The Prevalence of Mental Illness in California Jails is Rising: An Analysis of

Mental Health Cases & Psychotropic Medication Prescriptions, 2009-2019

February 2020

Topline Findings
In this brief we use data from the Board of State and Community Corrections (BSCC) to estimate the
relative prevalence of mental illness among jail-incarcerated individuals in California over the past ten
years. We reviewed data from counties that completed the BSCC Jail Profile Survey (JPS) between 2009
and 2019. On average, we used data from 50 counties each year for our analytical sample.

Based on our sample, the share of the California statewide jail population either with an active mental
health case or a prescription for a psychotropic medication increased significantly between 2009 and
2019 (see Figure 1 on the next page):

• Active Mental Health Cases. On the last day of any given month in 2009 there were roughly
80,000 people in jail custody throughout California and 15,500 people with an active mental
health case. On the last day of any month in 2019 there were approximately 72,000 people in
jail custody and 22,000 people with an open mental health case. This represents a 42 percent
increase in the number of active mental health cases. In addition, the proportion of
incarcerated people in California jails with an active mental health case rose by approximately
63 percent, rising from 19 percent in 2009 to 31 percent in 2019.

• Psychotropic Medication Prescriptions. In 2009, on the last day of any month, there were
roughly 80,000 people in jail custody across the state and about 10,500 individuals receiving
psychotropic medications. However, in 2019, on the last day of any given month, there were
approximately 72,000 people in jail custody and roughly 19,000 individuals receiving these
psychotropic medications. This represents an 80 percent increase in the total number of
inmates receiving these medications. Moreover, the proportion of jail-incarcerated people
throughout California with a psychotropic medication prescription roughly doubled from 13
percent in 2009 to 26 percent in 2019.
Although these JPS data pertaining to mental illness in jail are useful for estimating the prevalence of
mental illness among the jail incarcerated population in California, these data are incomplete at times.
In our report we provide specific, actionable recommendations to improve the overall data quality.
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Figure 1. Prevalence of Active Mental Health Cases and Psychotropic Medications,

Statewide from 2009 to 2019
35

Active Mental Health Cases

30
Percent (%) of California Jail Population

25

Psychotropic Medication
Prescriptions
20

15

10

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

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Background
Data on mental illness among incarcerated populations is difficult to obtain. However, the available
data, which mostly comes from surveys, suggests that mental illness in jail or prison is prevalent and
that individuals with a mental illness are overrepresented in jail or prison. About 1 in 4 jail inmates self-
reported experiences that met the threshold for serious psychological distress (SPD) in the 30 days
prior to incarceration, according to the Bureau of Justice Statistics’ 2011-12 National Inmate Survey.1 In
comparison, data from the National Survey on Drug Use and Health2 found that only about 1 in 19
persons in the standardized U.S. general population met the threshold for SPD. In this study we rely
upon administrative data from the state of California to estimate the prevalence of mental illness
among the jail population. There are justifiable concerns about the prevalence of mental illness in jails
and prisons.

• Individuals experiencing mental illness are likely to remain incarcerated longer than their
peers. On average, individuals with mental illnesses receive sentences that are 12 percent
longer than individuals convicted of the same crimes but without mental health diagnoses.3
• Incarcerated people experiencing a mental illness are also more likely to be disciplined and
isolated in segregated housing (i.e., solitary confinement). Once in solitary confinement the
harsh conditions of the segregation worsen the symptoms of mental illness. Moreover, not only
are the mentally ill more likely to be placed in solitary confinement, they often find it
exceedingly difficult to meet the requirements for release.
• People with a mental illness diagnosis are more likely to commit suicide and/or be victimized.
Suicide is the leading cause of death in correctional facilities, and as many as half of all inmate
suicides are committed by the estimated 15 to 25 percent of inmates with serious mental
illness. Untreated mental illness can also contribute to violent victimization in custody.
Individuals with serious mental illness in jail were five times more likely to report that they
were sexually victimized by another inmate than individuals with no mental illness.4
• It is expensive to incarcerate individuals with mental illnesses since jails in the United States
are improperly equipped for treatment. Correctional health care professionals are constantly
constrained by limited or improper resources and large caseloads. Community mental health
treatment is less costly and more effective than incarceration.5

1
BJS National Inmate Survey (NIS).
2
SAMSHA National Survey on Drug Use and Health (NSDUH).
3
Stanford Justice Advocacy Project. “The Prevalence and Severity of Mental Illness Among California Prisoners.” 2017.
4
Bureau of Justice Statistics. “Sexual Victimization in Prisons and Jails Reported by Inmates, 2011-2012.” 2013.
5
The annual cost of incarcerating an average jail inmate in California is estimated at $30,000, not including mental health
care costs, while the cost of treating a person with mental illness in the community is approximately $20,000, according to
the Judicial Council of California report entitled “Task Force for Criminal Justice Collaboration on Mental Health Issues: Final
Report” from 2011.

