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Issues raised by the influx of defendants with serious mental illnesses are some of the most important that criminal judges confront. Because of the volume of defendants with mental illnesses, the impact goes beyond that of the individual case and extends to jails, police and sheriff departments, the treatment system, and ultimately to the role of the judge. This article suggests some of the ways in which communities have attempted to respond to these issues, and highlights the fact that judges have become significant leaders as well as innovators in such efforts. Not every judge will decide to adopt one or more of these roles, but regardless, it is likely that the issues that mental illness creates for the criminal justice system will exist far into the future.