The incarceration of mentally ill patients, who are often imprisoned due to issues related to untreated mental illness, is a major public health issue.1 Obtaining precise numbers of individuals with severe mental illness (SMI) in incarcerated facilities is difficult, as numbers vary by source. According to the National Alliance for Mental Illness, 2 million people with mental illness are imprisoned each year, and up to 15% of these men and 30% of these women have a serious mental health condition.2 The Treatment Advocacy Center estimates that approximately 20% of inmates in jails and 15% of inmates in state prisons have SMI.3 A survey of all 50 states from 2004–05 found that in 44 states, correctional facilities held more individuals with SMI than state psychiatric hospitals and that, in the United States, three times more people with SMI were incarcerated in jails and prisons than living in state hospitals.4
Definitions of SMI in the literature are inconsistent. Some research uses the National Institutes of Health definition of a “mental, behavioral, or emotional disorder resulting in serious functional impairment.”5 While this definition addresses the importance of functioning in determining severity, it requires that a functional measure be used in order to classify SMI. For the purpose of this review, we have defined SMI as a diagnosis of a psychotic disorder (e.g., schizophrenia, schizoaffective disorder, delusional disorder) or a major mood disorder (major depressive or bipolar disorder), which is in line with other research in forensic populations and with organizations that research SMI in correctional settings.6,7
Data from studies in Great Britain show that the prevalence of psychosis, in particular, is ten times higher in prison inmates than in the general population.8 Studies have also indicated that patients in the early stages of psychosis are more likely to be arrested and put in jail than those with chronic illness.9,10 In addition, minority patients from socially disadvantaged backgrounds are incarcerated at a higher rate. In a study of hospitalized African American patients with first-episode psychosis, nearly 60% of patients had a history of arrest and imprisonment.11 While the exact statistics on SMI in correctional facilities differ by source, the high prevalence of individuals with SMI in prisons and jails in the United States is undisputed and calls for the implementation of effective treatment solutions in correctional facilities.
Some have implicated deinstitutionalization, a movement that closed down state mental hospitals, in creating a “revolving door phenomenon” in which individuals with mental illness circle between homelessness and incarceration.12 As state mental hospitals closed, outpatient services were not established to treat patients with SMI, who had now moved from hospitals into the community.13 It is estimated that between 1955 and 1994, 94% of patients who had been living in state mental hospitals were no longer in these hospitals (adjusted for population growth).14,15 This change has resulted in increased disease severity among patients with SMI in the general population and increased numbers of acutely sick individuals with no care.16 Deinstitutionalization has also been blamed for increased violence by untreated individuals.17
Many patients with SMI, particularly patients with psychotic disorders, have their first encounter with psychiatric care while incarcerated.9 It has long been recognized that reducing the duration of untreated psychosis is pivotal in the long-term prognosis of patients.18 In a 2014 study of incarcerated and non-incarcerated patients, however, incarcerated patients had a duration of untreated psychosis of two years, whereas the non-incarcerated group had a duration of three months.19 The presence of significant psychotic symptoms also increases the risk of recidivism in inmates who are released,20 and a lack of appropriate treatment has been shown to increase risk of violence.21 In a study of released inmates, untreated patients were much more likely to commit violent acts due to persecutory delusions than those in treatment.22,23
Adequate medical and mental health care are constitutional rights of those in correctional custody. The U.S. Supreme Court has ruled that withholding medical care, including mental health care, from prisoners is considered cruel and unusual punishment.24,25 Despite the legal imperative to provide adequate mental health care, there is a long history in correctional settings of placing individuals with SMI in solitary confinement, especially when they are in acute psychiatric episodes.26 The conditions of solitary confinement vary by institution but are connected by the use of isolation and minimal social contact. Research has consistently shown the negative consequences of solitary confinement for all people and that individuals with mental illness fare even worse.27–31 An alternative to solitary confinement for incarcerated individuals with SMI is the creation of specialized mental health treatment units. In the literature, there is no comprehensive compilation and description of all mental health units (MHUs) in correctional facilities in the United States. The aim of this review is to identify existing MHUs and to collate information on them. A critical review of such data could be of value in designing and implementing new correctional MHUs in the future, and it will also serve as a step toward updating best practices for treatment units housed in correctional institutions. In our preliminary review of the published literature, we found scant data on such MHUs and identified major gaps in published details about these units. Hence, we then undertook a review of publicly available sources, including government websites, newspaper articles, and published legal reports, using the Google search engine in order to obtain a more comprehensive picture of current MHUs in the United States.