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Methodology
Since 2002, the BSCC has conducted the Jail Profile Survey (JPS) to collect data regarding local agency
jails and jail systems.6,7 County-wide data are gathered monthly and counties submit their data on a
voluntary basis. In the monthly survey, counties are asked to report average daily population (ADP) for
the month. ADP is the monthly average, excluding people on holding status. Importantly, the survey
also requests that counties report the “number of inmates on the last day of the month who are
receiving psychotropic medications for identified mental health disorders.” The survey also asks
counties to report the “number of open mental health cases on the last day of the month.” Active (i.e.,
open) mental health cases are inmates identified as having a psychological disorder and who are
actively in need of and receiving mental health services. The number of psychotropic medication
prescriptions and the number of inmates receiving mental health services are counted on the last day
of each month, and so they represent point-in-time counts.

We developed analytical samples of all California jails independently by both survey question and year.
Furthermore, we generated two samples per year – one for our analysis of active mental health
caseloads and another for our analysis of psychotropic medications. Jurisdictions that responded to the
JPS questions about mental illness for at least two reporting periods during a given year are included in
that respective analytical sample. Appendix A details which counties are included. We use data from
the vast majority of jails across the state and the sample is diverse.8 The JPS data is incomplete at times
and there are some notable issues that should be addressed with the survey series to improve its
quality and usefulness. In this report we took a conservative, descriptive approach to our analysis that
uses the maximum amount of the available non-missing data and summarizes it. In the final section of
this report we offer recommendations to improve the data. We believe that the mental health data
gathered from the JPS can be significantly enhanced with greater BSCC oversight.

In this report we use the results from this JPS series to better estimate the prevalence of mental illness
in jail. We focus our analysis on the data gathered from the questions pertaining to (1) the month-end
number of psychotropic medication prescriptions, (2) the month-end number of active mental health
cases, and (3) the month-end jail population (i.e., ADP). From these questions we calculated both
annual and statewide estimates for the following measures:9

• Raw number (i.e., count) of individuals with either an open mental health case or a
psychotropic medication prescription;
• Percent of the jail population with either an open mental health case or a psychotropic
medication prescription; and
• Total Change (i.e., long-run change) in the percent of the jail population with either an open
mental health case or a psychotropic medication prescription.

6
The BSCC provides a “workbook” with instructions for reporting entities. This form is publicly available.
7
The BSCC administers the JPS using an Excel fillable form. This form is also publicly available.
8
The sample is diverse in terms of geographic coverage since counties from every region of California are consistently
included. Moreover, the sample is diverse with respect to the underlying demographic makeup of the reporting county jails.

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Statewide Findings
A growing number of jail-incarcerated individuals are experiencing mental illness in California.
Moreover, the share of the statewide jail population experiencing some form of mental illness, as
reported to the BSCC, has increased significantly since 2009.

Active Mental Health Cases

The raw count of open mental health cases in California jails increased by a total of about 42
percent between 2009 and 2019. In 2009 there were an average of approximately 15,500 open
mental health cases on the last day of any given month, across all the jurisdictions in our
sample. During 2019 there was an average of about 22,000 open mental health cases on the
last day of any given month across all the reporting counties.

The percent of the statewide annual ADP with an open mental health case increased by 11
percentage points or about 62 percent. In 2009, approximately 19 percent of the annual ADP
had an active mental health case across the jurisdictions that reported. During 2019 though,
approximately 30 percent of the annual ADP had an open case in these same jurisdictions.

Psychotropic Medication
The raw number of incarcerated individuals receiving psychotropic medications increased by
roughly 81 percent between 2009 and 2019. During 2009, there was an average of about
10,500 individuals on psychotropic medications on the last day of any given month across all
the jurisdictions in this sample. During 2019,10 there was an average of 19,000 individuals
receiving psychotropic medications on the last day of any given month across the same
reporting jurisdictions.

