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Revisions in table.

Feldman and colleagues question whether an increase in psychiatric beds would reduce the number of incarcerated persons with mental illness. Mass incarceration in the United States has resulted from a number of confounding social, economic, and juridical factors. Institutional confinement spans many settings and waxes and wanes as a result of complex social factors.2 Although hotly debated, there is evidence that an inverse relationship exists between the availability of structured psychiatric settings and the number of incarcerated persons with mental illness.3 It is also the case that even with robust, well-funded, comprehensive community treatment— which we support—there will remain a group of individuals who will need a structured setting within which to live. The criminal justice system has taken on the role of long-term care provider for a proportion of these individuals,4 which is disturbing and unacceptable. Son’s experience is a reminder that community-based programs can provide essential hope when effective and that many individuals with a serious mental health illness can and do recover. By the same token, for those individuals who are unable to fully engage in such programs, the cycle of jail, homelessness, and repeated acute hospitalizations dashes hope. For individuals like Dr Miller’s son, a structured residential setting may be necessary. Similarly, the needs of families caring for loved ones with very serious intellectual disabilities have reached a crisis point in some areas of the country. Significant financial resources should be allocated to helping individuals with serious mental illness across a comprehensive range of services to provide them with dignified care that is evidence-based and scalable, which will make these services financially feasible. Integration of structured settings into accountable care organizations is one potential way to achieve cost-effectiveness and high quality and streamline a supportive transition from hospitalization to the community.5 In the end, there exists an important role for high-quality psychiatric hospitals.6 The entrenched false dichotomy between community care vs institutional care has created an unfortunate ideological schism that only hurts the people who need help.