Giving treatment options to offenders with severe mental health issues as an alternative to traditional criminal justice processing.
Focus of the intervention
Mental health courts (MHCs) 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 on the individual’s needs, with community supervision by a case manager to ensure that treatment is completed. The average length of treatment given as a sentence is 12 to 18 months. Upon satisfactory completion, graduates may be discharged from the programme and their criminal record for that offence may be removed.
What research is this summary based on?
This updated crime reduction toolkit summary is based on the findings of seven systematic reviews examining the impact of MHCs on reoffending. The overall findings of this summary are based on Review one, a systematic review and meta-analysis of 18 studies.
All the primary studies included in the reviews were based on evidence from the USA, except for one study in Review five which was conducted in Australia. The primary studies in the reviews identified a reduction in reoffending through a variety of measures, including:
- re-arrests
- new charges
- new convictions
- time in prison
- contact with the police
- booking rates (booking refers to a process where suspected criminals are taken into police custody after arrest)
Effect – how effective is it?
- The research suggests that mental health courts have reduced reoffending overall. However, some primary studies have shown increases in reoffending.
The meta-analysis in Review one showed a statistically significant, moderate reduction in reoffending among participants in MHCs compared to traditional criminal justice processing, 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high-quality and low-quality studies, those published in academic outlets showed much stronger effect sizes than unpublished studies.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.
All other systematic reviews included in this summary also found evidence that MHCs reduce reoffending. Depending on how effect was calculated in the reviews, the size and interpretation of the reduction varied: for example, Review two (based on 17 studies) reported a small overall reduction in reoffending, while the meta-analysis in Review three (based on many of the same studies as Review two) found that MHCs resulted in a 42% reduction in the odds of reoffending. Only one primary study included in the reviews (in Review five) found that MHCs resulted in a statistically significant, moderate increase in reoffending.
In relation to study design, Review two found that the timing of outcome measurement may moderate effects. Studies measuring reoffending after MHC exit reported statistically significant and stronger reductions in reoffending than studies measuring reoffending after enrolment.
How robust is the review evidence?
- The quality of review methods used to assess the impact of MHCs on reoffending was very strong.
Review one was sufficiently systematic that most forms of bias that could influence the study conclusions could 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, some biases remained within the primary studies, including dropout rates, the fact that some studies used non-completers as control groups, and how the study authors dealt with non-compliance or termination of programmes.
Review two was also sufficiently systematic that most forms of bias that could influence the study conclusions could be ruled out. Reviews three, four and five accounted for many sources of bias, while some forms of bias that could influence the study conclusions remained in Reviews six and seven.
Mechanism – how does it work?
- The quality of evidence in the reviews to assess how MHCs work was low.
Most reviews outlined possible mechanisms for how MHC reduce reoffending, but did not test empirically whether these mechanisms influenced the observed outcomes, or how outcomes differed by the type or severity of mental health condition.
The fundamental idea behind MHCs is that they are based on rehabilitation rather than punishment, applying ‘therapeutic jurisprudence’ alongside ‘effective intervention’ (Review three). The idea is that improving participants’ quality of life and providing appropriate treatment enhances mental health and helps prevent future offending. Review two highlighted the importance of a compassionate judge–participant relationship to this process, characterised by respect, engagement and active listening.
Reviews two and three described how specialised court dockets (lists of cases heard in court), mandated community treatment and calibrated incentives and sanctions can improve engagement and mental health functioning, thereby reducing reoffending. Another review emphasised that MHCs assist offenders by offering individualised treatment and linking them to services that address, rather than worsen, their mental health needs.
Review six argued that clinical and psychosocial factors contribute to offending, and that monitored treatment can strengthen individuals’ connections to behavioural health services, improving symptoms and reducing reoffending. However, it found no evidence that MHCs improve the frequency or consistency of service use. In the same review, only a minority of studies examined overall psychiatric functioning and just one assessed quality of life, limiting conclusions about MHC effectiveness on these outcomes.
Moderators – in which contexts does it work best?
- The quality of evidence in the reviews to assess the contexts where MHCs might work best was moderate.
Several reviews identified important contexts for how MHCs may affect reoffending.
Participant characteristics
- None of the reviews found evidence that age, sex or race moderated outcomes. Reviews one, five and six noted that most programme participants were white males in their thirties – unrepresentative of the wider US prison population (where black males make up approximately one third).
Programme completion and treatment dosage
- Reviews one, five and six suggested that completing the programme may be important. Review seven supported this: four of its seven primary studies found that participants who successfully completed an MHC had significantly lower re-arrest rates than those who only partially completed or were terminated and returned to traditional court.
- Review five noted that participants with multiple disorders (for example, co‑occurring substance misuse) were significantly less likely to graduate than those with a single disorder.