The percent of the statewide annual ADP on psychotropic medications increased by 13

percentage points or about 100 percent between 2009 and 2019. During 2009, approximately
13 percent of the annual ADP received these medications across the jurisdictions that reported.
In 2019, roughly 26 percent of the annual ADP received psychotropic medications throughout
these same jurisdictions.

10
January 2019 to June 2019.

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Figure 2a. Estimated Count and Prevalence of Active Mental Health Cases Statewide, 2009 - 2019
25,000 35
Average number of open mental health cases last day of month
Percent of jail population with open mental health case

30
Average number of open mental cases last day of month

Percent of jail population with open mental health case

20,000

25

15,000
20

15
10,000

10

5,000

0 0

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Figure 2b. Estimated Count and Prevalence of Psychotropic Medications Statewide, 2009 - 2019
20,000 30
Average number of people receiving psychotropic meds last day of month
Percent of jail population receiving psychotropic meds
Average number of people receiving psychotropic meds last day of month

25

Percent of jail population receiving psychotropic meds

16,000

20

12,000

15

8,000

10

4,000
5

0 0

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

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County Findings – Prevalence of Mental Health Indicators, 2019

The share of the county jail population experiencing some form of mental illness appears to differ
significantly across the state. There is considerable variation in between jurisdictions with respect to
the relative prevalence of both open mental health cases and psychotropic medications among the jail-
incarcerated.

Open Mental Health Cases

In 2019, the share of the jail ADP with an open mental health case varied across the state. In
the median California county approximately 32 percent of the jail-incarcerated people have an
open mental health case.11 However, in Kern and Santa Clara County, roughly 86 to 88 percent
of the ADP receive psychotropic medications. Conversely, in Trinity and San Benito County only
about 9 or 18 percent of the ADP have an active case, respectively. About 45 percent of San
Diego’s jail population and 42 percent of San Francisco’s have open cases.

Psychotropic Medications
In 2019, the share of the jail ADP receiving psychotropic medications varied widely between
counties. About 23 percent of the jail population receives at least one psychotropic medication
in the median California county.12 However, in Modoc and Siskiyou County, roughly 50 to 56
percent of the annual ADP receives psychotropic medications. Conversely, in Glenn and Madera
County only about 8 or 9 percent of the ADP receives psychotropic medications. In Los Angeles
approximately 35 percent of the jail population receives psychotropic medications. Roughly 25
percent of San Diego and San Francisco’s jail population receives some medications.

11
Orange county was the “median” (50th percentile) jurisdiction in terms of the prevalence of open mental health cases
amongst the jail population in 2019.
12
Fresno county was the “median” (50th percentile) jurisdiction with respect to the prevalence of psychotropic medications
amongst their jail population in 2019.

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Figure 3a. Percent of Jail Population with Active Mental Health Case in 2019
State Median State Median

Amador Nevada
Butte Orange
Calaveras Placer
Colusa Plumas
Contra Costa Riverside
Del Norte San Benito
El Dorado San Bernardino
Fresno San Diego
Glenn
San Francisco
Humboldt
San Luis Obispo
Imperial
San Mateo
Inyo
Santa Clara
Kern
Santa Cruz
Kings
Shasta
Lake
Siskiyou
Lassen
Solano
Los Angeles
Madera Sonoma

Marin Stanislaus
Mariposa Tehama
Mendocino Trinity
Merced Tulare
Modoc Tuolumne
Mono Yolo
Napa Yuba

0 10 20 30 40 50 60 70 80 90 100 0 10 20 30 40 50 60 70 80 90 100

Percent ADP with Open Mental Health Case

Figure 3b. Percent of Jail Population Receiving Psychotropic Medications in 2019

State Median State Median

Alameda Nevada
Amador Orange
Butte Placer
Calaveras Plumas
Colusa
Riverside
Contra Costa
San Benito
Del Norte
San Bernardino
El Dorado
San Diego
Fresno
Glenn San Francisco
Humboldt San Luis Obispo
Imperial San Mateo
Inyo Santa Barbara
Kern Santa Clara
Kings Santa Cruz
Lake Shasta
Lassen Siskiyou
Los Angeles Solano
Madera
Sonoma
Marin
Stanislaus
Mariposa
Tehama
Mendocino
Trinity
Merced
Modoc Tulare
Mono Tuolumne
Monterey Yolo
Napa Yuba

