A half-century ago, most Americans with serious mental illness received treatment—even if imperfect and too often coercive—in state psychiatric hospitals. Today, by contrast, the country’s largest concentrations of people with serious mental illness are not in hospitals but in jails and prisons. Sheriffs in Los Angeles, Chicago, and New York have long described their lockups as the “largest mental health facilities” in their regions—an indictment of a system that routinely routes people with clinical needs into correctional custody. The result is a sprawling, decentralized, and under-resourced “asylum” network inside carceral institutions that were designed for security and incapacitation, not health care.
This essay explains how we got here, what we know about the scale of mental illness behind bars, how correctional environments complicate care, and what evidence-based reforms point to a different future. The focus is the United States, with reference to broader trends that illuminate the distinctively American pathway from deinstitutionalization to criminalization. Throughout, the argument is simple: the more we rely on correctional institutions to manage untreated mental illness, the worse the clinical outcomes, the higher the human and fiscal costs, and the further we drift from the constitutional and ethical mandates that should govern both health care and punishment.
From Hospitals to Jails: A Brief History
Beginning in the 1950s and accelerating through the 1960s and 1970s, the United States closed tens of thousands of state psychiatric beds under the banner of “deinstitutionalization.” In principle, shuttered hospitals were to be replaced by a robust community mental-health system. In practice, the promised community infrastructure arrived unevenly, leaving many people with serious mental illness without timely access to treatment and housing. By the 1990s and 2000s, researchers and county officials were documenting what they called the “new asylums”: a carceral safety net in which jails and prisons held far more people with serious mental illness than the country’s remaining state hospitals (Torrey, Kennard, Eslinger, Lamb, & Pavle, 2010; Torrey et al., 2014). The shift was not accidental. As public inpatient capacity declined and community services lagged, police—who are legally obligated to respond to crises—became de facto front-line mental-health responders. Courts and correctional systems absorbed the downstream consequences.
The “new asylum” moniker is not mere rhetoric. One national survey by the Treatment Advocacy Center concluded that, by the 2010s, jails and prisons held several times as many individuals with serious mental illness as state psychiatric hospitals, and that many of those individuals would previously have received inpatient treatment rather than incarceration (Torrey et al., 2010; Torrey et al., 2014). The criminalization pathway is now so entrenched that even well-intentioned local initiatives often amount to triage rather than structural change.
What the Data Show: Prevalence and Need
Although measurement varies across studies, the weight of evidence indicates that the prevalence of mental health symptoms and diagnoses in correctional settings far exceeds that of the general population. The Bureau of Justice Statistics (BJS) found that 14% of state and federal prisoners and 26% of jail inmates met the threshold for serious psychological distress in the prior 30 days; 37% of prisoners and 44% of jail inmates reported having been told by a mental-health professional at some point that they had a mental disorder (Bronson & Berzofsky, 2017). That compares to about 5% meeting the same distress threshold in the general population sample used for comparison (Bronson & Berzofsky, 2017). Estimates from psychiatric advocacy and clinical literature commonly place the share of people with serious mental illness (SMI)—conditions such as schizophrenia, bipolar disorder, or major depression with severe impairment—at roughly 15% in prisons and 20% in jails (Treatment Advocacy Center, 2016).
These carceral numbers are not occurring in a vacuum. In the broader community, SAMHSA’s uniform reporting system estimates that millions of adults live with SMI in any given year, with significant unmet need for treatment (Substance Abuse and Mental Health Services Administration [SAMHSA], 2025). When community systems fail to engage those most at risk—often individuals with co-occurring substance use disorders, homelessness, and trauma histories—police and jails become the default point of contact.
Mortality and morbidity data underscore the consequences. BJS reports that suicide remains a leading cause of death in jails and a persistent concern in prisons (Bureau of Justice Statistics, 2021). Federal oversight bodies have repeatedly documented lapses in screening, monitoring, and follow-up—failures with direct implications for people with mental illness (U.S. Department of Justice Office of the Inspector General [DOJ OIG], 2025; U.S. Government Accountability Office [GAO], 2024).
Why Correctional Settings Struggle to Deliver Care
Mission mismatch. Prisons and jails prioritize safety, custody, and order. Clinical care—especially for chronic, relapsing disorders—requires continuity, privacy, therapeutic alliance, and post-release linkage, all of which are hard to sustain in carceral environments. The American Psychiatric Association (APA) has long emphasized that correctional facilities nonetheless carry a constitutional obligation to provide necessary mental-health services—a duty that stems from case law prohibiting “deliberate indifference” to serious medical needs (APA, 2024). Meeting that obligation, however, is resource-intensive.