Systematic Literature Review
A systematic review was conducted on Criminal Justice Abstracts, ERIC, PsycINFO, PubMed, and SocINDEX for articles published up to June 2019 using the following search terms: prison mental health unit; jail mental health unit; detention center mental health unit; prison mental health pod; jail mental health pod; detention center mental health pod; inmate mental health services; department of corrections mental health services; department of corrections mental health center. Articles were included if they described details of a specific treatment unit for SMI within an adult correctional facility in the United States. Only peer-reviewed journal articles were included.
Google Search Process
Due to the low yield from the peer-reviewed literature, we carried out an exploratory review using Google search between the months of February 2019 and June 2019. The 50 states and the District of Columbia were divided among four trained research staff. For each state, researchers conducted a Google search with the same search terms that were used for the literature search. All results were manually reviewed, and researchers examined all links until they reached a full page of Google results that were irrelevant to the review. This strategy enabled a thorough review of Google sources, with one search term for one state often resulting in more than 150 sources investigated. If an MHU that fit the inclusion criteria was found, an additional Google search was initiated with that unit’s name to gather more information about the specific unit. All relevant information was placed into an Excel document. If a researcher was unsure if a unit fit the inclusion criteria, the unit was flagged for discussion with the group.
Units were included if they were located in the United States. Units in other countries were excluded in an effort to collate information on prevalence and nature of MHUs in the United States.
Type of facility
Units were included if they were discrete units within an adult correctional facility established for the purpose of treating SMI. The type of facility was determined based on information that was found through the Google search process. The major categories were prison, jail, detention center, and federal prison. If a facility self-identified as a treatment or medical center but was not a forensic hospital, it was coded as “Other.” If it was unclear what type of facility the unit was housed in, we coded “Unknown.” Although forensic hospitals that house individuals who have been found incompetent to stand trial or those who are awaiting competency evaluations are technically correctional facilities, these facilities were excluded. We sought to identify MHUs in facilities that housed regular inmates. Units located within community centers or juvenile facilities were also excluded.
Units were included if they primarily served patients with SMI. Other specialized units such as substance abuse treatment units, veterans’ units, segregation units, suicide watch units, trauma units, and sex offender treatment units were not included. Units that served mostly SMI populations but also other special populations were included. Units that primarily served individuals awaiting competency trials or deemed incompetent to stand trial were excluded.
Units were included only if available resources suggested that they were currently open and functional at the time of our research. Units that had closed prior to February 2019 or were expected to open after June 2019 were excluded.
After the data collection was completed, research staff met to discuss which details were most important and consistently available from the Google search process. These categories were ultimately chosen for coding: type of facility; size of unit; gender of individuals in the units; presence of dedicated unit mental health staff; mental health training for correctional officers; presence of peer staff; cell occupancy; groups/programming offered; individual therapy offered; out-of-cell time per week; partnership with organizations outside of the state correctional department; partnership type; positive outcomes reported; negative publicity; and number of staff.
To ensure coding reliability across research staff, we designated four states (California, Maryland, North Carolina, and Pennsylvania)—one researched by each research staff—for a total of 37 units to code for reliability. Upon completion of this initial round of coding, it was clear that more details needed to be clarified and that the information relevant to the “number of staff” category was ambiguous. Before the second round of coding, we excluded the “number of staff” category and created clear definitions and answers for each category. These are represented in Table 1. For the second round of reliability, we again coded one more state by each researcher (Alaska, Michigan, Oklahoma, Washington) for a total of 31 units. We achieved a 97% agreement rate for coding these units.
All remaining states were then divided among the four researchers for final coding. In order to have multiple authors assess the appropriateness of inclusion for each unit in the final data set, researchers did not code the same states that they had researched. Units for which inclusion was still questionable were presented for discussion among the study team, and a final inclusion decision was made collectively.
The literature search identified a total of 8278 records (Supplemental Figure 1, available at http://links.lww.com/HRP/A120); 2647 duplicate records were eliminated. Of the 5629 remaining records, all but 37 were eliminated by a title and abstract review. Nine articles were ultimately selected for inclusion in the review, and an additional two articles were found in the references of the included articles. Characteristics and reported outcomes of MHUs found through the literature review are presented in Table 2.32–42 Study designs included retrospective reviews of health records, exploratory interviews, and comparisons of symptoms prior to admittance to the MHU and after release. Glowa-Kollisch and colleagues (2016)42 was the only identified study to include a control group, comparing outcomes for individuals who were placed in a Clinical Alternative to Punitive Segregation unit, a restrictive housing unit, or both. None of the studies used random assignment in their design.
