint at mental hospitals.
At Western State Hospital in Staunton, Va., the state stepped in after staff placed Cesar Chumil in a three-room "limited containment suite" in 1993, where he has remained since. Chumil averaged 300 assaults against staff and another 100 against patients over seven years before he was placed in the suite, according to records from a closed administrative hearing obtained by the AP.
Hospital officials claim the 58-year-old has more freedom than before, when records show he spent thousands of hours in a small seclusion cell or restrained to a bed or chair.
"It's a big step to put somebody in a room like this and say, 'You can't come out,' but we had so many people getting injured and so many staff were out of work," said Stephen Johnson, the psychologist on Chumil's ward. "It just got to the point where it was just untenable ... so we had this one solution."
Last summer, a state oversight committee determined that the hospital should move Chumil out of seclusion. The hospital moved all other patients off Chumil's ward this month and unlocked the door to his suite so he could go out into an activity room when he wanted. Hospital workers in padded gear and helmets must be present
for everyone's safety, but also so that he is no longer alone and therefore no longer technically in seclusion.
In Connecticut, a 23-year-old man has lived in a two-room cell since 2001, said Nancy Alisberg, an attorney for the state's Office of Protection and Advocacy. When he behaves, staff take him on walks around the grounds and sometimes take him to church and other places, she said, declining to identify the man because of privacy laws.
Often, the rooms where patients are held for months or years at a time are more pleasant than traditional seclusion rooms - usually tiny block rooms containing only a mattress. They have TVs and personal items. Chumil even has a phone.
"In a situation like that, the best you can do is to create a living environment that is as safe and contained as possible," said Kevin Huckshorn of the National Association of State Mental Health Program Directors. "And while yes, you could call it seclusion, the only other options are going to be things like restraint, which is even more restrictive."
Patients have been removed from long-term seclusion in other states, including Massachusetts, Oregon and Maryland, after advocates stepped in, some threatening lawsuits. Other states have paid millions of dollars for breaking restraint and seclusion laws.
In Florida, the state lost a lawsuit in 1998 and was forced to pay $18 million for strapping a man to a bed or wheelchair for 2½ years.
Connecticut has paid $600,000 a year since 2002 to house a former patient at a special facility in California as part of an out-of-court settlement. He had been tied to a bed in a small, concrete room at Connecticut Valley Hospital in Middletown for more than a year, said Susan Aranoff, an attorney with the nonprofit Connecticut Legal Rights Project who fought for his transfer.
Wayne Dailey, senior policy adviser for the Connecticut Department of Mental Health and Addiction Services, denied holding any patient in restraints for such a long a time.
Federally mandated advocates in each state protect the mentally ill and disabled but don't have the manpower or money for constant monitoring, said Curt Decker, executive director of the National Disability Rights Network, which represents advocates.
Like other groups that look out for the mentally ill, Decker said he didn't know patients were being held in long-term seclusion but that it was something his organization will begin looking into.
"We put these people sort of out of sight and out of mind," Decker said, "and bad things can happen."