Nearly 11 million people move through local jails in the United States each year. More than half of them have a mental health problem.
In fact, recent research shows that nearly one in three female inmates and one in seven male inmates has a serious mental illness — a diagnosable and impairing condition such as psychosis or a mood disorder. All told, the percentage of people with serious mental illnesses is about five times higher among inmates than among the general U.S. population.
When forensic psychologist Sarah Desmarais recalls these statistics, she says they describe a “crisis” — one playing out in jails across the nation, including the one just a few miles from her office in Raleigh. An associate professor of psychology at NC State, Desmarais says nearly 17 percent of the 13,000 inmates booked in the Wake County Jail each year screen positive for symptoms of serious mental illness at the time of booking.
It’s a problem, both for the people who need help and for the taxpayer-funded system charged with helping them. In an effort to reduce the burden, Desmarais is using science to forge solutions.
Desmarais and her team of NC State researchers are partnering with the Wake County Sheriff’s Office to study the intricacies of the jail’s current practices related to inmates with mental health problems. They’ll use their findings to recommend changes that benefit both those with mental health problems and the county’s budget. Although the numbers alone are staggering, their implications are even more striking.
When people with mental health problems are arrested, their social, financial and medical supports are often severed. They lose their disability benefits and other social assistance from the government. Their treatment needs also typically go unmet. It’s not because jails are unwilling to serve them, Desmarais said. Rather, it’s because jails — which, unlike prisons, house pretrial detainees or individuals serving misdemeanor sentences — typically don’t have the resources to manage an inmate’s mental health problems.
“As a result, when inmates with mental health problems are released, we see that many of them go homeless, and they don’t have access to the benefits they used to have — if they had any in the first place,” Desmarais says. “You can see how this would contribute to a cycle of incarceration.” According to the U.S. Bureau of Jail Statistics, about 26 percent of inmates with mental health problems have three or more prior incarcerations.
By the Numbers: Wake County Jail
inmates screened positive for
symptoms of mental illness
unique individuals booked into
jail during fiscal year 2015-16
Total inmates were referred
for additional evaluation
And then there’s the financial cost to consider. A study in Broward County, Florida, found that compared to the average cost of housing a “regular” inmate — about $80 per day — it costs about $130 per day to house an inmate with a mental illness. In Wake County, it costs more than $90 per day to house a typical inmate, excluding medical costs or specialty housing. That per-day cost can exceed $600 if an inmate requires psychiatric observation. In addition, once released, inmates who don’t have the resources to manage their conditions often visit hospital and psychiatric emergency rooms for treatment, also at a great cost to taxpayers.
The goal for Desmarais and other researchers is to pinpoint places to intervene in the cycle. For the Wake County Jail project, Desmarais is studying how the jail assesses, treats and releases inmates with mental health problems. By observing jail operations and analyzing jail records, she hopes to identify potential gaps.
When inmates are booked, for example, the jail uses an eight-question Brief Jail Mental Health Screen to determine which inmates should be assessed further or receive treatment for mental health problems. Desmarais used jail data to study the relationship between the number of inmates who screened positive and the number who were referred for additional testing.
I really like the idea of us taking what we already know and putting it into practice, but also using our findings to advance science.
Clearly identifying who needs help will ensure the right people get treatment and are referred to what are known as diversion programs, or resources such as post-release transitional housing and medication management programs. Those supports set the stage for better long-term outcomes, reducing the chance of recidivism and, in turn, the financial strain on the jail.
Answering these questions also contributes to another key tool in fixing the problem: science. One example is the Brief Jail Mental Health Screen itself. The screen is widely used to assess mental health at intake, but few research studies have examined the instrument’s effectiveness. Still, lawmakers in many states, including North Carolina, have mandated that jails employ the screening measure.
“Anything we’re doing in this project around the Brief Jail Mental Health Screen will help inform our entire field,” Desmarais says. “I really like the idea of us taking what we already know and putting it into practice, but also using the findings of our work with the Wake County Jail to advance science.”
A closer look
The Brief Jail Mental Health Screen
- Do you currently believe that someone can control your mind by putting thoughts into your head or taking thoughts out of your head?
- Do you currently feel that other people know your thoughts and can read your mind?
- Have you currently lost or gained as much as two pounds a week for several weeks without even trying?
