Fifteen to 20percent of inmates in prisons in the United States today self-report serious mental illness, according to several recent studies [1].

When many public psychiatric hospitals were closed in the period from the 1960s to 1990s, savings were not sufficiently reinvested into community mental health facilities. Those who were seriously ill and/or highly dependent on institutional support sometimes ended up in the streets or imprisoned [2].

Today there are about twice as many mentally ill people in prisons and jails than in inpatient mental health facilities.The problem is intensified because those who are mentally ill are generally given longer prison sentences, have higher rates of recidivism [3], and suffer disproportionately from long stays in social isolation units.

Several successful lawsuits on behalf of mentally ill inmates and negative publicity have led to the development of prison reforms and alternatives. In 2014, a federal judge ordered California prisons to create separate units for mentally ill inmates and offer extensive mental health services [4].

Forty-eight states have adopted at least a partial mental health courts diversion system. A third suggested alternative is a vast expansion of psychiatric facilities and, as Fuller-Torrey has long advocated, changing state laws to facilitate the involuntary confinement of individuals with severe mental illness (see A recent opinion piece in JAMA called for more long-term asylums [5].

However, there are practically no studies in the American professional literature evaluating the therapeutic benefits of inpatient treatment. Before we expand this option to reduce incarceration of the mentally ill, we need careful evaluation of such transfer.

Let me be a bit outrageous and ask: Just how superior are locked psychiatric units to prisons as a place for those suffering mental illness?

It should be noted that both prisons and psychiatric wards vary considerably in their treatment of inmates/patients. Some prisons and psychiatric wards offer excellent facilities that includes things such as individual therapy, meaningful activities, sports, and useful group counseling.

However, the conditions in some prison and psychiatric facilities are horrific. In 2013 for example, the privately owned Quincy Medical Center psychiatric unit in Massachusetts (the most expensive psychiatric unit in the state) was closed for a week to new patients because of squalid conditions and patient neglect, not an unusual situation according to inspectors [6].

Federal investigations of prisons have found cases of barbaric treatment by guards of the mentally ill [2], for example in the Mississippi prison system [7]. However, here I try to focus on the more average conditions.

Key Issue 1: Involuntary Lock Ups

By definition in the US, both prisoners and individuals who are involuntarily committed to psychiatric wards find themselves behind locked doors. Those who have gone to trial or plea bargained anticipate their situation and they have some preparation for it.

Those who are involuntarily committed for the first time are usually shocked and frightened. In many cases they agree to a voluntary commitment but when they ask to leave, they are blue papered (civilly committed). Under the law in all US states, persons brought into a psychiatric ward can be kept against their will, usually for 72 hours, after which time the signature of two psychiatrists and a judge is required to extend the commitment further. However, this is a pro-forma procedure; commitment is easily procured.

With the courts approval, such involuntary commitment can be extended for considerable lengths, depending on the state. For example in Pennsylvania, it can be beyond six months, in Maine for over 16 months, and in Alaska there is no time limit.

Those who are committed can appeal to mental health courts and are sometimes provided legal representation. However, these trials are also fairly pro-forma. In more than 90% of the cases, according to hospital psychiatrists I interviewed, the judge sides with the hospital psychiatrist who claims that the patient lacks self-awareness.

They ignore research that at least 40% of seriously mentally ill individuals are capable of making treatment decisions [8]. Thus their conviction rates are very high, their lock up period unclear, and their concerns ignored.

In comparison, criminal defendants who chose to go to trial have a conviction rate between about 59% and 84% in state courts (higher in federal courts) [9].

Key Issue 2: General Conditions

Patients (in contrast to prisoners) rarely are permitted to get fresh air and outdoor exercise; a treatment the criminal courts have repeatedly ruled is critical to the well-being of prisoners and may be a civil right [10]. Patients also routinely do not have access to interesting activities, productive work, libraries, hobbies, or computers and email, most of which are commonly found in prisons. In fact one of the common complaints of confined patients is a terrible, numbing boredom.

Of course prisoners in isolation cells suffer far worse conditions, but average prisoners have more activities and facilities than do patients in psychiatric wards.

Key Issue 3: Safety

Advocates for more involuntary commitment say that at least the ill person is safe in a ward. In reality, both inmates and patients suffer from the lack of physical security. The National Institute of Justice reports that in 20112012 an estimated 4% of inmates in prisons and jails reported incidents of sexual victimization within the preceding 12 months, and about 21% experienced physical assaults during preceding six months [11].

There is no such data available regarding American psychiatric wards, but we know that in Britain in response to the serious problem of sexual assaults on psychiatric wards, the government ordered male patients to be segregated from women on wards. In Victoria, Canada, 85% of female patients reported feeling unsafe during psychiatric hospitalization, with 67% experiencing some forms of harassment and/or assault [12].

In the US, wards are rarely gender segregated [13]. Patients also suffer from attacks by staff although much less often than by fellow patients.

Key Issue 4: Mental Health Treatment

In a recent Scientific American article [14], the author states that there is rarely any treatment for mental illness in prisons. However, it would be more accurate to say that ill inmates do not receive meaningful treatment. About 66% of those in prison and 32% of those jailed who are deemed to suffer mental illness are on medication, which means that they have been at least seen by a staff doctor [15]. However, the high rate of recidivism67% to 80% [16] or higher in the case of those who are mentally illsuggests a poor record of treatment success or rehabilitation in prisons.

What of treatment on psychiatric wards? Most of todays psychiatric wards routinely hold patients for less than two weeks because of limited beds and insurance issues. Thus the main function of psychiatric wards is stabilization of patients deemed to be in crisis. But even when individuals are held longer, the treatment for all patients is psychiatric medication. There may be group sessions run by inexperienced graduate students, such as exercise class, music, and arts and crafts, labeled as therapy. However, there often is no individual therapy available. Individuals who attempted suicide and are feeling distraught are told to take meds, feel remorse, and be compliant, which sounds a bit like a parole board.

How effective is the crisis treatment offered? The National Association of Psychiatric Health Systems found a 30% rate of return of Medicare patients within one year. The rate of recidivism is higher where there is low access to therapists [17], although still lower than for prisons.

However, the success of hospital psychiatrists is also challenged by the finding that 23% of discharged patients engaged in suicide-related behavior within one year after being released [18]. The highest rate is during the first few days after discharge (Crawford 2004).

Although after care programs are often insufficient, suicide attempts soon after discharge do not indicate a successful crisis stabilization, which is the primary justification for involuntary commitment.

Hospital psychiatrists often attribute suicide attempts and revolving door issues to the short stays on wards, but these problems are found where longer stays are mandated as well. As one hospital psychiatrist wrote, it is much harder to develop a trusting relationship with a patient when the doctor is also the jailer [19].

It is disturbing that locked psychiatric wards do not appear to be doing much better than prisons for the mentally ill. It is more disturbing when you learn that it costs about $140 to $450 dollars a day to house inmates with mental health support, but about $800 to $1500 dollars per day for patients in psychiatric wards [20]. Neither seem like a good choice.

Mental health courts that direct criminal defendants away from prisons and into community health care are cheaper and more effective at rehabilitation than prisons, and outpatient treatment in crisis centers and peer respite facilities are at least as effective, and far less expensive or traumatizing, than either prisons or wards. And while such community treatment centers may not be effective for all patients, it is quite clear that our present system seriously fails a significant percentage of mentally ill people.

We have nothing to lose and much to gain by turning away from forced treatment and toward offering treatment which attracts compliance by being voluntary, recovery oriented, and peer-based.