The initial Google search process identified 334 units. Upon further examination and discussion with research staff, 17 units were excluded, leaving 317 units that met the inclusion criteria. Seven units were excluded due to insufficient evidence of existence of the unit; five were excluded because they were not located within a correctional facility; four were excluded because they were not currently open as of June 2019; and one was excluded because the focus of the unit was not the treatment of SMI. One article that was found through the literature search was also found through the Google search.38 The information from that article was included in the coded data. A table with all sources used for the Google search is presented online as Supplemental Table 1 (available at http://links.lww.com/HRP/A118), and a table with the coding for all 317 units is presented online as Supplemental Table 2 (available at http://links.lww.com/HRP/A119).
Characteristics of Mental Health Units
Evidence for MHUs were found in all but four states: Delaware, Mississippi, Montana, and North Dakota. Absence of evidence of MHUs in these four states does not necessarily indicate that they do not have any MHUs but rather that no units were found through our search process. One unit each was found in Alabama, Idaho, Maine, and New Mexico. The most units (n = 49) were found in New York.
Type of Facility
Descriptive statistics for the number of units found in each type of correctional facility organized by gender is reported in Table 3. Facilities that did not fit into the prison, jail, detention center, or federal prison categories were coded as “Other.” These included California Health Care Facility, Stockton (California), Joliet Treatment Center (Illinois), Elgin Treatment Center (Illinois), Iowa Medical and Classification Center (Iowa), Patuxent Institution (Maryland), John Montford Unit (Texas), Wisconsin Resource Center (Wisconsin), and Wisconsin Women’s Resource Center (Wisconsin). If the type of facility was unclear, it was coded as “Unknown.”
Mental Health Services and Providers
One hundred sixty-nine units (53.3%) reported offering groups/programming to inmates; 104 (32.8%) reported offering individual therapy; and 89 (23%) reported offering both. One hundred sixty-six units (52.4%) reported dedicated unit mental health staff, and 75 (23.7%) reported providing mental health training to correctional officers.
Information on size, or number of beds, of the unit was found for 199 units. Of the 199 units, size information for 26 units was unclear (e.g., because of conflicting sources), leaving a total of 173 units with usable data. The average number of beds was 73.3 (SD = 96.7), with a median of 48.
Cell occupancy information was found for 38 units. Nineteen units (50%) reported single-cell housing; 7 (18.4%) reported double cells; 9 (23.6%) reported a mix of different types of sleeping arrangements; and 3 (7.8%) reported dorm-style sleeping.
Twenty units partnered with organizations outside of the state correctional department in the development of MHUs. Eleven (55%) partnered with other government agencies; 6 (30%) partnered with nonprofit organizations; and 8 (40%) partnered with universities. Seven units (35%) partnered with more than one type of external organization.
Information on funding or cost for the unit was found for 33 units. Units were funded by a variety of sources, including but not limited to federal, state, and nonprofit grants, legislation, and inclusion in state budgets. Details are presented in Table 4.
Information on outcomes was found for 38 units and is presented in Table 5. Reductions in violence and injury (including assaults, self-injurious behavior, suicide attempts) were the most common outcomes reported. Sedgwick County Jail in Kansas reported a decline in the recidivism rate for parolees with mental illness after the implementation of their MHU and reentry program for individuals with SMI. While almost all outcomes reported were positive, limited conclusions should be drawn from these outcomes because of the lack of information on the methodologies used to measure the outcomes. Positive outcomes should be treated as preliminary until additional research is conducted.
We conducted a comprehensive review of all identified MHUs in correctional facilities in the United States. We first performed a review of peer-reviewed literature and found a dearth of information and, more importantly, a dearth of specific information. Most published literature described in general terms the programs implemented as units for treating SMI, but most failed to provide basic information such as the facilities in which the units were located.
In an effort to understand how widespread MHUs are in the U.S. correctional system, we conducted an exploratory search using the Google search engine. Our search ascertained information from a range of sources, including government websites, media articles, and legal documents. The search identified 317 MHUs that met our inclusion criteria as described above.
Location/Type of Facility
Our data show that while MHUs are roughly evenly spread across the country, no evidence of MHUs was found for four states: Delaware, Mississippi, Montana, and North Dakota. A higher concentration of MHUs was found in the Northeast, driven by the density of units in New York (n = 49).
We identified 252 units (79.5% of sample) located within prisons. Individuals in prison typically have longer sentences than those in jail, who often are convicted of minor crimes with shorter sentences. The majority of units may therefore be in prison because of the opportunity to treat patients over a longer period of time. Longer sentences provide ample time to build a stable unit environment with lower turnover, which in turn may enable staff to familiarize themselves with the complexities of each patient’s case.
