Focus of the intervention
Mental health courts are designed to divert offenders suffering from severe mental health issues – such as schizophrenia, major depression and bipolar disorder – towards treatment options rather than imprisonment.
Customised sentences are given depending upon the individual’s needs, with community supervision by a case manager to ensure that their treatment is completed.
The average length of treatment given as a sentence is 12 to 18 months, and upon satisfactory completion the defendant graduates from the programme and their criminal record for that offence may be removed.
This narrative is primarily based on one systematic review covering 18 studies. A second review (covering 20 studies) provides additional evidence in relation to the mechanism, moderator and implementation sections below.
Effect – how effective is it?
Overall, the evidence from Review one suggests that the intervention has reduced crime, but there is some evidence that it has increased crime.
There was significantly less reoffending among mental health court participants compared to control groups, though the review did not test different crime types.
While there was very little difference in effect size between high-quality and low-quality studies, those published in academic outlets had much stronger effect sizes than unpublished studies.
The review did not explore the follow-up time at which reoffending was measured, which varied between 6 to 18 months.
Only one study saw a significant increase in reoffending.
How strong is the evidence?
Review one was sufficiently systematic that most forms of bias that could influence the study conclusions can be ruled out.
It had a well-designed search strategy, included unpublished literature and used appropriate statistical methods in the analysis of effect size.
However, biases remained within the primary studies, including:
- dropout rates
- the fact that some studies used non-completers as control groups
- how the study authors dealt with non-compliance or termination of programmes
Mechanism – how does it work?
Both reviews suggest that mental health courts may work by focusing on rehabilitation. This includes the notion that the law can be applied in a therapeutic way and aid individuals (a non-therapeutic way can be unhelpful or even harmful).
In applying the law therapeutically, mental health courts focus on rehabilitation rather than punishment.
By positively affecting the offender’s quality of life and providing the treatment they need, this may prevent future crimes.
Review two suggested that the compassionate judge-client relationship is the key to this, alongside treating participants with respect, engagement, and actively listening to them.
Neither review tested whether this suggested mechanism had an effect upon the outcomes, or looked at whether the type or severity of the mental health condition makes any difference to the outcome.
Moderators – in which contexts does it work best?
The reviews noted a number of potential moderators, with both reviews mentioning the potential importance of participant race, age and gender.
However, they also noted that most of the participants in the programmes were Caucasian males in their thirties, which was unrepresentative of the US prison population with over one third African-American males.
Both reviews also suggested that programme completion might be a moderator as treatment dosage could be important.
Review two also noted that participants with multiple disorders (for example, those that also have substance misuse problems) are significantly less likely to graduate from the treatment programme than those with a single disorder.
Neither review tested whether any of these suggested moderators had an effect upon reoffending, however.
Implementation – what can be said about implementing this initiative?
Review two noted that there is no overall consensus about what constitutes a mental health court – they vary depending upon the procedures in their location and the available treatments in the area.
Nevertheless, there are a number of common components that are discussed in both reviews.
Participants must report to the court on a regular basis to discuss their progress or revise their treatment plans, with sanctions being applied for noncompliance.
All participation is on a voluntary basis, and graduation happens once they meet their individual goals and are able to handle their mental illness. In some cases, monthly drug screening is required for participants who also have a substance-related disorder.
Review one noted a number of factors that were associated with the successful implementation of mental health courts. These included:
- good relationships between judges and court personnel and the participants
- the fact that judges acted more like case managers than traditional judges
Consistency is critical throughout the process and success was related to the quality of services provided to participants.
One potential barrier was that a lack of staffing affected compliance rates by participants.
Economic considerations – how much might it cost?
While neither of the reviews conducted a full cost benefit analysis, some mention of costs was reported in a primary study in Review one.
This estimated that a mental health court in Pennsylvania saved approximately $3.5 million over a period of two years ending in 2007.
This primary study specifically noted that mental health courts had the potential to decrease the cost of the most expensive forms of treatment that participants would otherwise face, such as hospitalisation.
- All mental health court studies included in the reviews were conducted in the USA, so care must be taken when transferring these findings to the British context.
- Mental health courts require participants to plead guilty. There are questions as to whether individuals with mental health issues are able to fully understand the implications of this and provide informed consent to their participation.
- Mental health courts are difficult to research due to the issue of a high degree of confidentiality in participant records.
- There were difficulties with how to deal with individuals who refused to participate in mental health courts. Arguably those who chose to participate were more likely to wish to receive treatment and were therefore not necessarily comparable to those who refused. Despite this, some primary studies used those who refused treatment as part of a control group.
Overall, the evidence suggests that the intervention has reduced crime, but there is some evidence that it has increased crime.
Participants in mental health courts had significantly less reoffending than control groups, though questions remain about the composition of these control groups in the primary studies.
Successful mental health courts were those where good relationships were maintained between the judge and participants.
Summary prepared by
This narrative was prepared by UCL Jill Dando Institute and was co-funded by the College of Policing and the Economic and Social Research Council (ESRC). ESRC grant title: 'University Consortium for Evidence-Based Crime Reduction'. Grant reference: ES/L007223/1.