Sunday, October 23, 2016

The Largest Psychiatric Hospitals in the USA

In about 2012, I read an article that described the largest psychiatric hospitals in the USA as

1.  LA County Jail
2.  Riker's Island
3.  Cook County Jail

In the past month there is good evidence that in Minnesota, one of the most liberal states in the country - the situation is no different.  A recent study estimated that 25-30% of the jail population had a mental illness and 11% were on maintenance antipsychotic medications.  The  Hennepin County Sheriff Rich Stanek is quoted:

“What we’re seeing is crisis levels of mental illness among our inmates. This is solid evidence that our jails continue to serve as the largest mental health facilities in the state.” (1)

That same article refers to a Legislative Auditor's report describing the problem as widespread throughout Minnesota.  There is an alarming statistic that since the year 2000 there have been 770 suicide attempts and 50 suicides in Minnesota jails.  The article does outline some helpful measures.  Inmates will be screened by psychologists and psychiatric nurses.  The screening by psychologists is focused on low level offenders who can possible be released earlier,  although the offenses of the mentally ill were not substantially different from the non-mentally ill population.   The mentally ill inmates had a higher recidivism rate and were 30% more  likely to have 10 or more bookings at the jail. In a separate opinion piece (2), Sheriff Stanek reports that jail personnel are all going through 32 hours of crisis intervention training (CIT) to learn about the specific problems that mental illness causes and how to interact with people experiencing those symptoms.  The Barbara Schneider Foundation - a non-profit organization dedicated to end the criminalization of the mentally ill through positive training and education -  provides the training.  In his opinion piece the following quote is instructive:

"The urgent need for this training is a direct consequence of federal action requiring states to close our state psychiatric hospitals with no immediately viable community alternative. Our county jails should never have become the largest mental health facilities in the country."

I have previously written many times about the abysmal system of care that is available for people with severe mental illnesses.  In my experience, the people rationed out of the system include many of those who end up homeless and in jail.  If you have severe problems with mental illness that affect your decision-making, your social behavior, and your ability to assess the impact of your decisions you are at much higher risk  of an adverse interaction with the police or incarceration.  If incarcerated you are less like to have the resources to make bail, obtain and cooperate with an attorney, or follow the conditions of release. 

 These impairments combined with severely rationed resources accounts for the explosion of mentally ill in jails and this is not an acute problem.  It has been progressively worse over the past 20 years.  Stanek also call on the Governor and the legislators to provide finding for adequate placements (and hopefully supervision) and funding for CIT.  So far legislators have passed a law that allows Sheriffs to transfer mentally ill offenders to the limited beds at Anoka Metro Regional Treatment Center (AMRTC).  That has resulted in an increasing backlog of admissions of committed patients and increasing violence at the hospital.  Nobody in any of this controversy has spoken to the needs of the antisocial or career criminal with severe mental illness.  The issue of addiction and how that creates mental illness, criminal offenses, and leads to recidivism and worsening mental illness is also not addressed. 

In these articles and most, the families are left out of the equation.  The families I have seen are typically parents who have been dealing with the severe mental illness of their children for years.  They are shocked to find out that their children have been incarcerated instead of being hospitalized.  They are shocked that their children are not receiving any care for their mental illness while incarcerated especially that their medications have been acutely discontinued.  I have talked with many of these patients who were on methadone or buprenorphine for opioid addiction who had these medications acutely discontinued and went into opioid withdrawal until that resolved.  Psychiatrists everywhere have heard the pleas of these parents and their request to assist them in getting their child out of jail.  There is generally noting that can be done.     

 An associated issue is how government systems are managed at all levels.  In recent times, the idea that government systems can be managed like for-profit businesses that much show a profit for shareholders is all the rage.  It was one of the reasons that scientific and humane treatment of mental illness could be rationed out of existence.  Suddenly there was no longer a concern that a patient with mental illness was disruptive and might end up in jail or homeless if that behavior continued.  Now they had to be "dangerous" or the hospital asked them to leave.  When there were still too many demands on rationed beds they had to be "imminently dangerous" or they were asked to leave.  Sheriff Stanek and sheriffs across the country are dealing with the fallout of this managerial practice.  If people can't be treated in a cost effective manner (defined as getting them out in a defined number of days that are paid for)  they are not admitted.  Many of these patients are brought to hospitals by the police and not admitted because the hospital knows they will be taken to jail.       

The other problem of course is that jails are not really hospitals.  In today's political climate - even saying that out loud can set a dangerous precedent.  Even though Sheriff Stanek is doing what he can and he has a mandate by the Minnesota legislature allowing him to hospitalize patients on a priority basis at a state hospital, minimal to non-existent standards of care in jails do not make them hospitals.  The clear evidence from the editorial is the sparse medical coverage (1 RN very 12 hours for over a hundred mentally ill inmates), lack of adequate medical training (provided in this case by a not-for-profit foundation), and a lack of discharge resources for continuity of care.    

There are no psychiatric hospitals that can function or legally operate with that level of care.

George Dawson, MD, DFAPA


1.  Chris Serres.  Mental illness in Hennepin County jail far higher than previous estimates, new study finds.  Star Tribune September 22, 2016.

2.  Rich Stanek.  Commentary:  Addressing the mental health crisis in our jails.  Star Tribune October 14, 2016.


1.  The photo is Hennepin County Jail from Wikimedia Commons.  The source information is by Micah (Transferred from en.wikipedia by SreeBot) [Public domain], via Wikimedia Commons.  The page URL is:

1 comment:

  1. But why would they end up in the criminal justice system if psychosis is just someone else's equally legit reality that shouldn't be judged?

    It's amazing to be that such thinking still exists after fifty years of bad experience. King of Hearts lives.