0 10 20 30 40 50 60 0 10 20 30 40 50 60

Percent ADP with Pyschotropic Medications

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County Findings – Trends in the Prevalence of Mental Health Indicators, 2009-2019

Nearly all California jails have experienced a cumulative rise in the share of their incarcerated
population with some mental illness. However, the amount of total change has been markedly
different between jurisdictions.13

Open Mental Health Cases

Since 2009 California jails have experienced different amounts of total change in the
estimated share of their jail population that requires behavioral healthcare and counseling. In
both Yolo and Yuba Counties, the proportion of their ADP with an active mental health case
increased by about 35 percentage points from 2009 to 2019. In Los Angeles County, this rate
increased by a full 12 percentage points over this same period. However, in Orange County this
rate increased by only a total of 2 percentage points. The average county experienced a 15
percentage point increase in the segment of their jail population with an active mental health
case between 2009 and 2019.

Psychotropic Medications
Similarly, counties have experienced markedly different degrees of total change in the
estimated share of their jail population receiving psychotropic medications since 2009. In
Santa Clara County, the share of their jail population receiving psychotropic medications
increased by about 30 percentage points from 2009 to 2019. In Los Angeles County, this rate
increased by 22 percentage points over this same period. However, in Butte County this rate
fell by a total of 2 percentage points. The average county saw the percent of their jail
population receiving psychotropic medications climb approximately 11 percentage points
between 2009 and 2019.

13
See Appendix C for a discussion about the annualized year-over-year change in both the percent of county jail
populations with either an active mental health case or a psychotropic medication.

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Figure 4a. Total Change in the Percent of the Jail Population with an Active Mental Health Case
by County Between 2009 and 2019
Butte
Calaveras
El Dorado
Fresno
Humboldt
Imperial
Kern
Kings
Lake
Los Angeles
Madera
Mendocino
Merced
Napa
Nevada
Orange
Placer
Riverside
San Benito
San Bernardino
San Diego
San Francisco
San Luis Obispo
San Mateo
Santa Clara
Santa Cruz
Shasta
Solano
Sonoma
Stanislaus
Tehama 2019
Tuolumne
Yolo 2009
Yuba

0 20 40 60 80 100
Percent ADP with Open Mental Health Case in 2009 vs 2019
Note: The 36 largest counties, by resident population, with non-negative JPS responses in 2009 and 2019 are shown.

Figure 4b. Total Change in the Percent of the Jail Population Receiving Psychotropic Medications
by County Between 2009 and 2019
Alameda
Butte
El Dorado
Fresno
Humboldt
Imperial
Kern
Kings
Lake
Los Angeles
Madera
Mendocino
Merced
Monterey
Napa
Nevada
Orange
Placer
Riverside
San Benito
San Bernardino
San Diego
San Francisco
San Luis Obispo
San Mateo
Santa Barbara
Santa Clara
Santa Cruz
Shasta
Solano
Sonoma
Stanislaus
Tehama 2019
Tuolumne
Yolo 2009
Yuba

0 10 20 30 40 50
Percent ADP Prescribed Psychotropic Meds in 2009 vs 2019
Note: The 36 largest counties, by resident population, with non-negative JPS responses in 2009 and 2019 are shown.

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Discussion
According to the BJS’s national studies on this population, about a third (roughly 35 percent) of jail
inmates who met the threshold for serious psychological distress (SPD) had received mental health
treatment since admission to their current facility.14 In comparison, 38 percent of jail inmates who had
ever been told that they had a mental disorder said they were currently receiving treatment for a
mental health problem. 15 An estimated 30 percent of jail inmates said they were currently taking
prescription medication.16 In our study we rely upon the number of psychotropic medication
prescriptions and open psychiatry cases to estimate the prevalence of mental illness. However, our
estimates are likely biased downwards (i.e., our estimates are likely conservative), since national
studies have shown that a significant share of the jail-incarcerated people battling mental illness do not
receive treatment.

