According to a survey by the Bureau of Justice Statistics, approximately one in four individuals in jail (26 percent) reported experiences that met the threshold for serious psychological distress, five times higher than the general population. The same study found that 44 percent of jail incarcerated individuals had been told in the past by a mental health professional that they had a mental health disorder. In jurisdictions that lack community-based mental health services, individuals with mental illness tend to cycle in and out of jail for minor offenses such as trespassing, public urination, open container violations, or disorderly conduct. While incarcerated, the isolation from loved ones, constant noise of jail, lack of control, and barriers to mental health care can increase depression, anxiety, and post-traumatic stress disorder (PTSD).
The risk of suicide is also increased in carceral settings. Many people enter jail with multiple risk factors for engaging in suicide behavior, including having a serious mental illness and/or substance use disorder, a history of trauma, a history of suicide attempts, and recent suicidal ideation. Individuals entering jails with substance use disorders face an increased risk of suicide during their incarceration. Substance withdrawal can heighten feelings of depression and anxiety, and intoxication can lower behavioral inhibitions, which may exacerbate suicide risk.
Best practices for suicide prevention and response for correctional systems exist, and a growing body of research establishes the essential components of an effective suicide prevention program in jails.
Nearly half of the suicides in jail settings between 2015–2019 (48 percent) occurred between 6:00 p.m. and 6:00 a.m. Because correctional officers are often the only staff available 24 hours a day, they are considered the front line of defense in preventing suicides. Therefore, officer training around suicide risk detection is crucial for prevention efforts. Correctional staff must be trained to understand the risk factors present that increase the chance of suicide and high-risk periods for suicide, which include the following: the first 2 to 14 days of incarceration; periods of withdrawal from drugs or alcohol; waiting periods before trial, sentencing, or release; holidays or personal anniversary dates; after admittance to restrictive housing or single-cell housing; after the receipt of bad news regarding self or family; and periods when there is less staff present for supervisions (e.g., weekends, nights, and holidays).
Screening during jail intake provides a critical opportunity to identify the mental health needs of individuals being booked into the jail. Jails frequently elect to train correctional officers to administer brief, validated screening tools and/or a set of structured questions and record the answers to a brief list of questions about an individual’s physical and mental state at intake. Timely identification of mental health needs, including heightened risk of suicidal ideation is essential as the median time served before suicide in past studies is nine days. Individuals with a positive screen for serious mental health needs or suicidal ideation should be assessed as soon as possible, ideally within two hours of intake. This information is vital for determining treatment plans and ensuring that individuals are properly monitored. View screening instruments here.
Ongoing screening is necessary to ensure proper treatment and placement of the incarcerated person, as their conditions (e.g., worsening of symptoms) may change during incarceration. Custody staff are vital in conducting ongoing screening due to frequent contact and knowledge of the person’s behavior. If the incarcerated person’s behaviors or patterns are observed as changing, a referral for assessment may be warranted.
Though screening instruments for suicide risk inform staff of individuals at elevated risk of attempting suicide during incarceration, these screenings do not predict when an attempt will occur. Jails should use the least restrictive housing necessary to ensure everyone’s safety and avoid restrictive housing for those with serious mental illness. In situations where individuals are placed in administrative restrictive housing or similar specialized housing assignments (e.g., single-celled), they may have difficulty coping with the isolation and be at increased risk of suicide. Historically, a disproportionate number of suicides in specialized housing units have occurred. Forty-six percent (46 percent) of suicides during 2000–19 occurred in the jail’s general housing areas, and 21 percent occurred in restrictive housing units. If restrictive housing is the only option for housing a suicidal person, constant observation should be provided.
Incarcerated decedents, individuals who died in custody, often disclose suicidal intent to family, other incarcerated people, the arresting/transporting officer, and/or correctional staff. Educating family members, fellow incarcerated people, and correctional staff on reporting suicidal disclosures and developing mechanisms to ensure notifications are relayed to appropriate facility personnel may reduce suicide of the incarcerated population. All jail personnel must be trained to relay their observations about detained individuals. These open channels of communication keep staff informed and promote basic safety standards. In addition, some correctional facilities have implemented peer-to-peer programming among incarcerated individuals to enhance social support and prevent suicide.
The American Psychiatric Association’s (APA’s) Psychiatric Services in Jails and Prisons notes that “timely and effective mental health discharge planning is essential to continuity of care and an integral part of adequate mental health treatment.” APA has indicated that essential elements of discharge planning include arranging follow-up appointments for individuals with serious mental illnesses, transferring their treatment records to the referral entity, and arranging to have prescriptions renewed or reevaluated.
Suspended or delayed access to insurance coverage may result in delayed scheduling of behavioral health care appointments and lapses in access to medication. The best practice is to provide an adequate supply of medication upon release to bridge the gap until the individual can receive care from a community-based provider.
In-reach care coordination, a practice through which case managers or social workers come into correctional facilities and provide in-person assistance, is becoming more common. These staff may provide transitional support information to the individual or may personally transport and introduce the released individual to a mental health or substance use counselor, a coordinator of a local Forensic Assertive Community Treatment (FACT) team, or a community resource caseworker. These “warm hand-offs” ensure that, upon reentry, individuals have timely access to people and support.
