One of New Zealand's most experienced forensic psychiatrists says more people with severe mental illness are being sent to prison because there is nowhere else to put them.
Dr Erik Monasterio, who provides expert opinion about defendants' mental health in court, estimates there are "dozens of people" who "are languishing in prison or on the streets" instead of getting the treatment they need under the Mental Health Act.
The Mental Health Act sets out a legal framework that can make it compulsory for an eligible patient to get assessed and treated for a mental disorder. This can apply to defendants where a judge has decided they are unfit to stand trial because of their mental health, or people who have been found not guilty by reason of insanity.
"If you have an acute severe mental disorder and qualify for the Mental Health Act, it's the equivalent… to somebody who needs an operation here and now," Monasterio said.
"Let's say it's the equivalent of an acute appendicitis. Now, no matter how stretched the health services, if you turn up to ED and you have an acute appendicitis, you will get your operation."
But the same isn't true for people with acute mental health needs, he said of what he observed working in prisons.
"What we're seeing in New Zealand is prisons are becoming the new psychiatric institutions; we are incarcerating the mentally disordered.
"Often, they're in prison on trivial charges simply because there are no beds available in the public health system.
"So it's become the new norm to place somebody into prison rather than to take them into hospital…. and the environment and prison will almost guarantee a worse outcome for them," Monasterio said.
He said the most common diagnosis of severe mental illness is a psychotic disorder.
"So, as they're out of touch with reality, they are often disruptive in their behaviours. They don't engage well [and] they often become disenfranchised from their families.
"They either end up living on the streets or behaving oddly… if you're going to prison and you behave oddly, you're at risk to yourself and potentially to others."
Monasterio said the risk this poses means people often end up in what's known as an intervention and support unit.
He said, in these units, people could be isolated for 23 to 24 hours a day.
"They often don't have a window to the outside world. If their behaviours are disturbed enough, they won't even have a toilet."
Monasterio said isolation "we know unequivocally leads to worse outcomes for people with serious mental illness".
"They may be there for weeks waiting to come into hospital. At times, they never get into hospital at all."
He said Corrections staff aren't trained to deal with people with high mental health needs.
Corrections said its "Intervention and Support Practice Teams" and clinical nurse specialists provided mental health care for nearly 6000 people in prison in the 2022/23 year.
Corrections estimates about nine in 10 prisoners would have met the criteria for a mental health or substance use disorder in their lifetimes.
A 2018 paper by Monasterio and James Foulds, a University of Otago associate professor of psychiatry, found defendants who had stable housing were more likely to be granted bail. They noted people with chronic mental illness were finding it increasingly difficult to access affordable housing.
Monasterio was the clinical director of Mental Health Services for the Canterbury Regional Forensic Service between 2015 and 2021.
He quit working in the public service after seeing "this decay in the mental health services in New Zealand" in the past "five to seven years".
"I did everything in my power to try to change that. And from within the system, I couldn't achieve that change.
"Therefore, as a leader, I felt if I couldn't achieve that change while I was leading - and in a leadership position I was seeing intolerable situations - the only option available to me was to resign and eventually try to work from outside of the system."
Q+A is public interest journalism funded by NZ On Air.
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