There are a few different explanations for why the share of the statewide jail population with either a
prescription for psychotropic medications or an active mental health cases has increased since 2009:

• This finding could reflect a trend toward the increased incarceration of seriously mentally ill
individuals. Local factors, such as increased homelessness or defendants increasingly found
Incompetent to Stand Trial (IST), could potentially contribute to this trend. Alternatively, the
consequences of state policy changes under Public Safety Realignment that have redirected
inmates with lower level offenses to jail who previously had been sentenced to prison could be
driving this trend. One policy objective of Realignment was to make it easier to connect inmates
serving short sentences with community resources, such as behavioral health services and
treatment, that would improve recidivism.
• The increase we observe in the rate of the incarcerated jail population with either an open case
or an active psychotropic medication prescription might not be due to increased numbers of
incarcerations of mentally ill individuals, but rather to better identification, diagnosis, and
treatment of seriously mentally ill individuals in jails. Further research should focus on
identifying the ways in which jails have changed their practices during this period.
Measuring the number of jail inmates receiving psychotropic medications or with an open case file
could serve as a possible proxy for the number of individuals with mental illness in jail. However,
the reliability of these figures depends on the consistency of mental health assessment, diagnostic,
and treatment practices in all jails. A standard screening and assessment process could allow for a
more precise accounting of the mentally ill population in California and allow for more efficient
allocation of funds/resources.17 However, in the short term, the BSCC data provides a useful
baseline to help understand local incarceration trends related to individuals with mental illness and
can help inform policies that attempt to address this issue.

14
BJS Indicators of Mental Health Problems Reported by Prisoners and Jail Inmates, 2011-2012.
15
Ibid.
16
Ibid.
17
The Council on Criminal Justice and Behavioral Health (CCJBH), formerly known as the Council of Mentally Ill Offenders
(COMIO), and others have recommended the adoption of standardized screening and assessment tools at booking.

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Recommendations for Improved Data Collection

Jails are facing a growing crisis as the proportion of incarcerated individuals with serious mental illness
continues to rise. State and local policymakers are working to confront the problem, but the need for
accurate data is critical. The available data from the BSCC about mental health in jails are incomplete.
However, there are several things that can be done to improve our accounting of mental illness in jail:

1. Improve the uniformity of reporting.

The BSCC should take steps to improve the uniformity of reporting. The workbook that the
BSCC distributes alongside the JPS could be made more detailed. For example, the BSCC does
not provide a clear, concrete definition of what counts as a psychotropic medication. It is
unclear what each jurisdiction uses as their definition for the purposes of reporting in this
survey. Section 3500(c) of the California Penal Code defines a “psychotropic drug” as a drug
that has the capability of changing or controlling mental functioning or behavior through direct
pharmacological action. 18,19 CalHPS was unable to verify the definitions used by the jails
included in this analysis.

2. Increase the consistency of reporting.

Several counties inconsistently report information about the number of individuals receiving
psychotropic medications and/or the number of open mental health cases. In terms of
consistency, Marin, Sacramento, Riverside, and San Diego are counties that have relatively poor
reporting history. Moreover, a number of counties not only inconsistently report answers to
this part of the JPS survey, but they rarely report at all. San Joaquin, Lassen, Marin, and Tulare
are counties that missed reporting for over 50 percent of all the JPS reporting periods between
January 2002 and June 2019. Appendix B contains details about the missing data and
demonstrates which counties report most and least consistently.

3. Enhance the accuracy of reporting.

The BSCC should work more closely with the reporting jurisdictions to obtain more accurate JPS
responses. In our review of the JPS data we found several inaccuracies and errors in data
reporting. For example, it should be always true that the highest one-day population is always
greater than or equal to the number of open mental health cases on the last day of the month.
However, this is not consistently the case in the data. There are some counties, during some
reporting periods (i.e., months) that report a greater number of open mental health cases than
the peak population for that month. For example, in October 2018 Humboldt reported that
their highest single day population count was 412 inmates, but they reported having 481 open
mental health cases on the last day of that same October. In fact, between 2009 and 2019 there
were more than 30 other instances in the JPS data where the number of reported open mental
health cases at month end was greater than the peak single-day population during that month.

18
California Penal Code Section 3500(c) [Link]
19
These drugs include, but are not limited to, antipsychotic, antianxiety, sedative, antidepressant, and stimulant drugs.
Psychotropic drugs also include mind-altering and behavior altering drugs that, in specified dosages, are used to alleviate
certain physical disorders, and drugs that may be ordinarily used to alleviate certain physical disorders.

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About the Author

Konrad Franco is a Researcher with CalHPS. He is currently pursuing a PhD in Sociology with
concentration in quantitative research methods at the University of California, Davis. He studies the
physical and behavioral health of individuals cycling through jails, prisons, and immigration detention
facilities. He can be reached at [email protected].

About California Health Policy Strategies (CalHPS), L.L.C.