Other predictive characteristics
Review six identified several characteristics associated with lower reoffending:
- having a more serious offence at MHC admission
- lower pre‑MHC arrest rates and imprisonment days
- receiving mental health treatment at intake
- no substance misuse history
- a bipolar disorder diagnosis (compared with schizophrenia or depression)
It also highlighted factors associated with poorer outcomes:
- substance misuse disorders
- higher lifetime arrests or imprisonment days
- more serious historical offending
- lower educational attainment
- reliance on disability benefits
Implementation – what can be said about implementing this initiative?
- The quality of evidence in the reviews to assess how to implement MHCs was moderate.
There is no single definition of MHCs. Practice varies by local procedures and available treatments. However, common components recur across reviews. For instance, Reviews three and five introduced the ‘10 Essential Elements of MHCs’ (Bureau of Justice Assistance, 2007). These are:
- Planning and administration: Multi‑agency planning sets goals, oversees delivery and monitors performance
- Target population: Clear eligibility that balances public safety, treatment capacity and links between offence and illness
- Timely identification and linkage: Early referral, rapid eligibility/competency decisions and swift connection to services
- Terms of participation: Written, proportionate, individualised conditions and positive legal outcomes on completion
- Informed choice: Voluntary entry by offenders with legal advice offered
- Treatment supports and services: Comprehensive, evidence‑based, integrated care with case management and planned aftercare
- Confidentiality: Only information which is necessary and lawful should be shared. Clinical information should be kept out of the public record
- Court team: Judge‑led, collaborative team that continuously reviews and improves practice
- Monitoring adherence: Joint monitoring, graduated incentives/sanctions, and adjust treatment first for non‑adherence
- Sustainability: Measure outputs/outcomes, codify processes, plan for turnover, secure funding, engage the community
Review one identified enablers to the implementation of MHCs, including:
- good relationships between judges, court personnel and participants
- judges acting more like case managers than traditional judges
- consistency throughout the process
- outcomes linked to the quality of services provided
Review seven suggested that case managers and access to vocational and housing services may also be associated with lower re‑arrest rates. By contrast, Review one noted that lack of staffing may affect participant compliance rates.
Economic considerations – how much might it cost?
- The reviews provided insufficient evidence to assess how much MHCs might cost.
While none 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 an MHC programme in Pennsylvania saved approximately $3.5 million over a period of two years ending in 2007. This primary study specifically noted that MHCs had the potential to decrease the cost of the most expensive forms of treatment that participants would otherwise face, such as hospitalisation.
General considerations
- All studies included in the reviews were conducted in the USA (except one primary study conducted in Australia), so care must be taken when transferring findings to the UK context.
- There is some overlap of studies included in each of the reviews. For example, Reviews three and four have primary studies in common with Review two, and Review five lists review one as one of the included studies.
- High variability between primary studies in some reviews (for instance Review three) suggests effects vary across settings, outcomes and follow-up periods.
- MHCs require participants to plead guilty, and there are questions as to whether individuals with mental health issues can fully understand the implications of this, and provide informed consent to their participation.
- MHCs 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 MHCs – 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.
- Bias caused by the primary study designs was a common finding across the reviews. A majority implemented post-test only control groups, static group comparisons, or one group pre-test post-test designs.
Summary
- Overall, the evidence suggests that MHCs have reduced crime.
Across all reviews, participants in MHCs had less reoffending than control groups, though questions remain about the composition of these control groups in the primary studies. Successful MHCs are those where good relationships are maintained between judge and participants. There is currently no review-level evidence about the cost-effectiveness of MHCs, therefore, more rigorous evaluations are needed in this area.
Reviews
Review one
Reference
Sarteschi CM, Vaughn MG and Kim K. (2011). Assessing the effectiveness of mental health courts: A quantitative review, Journal of Criminal Justice, volume 39, pages 12–20.
Review two
Reference
Lowder EM, Rade CB and Desmarais SL. (2018). Effectiveness of mental health courts in reducing recidivism: A meta-analysis, Psychiatric Services, volume 69, issue 1, pages 15–22.
Review three
Reference
Jalain CI, Lucas PA and Higgins GE. (2024). Assessing the Effectiveness of Mental Health Courts in Reducing Recidivism: A Systematic Review with Meta-analysis, Justice Evaluation Journal, volume 7, issue 2, pages 212–230.
Review four
Reference
Fox B and others. (2021). Assessing the effect of mental health courts on adult and juvenile recidivism: A meta-analysis, American Journal of Criminal Justice, volume 46, issue 4, pages 644–664.
Review five
Reference
Cross BL. (2011). Mental health courts’ effectiveness in reducing recidivism and improving clinical outcomes: A meta-analysis, Masters dissertation, University of South Florida.
Review six
Reference
Honegger LN. (2015). Does the evidence support the case for mental health courts? A review of the literature, Law and Human Behavior, volume 39, issue 5, pages 478–488.
Review seven
Reference
Loong D and others. (2019). The Effectiveness of mental health courts in reducing recidivism and police contact: A systematic review, Community Mental Health Journal, volume 55, pages 1073–1098.
Additional resources
Bureau of Justice Assistance. (2007). Improving responses to people with mental illnesses: The essential elements of a Mental Health Court, US Department of Justice.