A recent Colorado Springs Gazette headline betrays the grim reality: “Colorado’s jails and prisons house many of the state’s mentally ill.”
Over the last half-century, America’s psychiatric treatment system for the most severely ill has been dismantled. The basic infrastructure needed to address the scourge of mental illness — a public health epidemic — has been stripped bare. Jails and prisons have been left to take up the slack. Colorado’s problems typify this national crisis.
A functional mental health system requires a combination of community services and at least 50 psychiatric treatment beds per 100,000 people to provide individuals with severe mental illness with a minimal level of care. However, Colorado provides just 10 such beds per 100,000 people. In 2016, that meant just 543 psychiatric beds for the estimated 144,000 Coloradans with schizophrenia and bipolar disorder.
Without inpatient treatment beds for this population, those most in need become trapped in an endless cycle of deterioration and crisis. Many wind up on the streets, vulnerable to abuse and exposed to medieval diseases like typhus and tuberculosis. They also overcrowd hospital emergency rooms, where they sit amidst the chaos, sometimes for weeks at a time.
And, as The Gazette reported, many inevitably land behind bars. The Colorado Department of Corrections estimates that one out of every three men and four out of every five women imprisoned in Colorado has some type of moderate to critical mental health need. At the El Paso County jail alone, nearly a third of the inmates — more than 6,000 people — had a mental health diagnosis or history, or had been flagged as suicide risks.
Science now shows us that mental illnesses are medical conditions requiring a medical response. The provision of health care behind bars is a constitutional responsibility, but it is not a viable solution to this problem. The correctional system is neither designed nor equipped to provide appropriate psychiatric treatment.
Moreover, jails and prisons are arguably the worst possible place for people in serious psychiatric distress. And the consequence of warehousing people in medical crisis in cells is too often deadly.
A national effort to track the deaths of those with mental illness in jails identified more than four hundred since 2010. The actual number of deaths was likely significantly higher. And when people with severe mental illnesses die in custody, taxpayers foot the bill for the massive settlements that the correctional and criminal justice systems reach.
The means for repairing the mental health system and averting future tragedies is to ensure that people with severe mental illnesses receive a full continuum of medical care when they need it and before they are incarcerated, as we would for those with other diseases.
Colorado recognized this when it passed bipartisan legislation to begin to address the crisis. But the Centennial State has more to do.
In Grading the States: An Analysis of Involuntary Psychiatric Treatment Laws, my organization examined whether state law allows an individual in need of involuntary treatment to receive it in a timely fashion, for sufficient duration, and in a manner, that promotes long-term recovery. Colorado’s laws received a D+.
To improve that grade, state lawmakers can and should revise their treatment statutes to reflect the latest science on mental illness. They must ensure treatment does not demand police intervention and avoid unnecessary over-reliance on outdated and stigmatizing notions of dangerousness before someone can get help.
Colorado must also address its critical bed shortage. Late last year, Secretary Alex Azar of the U.S. Department of Health & Human Services announced important regulatory changes that will finally allow states to overcome The Medicaid Institutions for Mental Diseases (IMD) exclusion — an outdated federal barrier that disincentivizes states from building needed treatment beds. Colorado should take advantage of those changes to add needed beds immediately using federal Medicaid matching funds.
Colorado has finally recognized having a mental illness is not a crime. That is a vitally important realization. But Gov. Jared Polis and the Colorado Legislature must not stop now. They must modernize their treatment laws and add needed treatment beds by making Colorado’s waiver application a top priority.
John Snook is the executive director of the Treatment Advocacy Center, a nonprofit that works to eliminate barriers to treatment for people with severe mental illness.