- Have you or your family or friends noticed that you are currently much more active than you usually are?
- Do you currently feel like you have to talk or move more slowly than you usually do?
- Have there currently been a few weeks when you felt like you were useless or sinful?
- Are you currently taking any medication prescribed for you by a physician for any emotional or mental health problems?
- Have you ever been in a hospital for emotional or mental health issues?
System Shaken Up
In the 19th century, a high prevalence of mental illness in jails led to the mental health reform movement. Spurred by activists such as Dorothea Dix, the movement led to the creation of many mental hospitals across the U.S., diverting those with mental illnesses away from jails and into the new asylums.
By the 1960s, however, developments in medicine, the creation of welfare programs and changing public perceptions led politicians to call for deinstitutionalization. The number of people in mental hospitals declined sharply. The trend has continued in recent years, with many governmental agencies decreasing hospital bed allocations or shuttering facilities altogether.
North Carolina officials agreed in 2012 to close its oldest state facility, Dorothea Dix Hospital in Raleigh. The decision was part of the state’s divestiture of mental health services, which included not only the sale of state-owned property but also a shift away from providing services locally. Instead of employing its own providers of mental health services, counties now contract with private companies who manage mental health care in jails.
The system was shaken up.
“Ultimately, you have people who were used to going to public health centers or Dorothea Dix for their mental health services, and now they don’t know where to go,” says Sara Warren, an NC State alumna and budget analyst for the Wake County Sheriff’s Office. “They can’t get their meds, they can’t get the treatment they’re used to getting and these individuals with mental health problems started showing up more in court and in the jails.”
Warren, who earned her bachelor’s degree in political science and master of public administration from NC State, says the county has more than doubled its budget for mental health services in the jail since 2012. The increased funding includes costs for additional staff and a forensic post-release program that helps inmates obtain housing and benefits such as Medicaid.
Budgetary adjustments, however, can only be part of the solution. So in 2015, Warren convened local elected officials, police officers, researchers and health care providers to form the Wake County Criminal Justice/Mental Health Advisory Committee. The group meets regularly to find ways to intervene in the cycle of incarceration.
As a member of the group, Desmarais began working with Warren to measure the prevalence of mental health problems in the jail. The county formally backed the partnership in January 2017, allocating $95,000 for Desmarais’ six-month study at the jail. The project is part of Wake County’s participation in the larger Data-Driven Justice Initiative, a national effort launched by the Obama administration and now being led by the National Association of Counties.
“This is one of those perfect examples of having a champion in your community,” Desmarais says of Warren’s leadership. “I’m very confident that none of this would happen without Sara putting her time and energy into solving these problems.
“This is something that she believes in, and she sees the value in this from her position as a budget analyst, as well as the value it has for the well-being of these people.”
Complex Issue Requires Multiple Approaches
Former NC State graduate student Evan Lowder has been invested in the Wake County Jail project alongside Desmarais for nearly four years. Lowder, who recently earned her Ph.D. and has accepted a research position at Indiana University, helped write a grant in 2014 that paved the way for the current partnership.
The grant paid for a daylong Substance Abuse and Mental Health Services Administration training for more than 35 community leaders who play a role in how people with mental health problems move through the criminal justice system. Participants, including Wake County Sheriff Donnie Harrison and District Court Judge Robert Rader (political science ‘78), talked openly about how they fit into the broader system. They also brainstormed possible resources and diversion strategies.
“There are various points of contact that a person has with the criminal justice system,” Lowder said. “Our goal, through this training, was to identify those points and how we can intervene and provide community treatment services.”
One point of contact is the jail. Others include law enforcement interactions, post-release programs and the court system. Mental health courts, for example, are designed to divert offenders with mental health problems from jail and into community-based treatment programs. Lowder, Desmarais and NC State undergraduate Daniel Baucom conducted a 2015 study that showed how mental health courts significantly reduce repeat offending and limit jail time.
There are more than 300 mental health courts in the U.S., including five in North Carolina. Wake County does not have a mental health court.
No matter what specific changes come from the researchers’ study, it’s clear the conversation is thriving. That’s change in itself. As Lowder says, “When you research these types of things, you often generate answers that lead to more questions.”
If that means helping the sick and bettering the community, the more questions, the better.