CalHPS is a mission driven health policy consulting group based in Sacramento. For more information,
visit www.calhps.com.

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Appendix A: State Sample Composition

For our statewide analysis of the JPS data we constructed samples on an annual basis, individually for
each data point of interest – psychotropic medications and open mental health cases. We only
included counties that provided at least two non-missing answers per year pertaining to the JPS
questions regarding the (1) the month-end number of psychotropic medication prescriptions, (2) the
month-end number of active mental health cases, and (3) the month-end jail population (i.e., ADP). In
other words, we included a county if they responded to these particular questions of interest in the JPS
at least twice in any given year.

The following two tables demonstrate which counties are included in our study and during which
years. A black check mark (✓) indicates that a given county reported for that period and is included in
the statewide sample. Conversely a red highlighted cross mark (✗) indicates that a given county is
excluded from the statewide sample because they did not sufficiently report during that period.

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Table 1. Sample Composition: Open Mental Health Cases

County 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Alameda ✓ ✓ ✗ ✗ ✗ ✗ ✗ ✗ ✗ ✗ ✗
Amador ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Butte ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Calaveras ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Colusa ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Contra Costa ✗ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Del Norte ✓ ✓ ✓ ✓ ✓ ✗ ✗ ✗ ✗ ✓ ✓
El Dorado ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Fresno ✓ ✓ ✓ ✗ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Glenn ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Humboldt ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Imperial ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Inyo ✓ ✓ ✓ ✗ ✗ ✗ ✗ ✓ ✓ ✓ ✓
Kern ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Kings ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Lake ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Lassen ✗ ✗ ✗ ✗ ✗ ✗ ✓ ✓ ✓ ✓ ✓
Los Angeles ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Madera ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Marin ✗ ✗ ✗ ✗ ✗ ✓ ✓ ✓ ✓ ✓ ✓
Mariposa ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Mendocino ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Merced ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Modoc ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Mono ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Monterey ✗ ✗ ✗ ✗ ✗ ✗ ✗ ✗ ✗ ✗ ✗
Napa ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Nevada ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Orange ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Placer ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Plumas ✓ ✓ ✓ ✓ ✗ ✗ ✗ ✗ ✗ ✓ ✓
Riverside ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Sacramento ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✗
San Benito ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
San Bernardino ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
San Diego ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
San Francisco ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
San Joaquin ✗ ✗ ✗ ✗ ✗ ✗ ✗ ✗ ✗ ✗ ✗
San Luis Obispo ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
San Mateo ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Santa Barbara ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✗ ✗
Santa Clara ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Santa Cruz ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Shasta ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Siskiyou ✓ ✗ ✗ ✗ ✗ ✓ ✓ ✓ ✓ ✓ ✓
Solano ✓ ✗ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Sonoma ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Stanislaus ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Sutter ✓ ✓ ✓ ✓ ✗ ✗ ✗ ✗ ✗ ✗ ✗
Tehama ✓ ✓ ✓ ✗ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Trinity ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Tulare ✗ ✗ ✗ ✗ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Tuolumne ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Ventura ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✗
Yolo ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Yuba ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
The black check mark (✓) indicates that a given county is included in the statewide sample.
The red highlighted cross mark (✗) indicates that a given county is excluded from the statewide sample.
Included counties reported both the month-end number of active mental health cases and their month-end ADP
at least twice in any given year.

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Table 2. Sample Composition: Psychotropic Medications

County 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Alameda ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Amador ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Butte ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Calaveras ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Colusa ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Contra Costa ✗ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Del Norte ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
El Dorado ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Fresno ✓ ✓ ✓ ✗ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Glenn ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Humboldt ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Imperial ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Inyo ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Kern ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Kings ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Lake ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Lassen ✗ ✗ ✗ ✗ ✗ ✗ ✓ ✓ ✓ ✓ ✓
Los Angeles ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Madera ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Marin ✗ ✗ ✗ ✗ ✗ ✗ ✗ ✗ ✗ ✓ ✓
Mariposa ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Mendocino ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Merced ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Modoc ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Mono ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Monterey ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Napa ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Nevada ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Orange ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Placer ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Plumas ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Riverside ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Sacramento ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✗
San Benito ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
San Bernardino ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
San Diego ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
San Francisco ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
San Joaquin ✗ ✗ ✗ ✗ ✗ ✗ ✗ ✗ ✗ ✗ ✗
San Luis Obispo ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
San Mateo ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Santa Barbara ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Santa Clara ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Santa Cruz ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Shasta ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Siskiyou ✓ ✗ ✗ ✗ ✗ ✓ ✓ ✓ ✓ ✓ ✓
Solano ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Sonoma ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Stanislaus ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Sutter ✓ ✓ ✓ ✓ ✗ ✗ ✗ ✗ ✗ ✗ ✗
Tehama ✓ ✓ ✓ ✗ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Trinity ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Tulare ✗ ✗ ✗ ✗ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Tuolumne ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Ventura ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✗
Yolo ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
Yuba ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
The black check mark (✓) indicates that a given county is included in the statewide sample.
The red highlighted cross mark (✗) indicates that a given county is excluded from the statewide sample.
Included counties reported both the month-end number of individuals receiving psychotropic medications and
their month-end ADP at least twice in any given year.