Churn and fragmentation. Jails experience massive turnover—millions of bookings annually—which complicates intake screening, medication reconciliation, and continuity of care. Many individuals arrive off their regimens, in withdrawal, or in acute crisis. Short stays mean clinicians have days—not months—to stabilize patients and arrange community follow-up. When those handoffs fail, people cycle back through custody.
Staffing and training constraints. Chronic vacancies among custody and clinical staff undermine both safety and care. Oversight reviews have linked staffing shortages to missed rounds, delayed assessments, and gaps in suicide prevention protocols (DOJ OIG, 2025). The GAO has separately found that the Bureau of Prisons has not fully implemented dozens of recommendations related to restrictive housing and associated mental-health risks (GAO, 2024).
Segregation and restrictive housing. Prolonged isolation can exacerbate psychiatric symptoms. National correctional health bodies advise excluding seriously mentally ill people from extended segregation or, where segregation is unavoidable, modifying conditions and providing structured therapeutic time out of cell (Metzner, Tardiff, & Fellner, 2015). Yet practice often lags policy.
Legal and ethical complexity. Treating people who refuse medication raises due-process and clinical questions that many systems navigate inconsistently. Surveys show wide variation in state policies governing involuntary treatment and access to hospital-level care for the sickest incarcerated patients (Torrey et al., 2014). Without clear, humane pathways to higher levels of care, jails and prisons become holding areas for untreated illness.
Constitutional Floor, Systemic Ceiling
When correctional conditions deteriorate, litigation is often the forcing function. In Brown v. Plata (2011), the U.S. Supreme Court upheld a population-reduction order for California’s prisons after finding that overcrowding produced constitutionally inadequate medical and mental-health care. The record described a system where preventable suffering and death flowed from structural dysfunction: insufficient space and staff, treatment delays, and a security posture that obstructed clinical access (Brown v. Plata, 2011). While Plata addressed state prisons, its logic echoes in local lockups and federal facilities facing similar barriers. Court orders can impose a constitutional floor; they cannot, by themselves, build the community systems that keep people out of custody or the clinical capacity inside facilities to meet complex needs.
Why Jails and Prisons Became the Default
Three dynamics explain the “asylum” shift:
-
Deinstitutionalization without parity. The rapid reduction of state hospital beds far outpaced the build-out of community services, leaving a shortfall in crisis stabilization, assertive community treatment, housing, and outpatient supports (Torrey et al., 2010).
-
Co-occurring disorders and homelessness. Many individuals with SMI also struggle with substance use and unstable housing—factors that raise the likelihood of police contact for low-level offenses or quality-of-life ordinances. Without diversion pathways, those encounters end in jail.
-
Legal and clinical thresholds. Civil commitment statutes and clinical practice trends place a premium on dangerousness and imminent risk; many people with SMI do not meet those thresholds until crises become acute. Police then become the gatekeepers.
Costs—Human and Fiscal
Housing and attempting to treat mental illness in jails and prisons is expensive. People with significant psychiatric needs require more staff time, medication, observation, and clinical services. They are also more likely to be victimized, to accrue disciplinary infractions, and to spend time in restrictive housing—all of which drive costs with little therapeutic payoff. Studies of large urban jails have documented per-diem costs that double or triple for people with serious mental illness compared to the general jail population because of added security and clinical supervision (see synthesis in Treatment Advocacy Center, 2016). Beyond custody, the “revolving door” of repeat bookings, emergency department use, and homelessness exacts a heavy toll on local budgets and, most importantly, on human life.
What Works: Evidence-Based Off-Ramps
If the pipeline into carceral “asylums” is the problem, diversion and treatment at the right time and place are the solution. Four strategies have the strongest evidence base:
1) Behavioral-health crisis response and 988 linkage. Mobile crisis teams, crisis receiving and stabilization facilities, and co-responder models reduce arrests during mental-health emergencies by providing an immediate clinical alternative to jail. When these services are integrated with the 988 Suicide and Crisis Lifeline and law-enforcement dispatch, officers can hand off safely and quickly, avoiding unnecessary bookings. The logic is straightforward: build something better than jail for people in crisis.
2) Pre- and post-arrest diversion. Mental-health courts, prosecutor-led deflection, and sheriff-based diversion units can route eligible individuals into treatment plans with accountability and support. Miami-Dade County’s Criminal Mental Health Project is a frequently cited example: by coupling officer training with court-supervised treatment and housing navigation, the county sharply cut jail days among participants (see program syntheses in TAC and professional association reports; Torrey et al., 2014; Treatment Advocacy Center, 2017).
