The Journal — November 2016
Tex Med. 2016;112(11):e1.
By Emilie Attwell Becker, MD
Send correspondence to Emilie Attwell Becker, MD, Austin State Hospital, 4101 Guadalupe, Austin, TX 78751; email: emilie.becker[at]dshs[dot]state[dot]tx[dot]us.
Jails and prisons in the United States have become the places where people with mental illness go. Texas jails were surveyed in 2012 to learn how they screened inmates for mental illness. Of these jails, 13% responded. Most screened for suicidal ideation and whether or not an inmate took a medicine. About half the jails offered in-house care, and the other half referred inmates to the local mental health authority. Most jails had a formal jail diversion program, and most thought that mental health illness was increasing. About half had an annual 4-hour training program for staff. Recommendations are made for future care in jails.
Jails and prisons in the United States have become the places where people with mental illness go. Many factors contribute to the "criminalization of the mentally ill." State hospitals have either reduced their census or become largely forensic. Private hospitals and substance abuse centers have likewise closed. Outpatient services have not increased correspondingly, and many private payers have considered mental health services optional.1 Although parity of medical and mental health coverage became federal law in 2008, enforcement has been uneven.2 Texas, like most of the rest of the country, has switched from putting those with mental illness in a hospital institution to putting them into a correctional institution. The Harris County Jail treats more psychiatric patients than all of the state-run hospitals combined.3
Texas has 254 counties, each with its own jail and funding. Although the 8th Amendment's prohibition of "cruel and unusual punishment" guaranteed prisoners an entitled right to health care,4 the provision of said health care varies markedly among counties. The Sandra Bland suicide in the Waller County jail in 2015 highlighted the need for procedures to treat those with mental illness in correctional facilities.5
In September 2012, the Mental Health Substance Abuse Division (MHSA) of the Department of State Health Services (DSHS) surveyed the jails to learn how they treated inmates who had mental illness. The Texas Jail Association, which kept current email addresses for the county facilities, sent the survey to all 254 Texas jails. Respondents faxed or emailed their responses to MHSA. Workforce moves resulted in the data being collected but not collated for 3.5 years. To encourage full disclosure of results, the survey promised anonymous reporting of results. Not all boxes were checked, so results did not always have the same total.
Thirty-two (13%) jails responded from across the state, representing both large and small jails. Thirty-one of the 32 jails screened for mental illness (the lone dissenter reported not knowing if screening occurred), and the majority (30) screened also for suicidal ideation and whether a patient took medication. Almost all (29) offered suicide prevention services to inmates, and most (27) offered also crisis intervention and provision of psychiatric medication. One county said inmates could only get psychiatric medicine if they already had a prescription and their families could bring the medicine to the jail.
Most counties (22) offered in-house psychiatric care, and a little more than half (18) referred inmates outside the jail if they needed more intensive psychiatric services. A large number (28) had ways to segregate those inmates with mental illness from those without mental illness, although the provision might just be a single cell in isolation. Most (23) offered psychotherapy or counseling. A minority (12) offered discharge planning.
If in-house mental health care was not available, half of the jails (16) used the local mental health authority (LMHA) to see the inmates. One jail also used staff from a local mental health hospital and a substance abuse center. About two-thirds of the jails (20) had a formal diversion program (programs where ill patients go to mental health facilities in lieu of being charged criminally and placed in jail).
Not only did most of the jail programs (31) think that the number of mentally ill inmates was increasing, this question elicited the most free-form additions. Many responders wrote emphatically that they dealt with this surge the best they could with few resources. One jail wrote that a local state prison inappropriately released mentally ill inmates early, and these prisoners were soon locked up in their jail.
Only slightly more than half of jails (18) had training programs that usually totaled 4 hours a year for staff dealing with inmates with mental illness. The training programs might cover the following:
- Psychiatric diagnosis, symptoms, and behaviors;
- Procedures (crisis intervention);
- Custodial options;
- Community options; and
- Values and attitudes of persons with mental illness.
Of the training programs, Crisis Intervention Team (CIT) was viewed as either positively or negatively (one jail commented that staff were "sent" to CIT training).
The gathered responses may not reflect what is happening then or now in jails. Response rates were predictably low, and although anonymity was promised, jails may have been reluctant to write what was actually happening for fear of recrimination.
The Sandra Bland suicide highlighted that Texas had a 65% increase in jail suicides in 2015 (D. Spiller, Texas Commission on Jail Standards, written communication, March 2016). Since then, the Texas Department of Criminal Justice adopted a new screening process as of December 2015,6 and no subsequent suicides have occurred.
Suicide is just one adverse mental health outcome for mentally ill inmates while in jail. Screened inmates should have access to treatment, both medical and mental therapies. To avert the proverbial revolving door, more discharge planning needs to be done for those inmates identified with mental illness, and the sister LMHA is a likely solution. Ideally, jails would have substance abuse centers. Best of all, mentally ill persons would be offered diversion, not jail time.
- Honberg R, Diehl S, Kimball A, Gruttadaro D, Fitzpatrick M. State Mental Health Cuts: A National Crisis. Arlington, VA: National Alliance on Mental Illness; 2011.
- National Alliance on Mental Illness. Parity for mental health coverage. https://www.nami.org/Learn-More/Public-Policy/Parity-for-Mental-Health-Coverage.
- De Prang E. Barred care: Want treatment for mental illness in Houston? Go to jail. Texas Observer. January 13, 2014. https://www.nami.org/Learn-More/Public-Policy/Parity-for-Mental-Health-Coverage.
- Estelle v Gamble. 429 US 97 (1976).
- Deitch M, Mushlin MB. What's going on in our prisons? The New York Times. January 4, 2016. http://www.nytimes.com/2016/01/04/opinion/whats-going-on-in-our-prisons.html.
- Texas Administrative Code. Title 37, Part 9, Chapter 273, Rule §273.5. Mental disabilities/suicide prevention plan. http://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=37&pt=9&ch=273&rl=5.
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