Amid a severe shortage of psychiatric beds and community-based treatment throughout the state and nation, jails have become repositories for people in the throes of acute mental health crises.
The number of people with mental illness in jails and prisons around the nation is “astronomical,” said Michael Romano, director of Three Strikes & Justice Advocacy Project at Stanford Law School, who was not involved in the research. “In many ways, the whole justice system is overwhelmed with mental illness.”
Contributing to the problem in California is that county jails received a large influx of inmates from state prisons to jails as a result of a federal court order to ease prison crowding. In 2011, the U.S. Supreme Court ordered California to reduce the prison population because of overcrowding linked to poor medical and mental health care that it said constituted cruel and unusual punishment.
Three years later, a state proposition reclassified some felony crimes as misdemeanors, meaning offenders went to county jails instead of state prisons.
The new analysis, based on survey data from 45 of California’s 58 counties, opens a window into how the state is coping with the influx. “We think this is the first part of a more systematic discussion about what is going on in the jails and in the broader community with respect to mental health,” said David Panush, a co-author of the report by CHPS, funded in part by the California Health Care Foundation. (California Healthline is an editorially independent publication of the California Health Care Foundation.)
Across California and the U.S., far more people with mental illness are housed in jails and prisons than in psychiatric hospitals. That poses well-documented challenges: Insufficient staff training and patient treatment have contributed to inmate suicides, self-mutilation, violence and other problems.
One complaint among advocates for the mentally ill has been poor access to psychiatric prescriptions to treat such conditions as schizophrenia and bipolar disorder. The medications include antipsychotics, antidepressants, anti-anxiety drugs and others.
Jail officials in California say they are trying to better identify inmates who can benefit from such drugs. The numbers suggest that may be working. According to the analysis, an average of 13,776 inmates in the 45 California counties were on psychotropic medications in 2016-2017, up from 10,999 five years ago. But the portion of inmates on psychotropic medications varies widely by county, from 8 percent in Glenn to 32 percent in Sonoma and Napa, according to the analysis. The report is based on data from the Board of State and Community Corrections, an independent state agency.
In Los Angeles County, whose jails have been described as the largest mental institution in the country, about 30 percent of the 18,000 inmates are mentally ill and most of those diagnosed are on medication, said Joseph Ortego, chief psychiatrist for correctional health services in L.A. County. Although some still are missed in the screening process, he said, the county jails have improved identification and treatment of inmates and expanded staffing as part of a 2015 settlement with the U.S. Justice Department. The department had alleged inadequate mental health care and suicide prevention in the jails.
Overall in jails, some experts say, medications are likely underprescribed. “You need enough mental health professionals to treat the very large numbers of mentally ill people in jails,” said H. Richard Lamb, professor emeritus of psychiatry at the USC School of Medicine. These medications are among the most critical parts of psychiatric treatment, he added: “There probably aren’t enough.”
Some advocates for the mentally ill worry, however, that the drugs are at times prescribed inappropriately. Ron Honberg, senior policy adviser at the National Alliance on Mental Illness, said that because jails have limited resources for treatment, officials may in some instances administer psychiatric medications “to keep people calm and sedate.”
Zima Creason, president and chief executive officer of Mental Health America of California, said medications, while sometimes necessary, are no substitute for comprehensive care for jail inmates.
“Sadly, they just throw a bunch of pills at them because there is nothing else,” she said. Jails still need to provide individual and group therapy, more time outside of cells and sufficient recreation time, she said. “Jail is not conducive for real recovery,” she said. “We are never going to put a dent in the numbers unless we provide a therapeutic environment.”
Like people on the outside, inmates can be subject to involuntary drug treatment but only if a court deems it appropriate, officials said.
Medications are important but are not “the answer to everything,” L.A. County’s Ortega said. “We still need to be ethical and appropriate and do what’s right for the patient and not just medicate them.” He said the county also offers individualized hospital and outpatient care, as well as treatment groups and education. But he said the jails do not have enough exercise yards or spaces for therapy.
Other county jail officials, including Alfred Joshua, chief medical officer for the Sheriff’s Department in San Diego County, said the influx of mentally ill inmates and the rising need for psychotropic drugs stems from a lack of resources for patients in the community. “When they have exacerbations of mental illness, they do many times come into contact with law enforcement,” he said.
Rebecca Cervenak, staff attorney for Disability Rights California, which has repeatedly investigated jail conditions, said more investment is needed in programs to divert offenders to treatment rather than jail.
Some of the most common charges that bring people with mental illness to jail are drug offenses and parole violations. Those who are homeless frequently get charged with panhandling, public urination and related crimes. Inmates with mental illness also typically stay incarcerated longer than others, in part because of difficulty following rules and coping with the crowded or chaotic environment.
Edward Vega, 47, was taking medications for his bipolar disorder and schizophrenia but had just run out when he was arrested in August 2017 on suspicion of drug possession. He was convicted and spent five months in the San Diego County jail. When he arrived, he couldn’t quiet voices in his head and felt himself losing control, he said. “I knew if I didn’t get my medication, I was going to hurt someone,” Vega said.
A week after being arrested, he said, Vega assaulted a fellow inmate and ended up in isolation, which only made him feel worse. Finally, Vega said, a doctor prescribed medications that helped. Now, three months after his release, he is feeling almost back to normal. “The medication hasn’t totally taken away the voices, but I am able to differentiate reality from fiction,” Vega said.
In addition to trying to improve treatment inside the jails, Los Angeles and San Diego county officials say they are working more closely with community organizations to ensure inmates with mental illness get the services they need after their release.
Vega said a local community group, the Neighborhood House Association, was able to help in his case, ensuring he got meds and other treatment. “Without the medication, I would probably be right back in jail,” he said.