Releasing mental health care from prison

Mental health care in America is a sad state of affairs. As we described in a previous post,  prisons are, unimaginably, our largest and most utilized mental health treatment facilities. Making matters worse, not only is the treatment provided to inmates often medically inadequate, it is also not cost-effective. The average annual cost of treating each of the 36.2 million Americans who sought mental health care outside of prisons in 2006 was $1,591.The cost of treating individuals who suffer from mental illness in a prison, on the other hand, is up to $28,000 per year

This situation is neither sustainable nor morally acceptable. The remedy is not simply a matter of making correctional psychiatry more cost-effective. Rather, we must increase access to treatment outside of prison. A study published this month reconfirmed that increased access to medication and outpatient treatment reduced the likelihood of an arrest after hospitalization among individuals with serious mental illness. With increased access to care, fewer people with mental illness will be sent to prisons.

The death of Kendra Webdale, who was pushed in front of a New York City subway by a man with untreated schizophrenia, prompted a new law.

Legislative programs mandating involuntary outpatient treatment have helped to increase access to care for those at risk. Kendra’s Law, enacted in 1999 following the death of Kendra Webdale who was pushed in front of a New York City subway by a man with untreated schizophrenia, provides for outpatient mental health treatment for individuals who are unlikely to survive safely in the community without treatment. A recent study conducted by Duke University researchers found that Kendra’s Law resulted in a net 50% reduction in overall costs in New York City.

This is a significant finding because as states and municipalities look to cut costs they often eye mental health and addiction treatment services. The economic success of laws providing assisted outpatient treatment give policymakers strong arguments for their continuation and expansion. In 2010 they found that Kendra's law improved the use of medication and resulted in fewer arrests. About 2,000 New York state residents are treated under this law. In California, on the other hand, counties have the option of whether to implement a similar piece of legislation known as Laura’s Law. Most have not, resulting in an influx of the seriously mentally ill in jails and prisons.

Judicial solutions such as drug diversion courts offer a way get treatment to victimless offenders rather than locking them up. Such courts have been established in over 1,200 counties across the United States, including many counties in Pennsylvania and New Jersey . They mandate and provide addicts with appropriate treatment and have been shown to significantly reduce substance abuse and recidivism.

Other approaches based on the Housing First philosophy promise to provide stable housing to mentally ill people in need. Homelessness is a major problem for those suffering from serious mental illness, particularly those released from prison. Housing First initiatives are based on the common sense fact that at-risk homeless individuals will have a more successful recovery when they are in their own home rather than living in transitional facilities or institutional programs where housing is used as reward for treatment compliance. But long-term recovery first requires security, privacy and dignity. A studio apartment can prove to be more effective than months of expensive therapy and compulsory medication.

The Obama administration has also made steps toward improving access to mental health care. The 2014 fiscal year budget includes a $205 million investment in programs designed to identify mental health concerns and improve access to mental health services. More significantly, the Affordable Care Act mandates comprehensive mental health and substance abuse treatment by requiring that all new small group and individual private market plans cover mental health and substance abuse services, and that they be covered at parity with medical benefits. The administration is also taking steps to fight the stigma surrounding mental illness by encouraging a national dialogue about mental health.

With the implementation of the Affordable Care Act and the continuation of Kendra’s Law, drug diversion courts and new initiatives based on Housing First principles, there is hope for increased access to appropriate services for those in need. A likely consequence will be a reduction in the number of mentally ill people in prison— an outcome that would be both economically advantageous and morally appropriate.

Andrea Segal, MS, is a research associate with the Scattergood Program for Applied Ethics of Behavioral Health Care in the University of Pennsylvania Perelman School of Medicine’s Department of Medical Ethics & Health Policy. Dominic Sisti, Ph.D., directs the program and is an assistant professor at Penn.

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