Suicide Prevention Resource Guide: National Response Plan for Suicide Prevention in Correction Settings 2019
The National Commission on Correctional Health Care and the American Foundation for Suicide Prevention developed this guide that focuses on three areas key to suicide prevention in corrections: assessment, intervention and treatment, and training. The aim is to educate the field on how to better identify and help incarcerated individuals at risk for suicide, safely manage those identified as at high risk, and provide consistent, comprehensive training to all involved personnel.
Justice and Mental Health Collaboration Program (JMHCP)
From first contact to reentry, the Justice and Mental Health Collaboration Program (JMHCP) supports criminal justice and behavioral health systems nationwide as they safely divert people from the justice system and increase access to mental health treatment, innovative crisis services, housing support, and more.
Drug or alcohol intoxication deaths in custody quadrupled from 2000 (37 deaths) to 2019 (184 deaths). Drug or alcohol intoxication has accounted for an increasing share of deaths in local jails over time, accounting for 15 percent of all deaths in 2019. The median time served for individuals who died of drug or alcohol intoxication while in custody was one day.
Individual and environmental risk factors specific to carceral settings have contributed to the rise in drug-related deaths in custody. Individuals incarcerated in jails are likelier than the general population to have behavioral health needs such as substance use disorders. According to the 2007 and 2008–09 National Inmate Surveys (NIS), more than two-thirds (63 percent) of people sentenced to jail meet drug dependence or abuse criteria. Comparatively, general population data, collected from 2007 to 2009 for the Substance Abuse and Mental Health Services Administration (SAMHSA) National Survey of Drug Use and Health (NSDUH), suggest that only about 5 percent of adults meet the criteria for a substance use disorder.
The increasing mortality rate in jails may be due, in part, to fentanyl smuggled into facilities. According to a comprehensive review of public records, at least 61 fatal overdoses in jails were due to fentanyl between 2013 and 2020.
Systematic screening should be conducted immediately upon acceptance into jail custody. Individuals showing evidence of intoxication, reporting they are currently receiving medication-assisted treatment or using substances, should be referred to medical for further evaluation.
Medically managed withdrawal may be necessary when a person transitions to a controlled setting or begins treatment with naltrexone. Withdrawal symptoms may begin within four to six hours of the last opioid use, so protocols must be in place to identify people who might require medically managed withdrawal services within hours of intake. Jails should also have protocols to engage individuals with a substance use disorder in treatment, as medically managed withdrawal alone is not treatment.
Naloxone kits should be readily available to all people in the jail—health staff, correctional staff, and, optimally, incarcerated people. Staff should be educated on opioid overdose, its signs, and the correct technique for administering naloxone.
Guidelines for Managing Substance Withdrawal in Jails 2023
The rate of jail deaths due to drug or alcohol intoxication increased over 300 percent from 2000 to 2019.[i] Less often recognized but also potentially fatal, is the risk of substance withdrawal complications, such as profound dehydration and aspiration pneumonia due to severe vomiting. Responding to the urgent need to assist, the Bureau of Justice Assistance, in partnership with the National Institute of Corrections, developed Guidelines for Managing Substance Withdrawal in Jails.
Medication-Assisted Treatment (MAT) for Opioid Use Disorders in Jails and Prisons 2020
The National Council for Behavioral Health and Vital Strategies developed this toolkit to provide correctional administrators and healthcare providers the information necessary to plan and implement MAT programs within jails and prisons. Organized by core components, each section offers actionable steps, implementation questions, real-world case examples, checklists, tools, and resources drawn from the latest research, subject matter experts, and experiences from diverse settings across the U.S.
Jail-Based Medication-Assisted Treatment: Promising Practices, Guidelines, and Resources for the Field 2018
This publication supports the use of jail-based MAT and includes an overview of general tenets and best practices associated with developing, implementing, and sustaining a jail-based MAT program. It also highlights programs in action, providing a window into several real-world, jail-based MAT programs, including outcomes and lessons learned.
Comprehensive Opioid, Stimulant, and Substance Use Program (COSSUP)
COSSUP provides financial and technical assistance to states, units of local government, and Indian tribal governments to develop, implement, or expand comprehensive efforts to identify, respond to, treat, and support those affected by illicit opioids, stimulants, and other drugs of abuse. COSSUP funds can be used to implement comprehensive screening protocols, equip jail staff with naloxone, and implement evidence-based treatment practices, including medication-assisted treatment and withdrawal protocols in carceral settings.
Justice and Mental Health Collaboration Program (JMHCP)
The JMHCP supports innovative cross-system collaboration for individuals with mental illnesses or co-occurring mental health and substance abuse disorders who encounter the justice system.
Residential Substance Abuse Treatment (RSAT) for State Prisoners Program
The RSAT program supports state and local governments in developing and implementing substance use treatment programs in state, local, and tribal correctional and detention facilities.