There is a great unmet need to treat individuals during episodes of mania or psychosis in jails. These patients may cycle in and out of correctional facilities quicker, but they are also more likely to recidivate.12 Jails hold a larger percentage of individuals with SMI than prisons, making jails a necessary intervention point for patients with SMI.3 Only 10.7% of identified units were located within jails. Therefore, this situation presents a worthwhile opportunity to develop and implement MHUs in these facilities, where they may effectively serve more individuals with SMI and lead to better outcomes for patients with SMI involved in the criminal justice system.
Gender and MHUs
The majority of MHUs found served only men (76%; n = 241). This finding is not surprising, given that men comprise 93% of the U.S. prison population and 85% of the jail population.43,44 Although women make up 15% of the jail population, we identified only one jail MHU specifically for women. While 14 of the identified jail units treated both men and women, incarcerated women have particular needs and histories that are different from men, with high rates of victimization, trauma, and interpersonal violence.45–47 The prevalence of SMI is also higher in incarcerated women.3 One study of incarcerated women in jail found that 50% met lifetime criteria for SMI, and the National Alliance for Mental Illness reports that 30% of jailed women nationwide have SMI.2,48 In addition, while the incarceration rate for men is dropping, the incarceration rate for women is increasing.44 The high prevalence of incarcerated women with SMI, coupled with the growing population of incarcerated women, makes the development of women’s MHUs in jails another potential area for growth.
Development of a Therapeutic Environment
Implementing an MHU should not be conceptualized as simply a way to house individuals with SMI separately from the general inmate population, such as in segregation units.38,42 Segregation exacerbates symptomatology and is detrimental for patients with SMI.31 While separation from the general population is beneficial for patients with SMI, correctional facilities must facilitate a therapeutic and less restrictive environment in order for the MHU to be successful.
Based on our experience working in inpatient psychiatric care, we believe three areas are critical to the creation of a successful therapeutic environment: size, staffing, and programming. The average number of beds across the 173 units was 73.3 (SD = 96.7) with a median of 48. Twenty-nine (16.7%) of these units housed more than 100 inmates. In order to create a safe milieu with a high staff-to-patient ratio, MHUs should follow a structure similar to that of inpatient psychiatric units. We recommend that sizing should not exceed 40 individuals. Eighty-three units (47.9%) reported fewer than 40 patients, with a mean of 24 beds (SD = 9.9).
Patients in MHUs should be supported by trained clinical and correctional staff.49 One hundred sixty-six units (52.4%) reported dedicated unit mental health staff, a necessary foundation for a successful therapeutic program; trained staff are able to facilitate groups and programming, and to provide individual therapy. Eighty-nine units (23%) offered both groups/programming and individual therapy. Collaboration between clinical and correctional staff is vital in order to best serve incarcerated patients with SMI. Seventy-five units (23.7%) reported providing mental health training to correctional officers.
Twelve units were identified as meeting all of these standards: offering groups/programing and individual therapy; hiring dedicated unit mental health staff; and providing mental health training to correctional officers. These units included the Mike Mod Men’s Unit at Anchorage Correctional Complex West in Alaska, Intensive Mental Health Unit at Maine State Prison, Mental Health Unit at Jennifer Road Detention Center in Maryland, Crisis Intervention Unit at Montgomery County Correctional Facility in Maryland, Therapeutic Diversion Units in North Carolina (Polk Correctional Institution; Central Prison [2 units]; Maury Correctional Institution; North Carolina Correctional Institution for Women; Alexander Correctional Facility; Foothills Correctional Institution), and Gilliam Psychiatric Hospital at Kirkland Correctional Institution in South Carolina. Most likely, more units meet all of these criteria, but insufficient information was publicly available for us to make that determination.
In summary, creating a therapeutic and less restrictive environment requires a thoughtful approach to sizing, staffing, and programming. We recommend that an ideal MHU would have fewer than 40 patients, have dedicated mental health staff based in the unit, provide access to individual and group therapy, and ensure correctional staff receive proper mental health training.
We have provided the relevant data regarding funding for 33 MHUs in Table 4, including information on cost per bed, cost per year, funding source, and cost for full renovation. Given the diverse nature of the limited information available, it is difficult to put a firm number on what an MHU costs. The David L. Moss Mental Health Units (Levels 1–3; Level 4) in Tulsa Jail illustrates one successful funding effort. In 2014, Oklahomans voted for a 0.041% sales tax to raise $15.9 million for four new jail pods, two of which were built as MHUs. Other MHUs have received grants from various sources. For example: the Women’s Mental Health Unit in Alaska received a $1 million grant from the Alaska Mental Health Trust Authority board; the Durham County Jail Mental Health Pod received a Justice and Mental Health Collaboration Program grant of $228,000 from the Bureau of Justice Assistance to improve screening processes for inmates with mental illness; and Virginia MHUs received grants from the Virginia Department of Criminal Justice Services. The most common funding source was money allocated by the state budget, which occurred in Florida, Illinois, Iowa, Maine, North Carolina, and Wisconsin.
