Early last year, two suicidal patients showed up at a hospital emergency room in Pierre, S.D., seeking help. Although the incidents happened weeks apart, both patients ended up in an unexpected place: jail.
Across the country, and especially in rural areas, people in the middle of a mental health crisis are locked in a cell when a hospital bed or transportation to a hospital isn’t immediately available. The patients are transported from the ER like inmates, handcuffed in the back of police vehicles. Laws in five states — New Mexico, North and South Dakota, Texas and Wyoming — explicitly say that correctional facilities may be used for what is called a “mental health hold.” Even in states without such laws, the practice happens regularly.
“It is a terrible solution...for what is, at the end of the day, a medical crisis,” said John Snook, executive director of the Treatment Advocacy Center, a national group that advocates for the severely mentally ill. Research shows that the risk for suicide, self-harm and worsening symptoms increases the longer a person is behind bars.
But in a shift, Colorado recently outlawed using jail to detain people in a psychiatric crisis who have not committed a crime. The state delegated just over $9 million — with $6 million coming from marijuana tax revenue — to pay for local crisis centers, training for law enforcement and transportation programs.
The new law was passed after Colorado’s sheriffs lobbied the state to extend the amount of time a person could be detained. In rural counties, sheriffs testified, lack of manpower meant they were forced to hold onto people longer than the 24-hour legal limit. A state task force instead recommended ending the practice entirely.
There are no national figures on how many people are held each year in jail just because they have nowhere else to go in a mental health crisis. Reports from the federal agency overseeing hospitals — the Centers for Medicare and Medicaid Services — offer a glimpse. Since 2011, at least 22 hospitals in 16 states have been cited by CMS for failing to stabilize patients in need of mental health help, instead handing them over to law enforcement to wait for a psychiatric evaluation or a bed. The hospitals span the country, from Alabama and South Dakota to New York and Ohio.
The practice affects patients of all ages. At Avera St. Mary’s Hospital in Pierre, S. D., children from 12 to 16 were sent to spend the night in jail on at least seven occasions, CMS inspection reports show. One 16-year-old girl came to the emergency room after overdosing on Motrin and was escorted to jail less than an hour after her arrival, without a psychiatric evaluation. Hospital staff waited until the morning to notify her parents. At the same hospital, a 12-year-old girl arrived in the emergency room after an attempted hanging. She was sent to spend the night in jail less than an hour later. The hospital did not respond to requests for comment.
Few people think jail is an appropriate place for someone in a mental health crisis. Most jails, especially small rural facilities, do not have mental health staffers on site. For the suicidal, law enforcement agencies have few options other than periodically stopping by the cell to check on the person and putting potentially violent individuals in restraints and seclusion. Once someone has been held for 24 hours, he or she has to be charged, transferred to a treatment facility or released. “People should not, because of their mental illness, be in jail,” said Jennie Simpson, a public health analyst with Substance Abuse and Mental Health Services Administration, the federal agency that oversees national behavioral health policies.
The problem highlights a nationwide scarcity of available doctors and inpatient beds for people in a mental health crisis, particularly the poor. The number of psychiatric beds decreased by 96% across the country over the past 50 years, research shows. At the same time, awareness of mental health needs has increased and more people have access to health insurance, allowing them to seek care.
The issue was exacerbated by a 1972 federal law that was intended to help stop the widespread warehousing of people with mental illness. The law forbids the federal government from paying for inpatient mental health and drug treatment at psychiatric facilities with more than 16 beds. States are left to foot the entire medical bill for those on public insurance, straining budgets already struggling in the midst of the opioid crisis. A federal commission recently recommended that exemptions to the law be given immediately to states that request one.
In New Hampshire, a long waitlist for beds led the state to begin sending non-criminals who were ordered committed for their own safety to a prison psychiatric unit for treatment. Patients and inmates participate in the same therapy programs. During group therapy, to protect patients and staff, particularly violent inmates are placed in metal cages with a bench.
In Rapid City, S.D., the region’s largest hospital announced earlier this year that it would not make more room for psychiatric patients once its behavioral unit was full. Instead, it would call the county sheriff to pick up people it could not admit. The state psychiatric hospital is in Yankton, in the southeast corner of the state. That’s an hour and a half drive for Minnehaha County Sheriff Michael Milstead, who said he rarely has to hold people in jail while waiting for transport to the hospital. But it’s a nearly six-hour drive from Pennington County, in the western half of the state. There, people in crisis often have to wait in jail until Sheriff Kevin Thom can spare a deputy to transport them.
The decision of who gets sent to the sheriff and who gets to stay in the ER can have serious consequences. Baptist Memorial Hospital in Union City, Tenn., was cited by CMS in 2012 for allowing an eye doctor to evaluate suicidal patients. The doctor discharged one patient to jail who returned to the hospital the next day after attempting suicide. He later died of his injuries.
At another hospital in Tennessee, a suicidal man who waited 10 hours in a seclusion room was told he would have to finish his wait for a bed in jail. For the next two hours, the man banged on the door to his room, asking staff over and over what he had done to have to go to jail, according to federal inspection reports. Eventually he tried to escape. A security guard pushed him back into the room so hard that he was momentarily airborne before landing and fracturing his neck.
Though local strategies have led to some improvement, it seems the real solution may be federal. “We’re never going to train our way out of this problem,” said Snook of the Treatment Advocacy Center, “The reality is we need much more.”
Correction: An earlier version of this story misstated Jennie Simpson's last name and incorrectly described the role of the Substance Abuse and Mental Health Services Administration.