California Health Policy Strategies, L.L.C. www.calhps.com 916.842.0715 [email protected]

 Page 17

Appendix B: Measures of Change for Individual Counties

Total percent change is a measure of “long-run” change. This metric can also be called the cumulative
percent change.

2019 4$%5( − 2009 4$%5(

!"#$% '()*(+# ,ℎ$+.( =
2009 4$%5(

Annual percent change is a measure of “short-run” year-over-year change.

4$%5(8 − 4$%5(89:
7++5$% '()*(+# ,ℎ$+.( =
4$%5(89:
4$%5(8 = value in any given year (year k)
4$%5(89: = value in previous year (year k-1)

Average annual percent change is a measure of the average “year-over-year” change. This is a linear
measure that is the arithmetic mean of all the observed annual percent changes over the time period.

,ℎ$+.(;<<=9;<:< + ,ℎ$+.(;<:<9;<:: + ⋯ + ,ℎ$+.(;<:@9;<:=

74()$.( 7++5$% '()*(+# ,ℎ$+.( =
11
,ℎ$+.(;<<=9;<:< = percent change between 2009 and 2010
,ℎ$+.(;<:<9;<:: = percent change between 2010 and 2011

Annualized percent change (i.e., compound annual percent change) is a “smooth” measure of the
average observed annual percent change. This metric is the geometric mean of all the observed annual
percent changes. The annualized percent change is useful for comparing change between different
counties. The annualized percent change offers a single measure of change for the entire period which,
had it applied at all times throughout that period, would have led to the same total change as was
observed. Over long periods of time, the compound annual percent change is a generally acceptable
and preferred metric for average change. The most important limitation of this metric is that because it
calculates a smoothed rate of change over a period, it ignores volatility and implies that the change
during that time was steady.
:
2019 4$%5( ::
7++5$%AB(C '()*(+# ,ℎ$+.( = −1
2009 4$%5(

California Health Policy Strategies, L.L.C. www.calhps.com 916.842.0715 [email protected]

 Page 18

Appendix C: Annualized Year-Over-Year Change for Individual Counties

The majority of counties in California experienced increases in the prevalence of mental illness in their
jails year-over-year. However, the annualized year-over-year change in the relative prevalence of
mental illness among jail-incarcerated people was also significantly different across counties.

Open Mental Health Cases

Between 2009 and 2019, counties experienced markedly different degrees of annualized year-
over-year change in the proportion of their jail population with active mental health cases. The
median average year-over-year change in rate of mental health case prevalence in California
jails was roughly 8 percent, but across the state, annualized rates of changes ranged from 36
percent increases to 29 percent decreases. In Yolo County, the share of the jail population with
an active mental health case increased by roughly 15 percent per year, on average. Los Angeles
County experienced an average change in this metric of about 8 percent year-over-year. Some
counties, such as Orange experienced a small change of about 1 percent per year on average
over this time period.

Psychotropic Medications
Between 2009 and 2019, counties also experienced markedly different degrees of annualized
year-over-year change in the share of their jail population receiving psychotropic medications.
The median annualized change in rate of psychotropic medication prevalence in California jails
was roughly 6 percent, but across the state, annualized rates of changes ranged from 9 percent
increases to 23 percent decreases. In Fresno and Kern County, the number of people receiving
psychotropic medications increased by about 10 to 13 percent per year, on average. Los
Angeles County experienced an average change of about 9 percent year-over-year. Some
counties, such as Humboldt and Napa experienced small change of less than 1 percent per year
on average over this time period.

California Health Policy Strategies, L.L.C. www.calhps.com 916.842.0715 [email protected]