For the Google search, outcome data were available for only 38 units (12% of sample), and information on study design was available for only the Residential Treatment Unit in Washington state.38 The reports from these units show promising results for the benefits of implementing MHUs but also demonstrate the urgent need to conduct implementation and effectiveness trials for them. Similarly, the outcomes identified through the literature search identified a lack of controlled studies and highlighted the gap in published information on rigorously designed research to test the effectiveness of MHUs. The most common reported outcomes were reductions in violence (including against staff, other patients, and self), infractions, and misconduct. Outcomes were not limited to reductions in disturbances in the MHU. The Iowa Correctional Institution for Women saw a 66% decline in incidents (in which security needed to be called) across the institution as a whole after implementing an MHU in their newly designed facility—which is generally more conducive to creating a therapeutic environment.50 Individuals with SMI are often difficult to manage in the general population and may utilize a disproportionate amount of staff resources, thereby reducing the resources available for managing the general population.51,52 Nevertheless, if patients with SMI are adequately screened and placed in an environment where treatment is a priority, it is possible that infractions and disruptions may decrease in both the general population and the MHU. Establishing MHUs may consequently not only benefit the select few patients who are in the units but also enable the whole facility to run more smoothly and efficiently.
A major goal of MHUs is to decrease recidivism rates due to untreated mental illness.53 We found that this outcome was reported only for Sedgwick County Jail’s (Kansas) mental health pod.54 In Kansas, recidivism rates for parolees with mental illness declined from 75% in 2006 to 35% in 2016, after the implementation of their MHU and reentry program. As with the majority of reported outcomes, however, the methodology of the research is unknown; we therefore encourage caution in drawing inferences from this statistic alone. One issue with collecting and reporting recidivism data is that systematized data collection requires considerable effort and resources. If structures and mechanisms are put in place for data collection as part of the MHU planning and design process, outcomes could be measured with more granularity, and confidence in the conclusions drawn regarding the overall effectiveness of MHUs would increase.
Limitations and Future Directions
This review has several limitations. The first and most prominent limitation is the use of non-peer-reviewed sources. By incorporating newspaper articles, government websites, legal documents, and other sources identified through the Google search, we were able to maximize the amount, reliability, and specificity of information on the number and nature of MHUs around the United States. Most of these sources, however, were not peer reviewed, and confirming the accuracy of the collected information remains difficult.
The use of information that was found through the Google search process introduces many forms of bias. First, it is possible that the information reported is not an accurate depiction of certain MHUs and may reflect the bias or the interests of the person(s) who published the information on the internet. For example, although positive outcomes were reported for Treatment Diversion Units in North Carolina by the institution, we found a scathing report written by a former employee of those units that detailed a lack of resources and staffing, resulting in a “harmful” environment for patients.55 It is also possible that a lack of published information creates an inaccurate depiction of certain MHUs. For example, although an MHU might have dedicated mental health staff, this information might not be found through a Google search and would therefore not be reflected in our coding.
It has been noted that the use of internet search engines also introduces a confounding factor in the form of a “bubble effect.”56 That is, web search engines may selectively provide information based on the user’s previous searches and personalized information stored in the specific computer or web browser. We attempted to address this issue by investigating all links manually that appeared until a full page of results were not relevant to the review. This process often consisted of clicking and reading more than 150 links for each search term for each state. While this method is not foolproof, it does point to the thoroughness of our search process. Future research using Google search can try to mitigate the bubble effect by ensuring that cookies are not enabled in the researchers’ web browsers and by using a service (such as startpage.com) that endeavors to protect personal privacy and eliminate the bubble effect.
Finally, while we took measures to ensure a comprehensive review of all MHUs, it is likely that we missed the MHUs that did not have any information available online. Our data set may in that respect be incomplete. We believe, however, that our study provides important, easily accessible descriptive information on MHUs for interested scholars, clinicians, and the general public.
Our gathering and collating the published and publicly available information on these 317 units will help bridge the gap in the literature on MHUs and help facilitate the development of additional MHUs. Future research should collect systematized data from correctional facilities with MHUs in order to get a more comprehensive picture of the programs and to evaluate the effectiveness and feasibility of these treatment units.
Declaration of interest
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
We would like to thank Kelly Scanlon for helpful discussions.
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