3) Clinical capacity inside custody. Jails and prisons still need robust intake screening, prompt psychiatric evaluation, access to evidence-based medications, suicide prevention protocols, and timely referral to hospital-level care when indicated. National professional guidance—by APA and correctional health organizations—sets clear expectations for staffing, confidentiality, treatment planning, and continuity of care (APA, 2024; Metzner et al., 2015). Compliance, however, depends on staffing, leadership, and oversight—areas where federal watchdogs continue to identify gaps (GAO, 2024; DOJ OIG, 2025).
4) Reentry that begins at booking. Without warm handoffs—appointments on the calendar, active benefits, medications in hand, and transportation—people with SMI fall off a cliff at the jail door. Effective programs collaborate with community providers, ensure Medicaid activation upon release, and prioritize housing supports—especially medical respite and supported housing—for those with high needs.
The Role of Leadership and Oversight
Cultural and structural change require leadership. Police chiefs, sheriffs, judges, and corrections executives increasingly acknowledge that they cannot “arrest their way” out of untreated mental illness. Yet acknowledgment must translate into budgets, contracts, and accountability. GAO’s 2024 review of the Bureau of Prisons’ restrictive housing practices illustrates how slow implementation and incomplete follow-through on recommendations can perpetuate risk for vulnerable populations (GAO, 2024). DOJ’s Office of the Inspector General has likewise documented lapses that, while sometimes focused on general medical care, signal systemic deficits in screening, follow-up, and staffing that inevitably spill over into mental-health outcomes (DOJ OIG, 2025). These findings should be read not only as critiques but as a roadmap for investment and reform.
Reframing the Question
Calling jails and prisons “America’s asylums” is descriptively powerful but normatively dangerous if it suggests that carceral care can ever be an adequate substitute for a functioning community mental-health system. The constitutional minimum for care in custody—secured through litigation when necessary—should not become the policy maximum. A humane, fiscally rational system directs people to the least restrictive, most effective setting consistent with public safety and clinical need. For many, that means community-based care, not a cell.
Conclusion
The United States did not set out to make jails and prisons its primary mental-health institutions. It happened because we closed hospitals faster than we built clinics, relied on police to manage crises that medicine and housing should have addressed, and tolerated gaps in correctional health that would be unacceptable anywhere else. The data are clear: mental illness behind bars is common, care is difficult to deliver at quality and scale, and preventable harms—up to and including suicide—persist. The constitutional floor defined by cases like Brown v. Plata should motivate, not satisfy, our ambitions.
Changing course means funding crisis response and treatment upstream; creating lawful, clinical off-ramps in lieu of arrest; professionalizing and auditing correctional mental-health care where custody is unavoidable; and making reentry a clinical transition, not an administrative afterthought. We know what works. The question is whether we will invest in it—so that the phrase “America’s asylums” once again refers to hospitals and community clinics worthy of the name, not to the jails and prisons that have shouldered their absence.
References
American Psychiatric Association. (2024). Position statement on psychiatric services in jails and prisons. Author.
Bronson, J., & Berzofsky, M. (2017). Indicators of mental health problems reported by prisoners and jail inmates, 2011–12 (NCJ 250612). Bureau of Justice Statistics, U.S. Department of Justice.
Bureau of Justice Statistics. (2021). Suicide in local jails and state and federal prisons, 2000–2019: Statistical tables (NCJ 300954). U.S. Department of Justice.
Brown v. Plata, 563 U.S. 493 (2011).
Metzner, J. L., Tardiff, K., & Fellner, J. (2015). Mental health considerations for segregated inmates. National Commission on Correctional Health Care.
Substance Abuse and Mental Health Services Administration. (2025). 2022 serious mental illness/serious emotional disturbance estimates. U.S. Department of Health and Human Services.
Torrey, E. F., Kennard, A. D., Eslinger, D., Lamb, H. R., & Pavle, J. (2010). More mentally ill persons are in jails and prisons than hospitals: A survey of the states. Treatment Advocacy Center & National Sheriffs’ Association.
Torrey, E. F., Zdanowicz, M. T., Kennard, A. D., Lamb, H. R., Eslinger, D., Biasotti, M., & Fuller, D. A. (2014). The treatment of persons with mental illness in prisons and jails: A state survey. Treatment Advocacy Center.
U.S. Department of Justice, Office of the Inspector General. (2025). Inspection of the Federal Bureau of Prisons’ Federal Medical Center Devens (Report 25-009). Author.
U.S. Government Accountability Office. (2024). Additional actions needed to improve restrictive housing and related mental health care in the federal prison system (GAO-24-105737). Author.
Posts
