Editor’s note: This post is published in conjunction with the March issue of Health Affairs, which features a cluster of articles on jails and health.

Mental Illness in America’s Jails and Prisons

The United States continues to have one of the highest incarceration rates in the world, with 5 percent of the world population, but nearly 25 percent of the world’s prisoners.  Inmates are spending more time behind bars as states adopt “truth in sentencing laws,” which requires inmates to serve 85 percent of their sentence behind bars.

In 2012, about 1 in every 35 adults in the United States, or 2.9 percent of adult residents, was on probation or parole or incarcerated in prison or jail, the same rate observed in 1997.  If recent incarceration rates remain unchanged, an estimated 1 out of every 20 persons will spend time behind bars during their lifetime; and many of those caught in the net that is cast to catch the criminal offender will be suffering with mental illness.

Nearly a decade ago, I wrote an article with Patrick Brown titled “Crisis in Corrections: The Mentally Ill in America’s Prisons.”  It was about the alarming growth in the number of mentally ill individuals behind bars.  Since then, it has been shown that about 20 percent of prison inmates have a serious mental illness, 30 to 60 percent have substance abuse problems and, when including broad-based mental illnesses, the percentages increase significantly. For example, 50 percent of males and 75 percent of female inmates in state prisons, and 75 percent of females and 63 percent of male inmates in jails, will experience a mental health problem requiring mental health services in any given year.

It also appears that the individuals being incarcerated have more severe types of mental illness, including psychotic disorders and major mood disorders than in the past.  In fact, according to the American Psychiatric Association, on any given day, between 2.3 and 3.9 percent of inmates in state prisons are estimated to have schizophrenia or other psychotic disorder; between 13.1 and 18.6 percent have major depression; and between 2.1 and 4.3 percent suffer from bipolar disorder.

Across the nation, individuals with severe mental illness are three times more likely to be in a jail or prison than in a mental health facility and 40 percent of individuals with a severe mental illness will have spent some time in their lives in either jail, prison, or community corrections. I think we can safely say there is no doubt that our jails and prisons have become America’s major mental health facilities, a purpose for which they were never intended.

From Deinstitutionalization to Trans-institutionalization

In the early 1960s, states embarked on an initiative to reduce and close their publicly-operated mental health hospitals, a process that became known as deinstitutionalization.  Advocates of deinstitutionalization envisaged that it would result in the mentally ill living more independently with treatment provided by community mental health programs.  The federal government, however, did not provide sufficient ongoing funding for community programs to meet the growing demand.  Concomitantly, states reduced their budgets for mental hospitals, but provided no proportionate ongoing increases in funding for community-based mental health programs.

As a result, hundreds of thousands of mentally ill persons were released into communities that lacked the resources necessary for their treatment. The system was, and is, broken, an assessment underscored in a 1999 report from the Surgeon General’s Office, titled Mental Health: A Report of the Surgeon General, indicating that, “Even more than other areas of health and medicine, the mental health field is plagued by disparities in the availability of and access to its services.” Consequently, many of the individuals released into the community without support ended up incarcerated;  it is fair to say that instead of being “deinstitutionalized” a great number of individuals suffering with mental illness were, in fact, “trans-institutionalized” into America’s jails and prisons.

Understanding the Difficulties in Managing the Mental Illness in Jails and Prisons

There is an abundance of statistics compiled by government agencies and advocacy groups underscoring the challenges associated with the management of mental illness in jails and prisons.   Mentally ill individuals in the criminal justice system, for example, often have multiple disorders, including substance abuse and are often ostracized by other inmates and stigmatized by their illness.

Some become overly passive, withdrawn and dependent during incarceration; others may become agitated, episodically violent, or engage in non-suicidal self-injurious behaviors.  A 2009 Human Rights Watch report titled Ill Equipped: U.S. Prisons and Offenders with Mental Illness, described inmates with mental illness as often punished for their symptoms.  As a result, the report noted, prisoners with mental illness often have extensive disciplinary histories.

Meeting the Challenge

In Estelle vs. Gamble (1976), the Supreme Court clearly determined that the Eighth Amendment requires prison officials to provide a system of ready access to adequate medical care, including mental health care.  There is no doubt that federal and state governments have a mandate to provide access to adequate treatment for the mentally ill in America’s jails and prisons.  But in addition to providing access to necessary care, the critical issue for mental health programs is to “get smart on mental illness” by utilizing metrics that identify maladaptive inmate behaviors that often result in threats to institutional security, inmate and staff safety, and are costly in terms of human and financial resources.

Quality assurance, utilization management and risk management programs may be important in assessing the efficacy of mental health delivery systems,, but it is vital to begin incorporating new metrics that measure the impact of mental health programming on reducing disciplinary reports, use of force, self-injurious behaviors, cell extractions, placement of mentally ill inmates in restrictive housing, and reducing recidivism.

A Public Safety/Public Health Model

In developing effective care and management strategies, we need a paradigm shift that conceptualizes mental illness in jail and prison environments as a public safety/public health issue.  The rationale is that individuals with mental illnesses are more likely to be arrested, convicted, and move through a relentlessly revolving door between incarceration and the community.

Mentally ill offenders, for example, may refuse pre-release continuity of care planning or, after release, fail to show up for their initial appointment with a community provider.  Also, they are often unable to access community treatment because of limited access to community programs, a reluctance among providers to treat them, because community mental health centers are unprepared to treat people who have a criminal record, or all of the above.

Perhaps the optimal solution to curbing recidivism of the mentally ill would be to conceptualize mental illness as a chronic illness and extend public health services into the prisons immediately upon individuals’ incarceration.  By managing mental illness as a chronic illness – where the severity of the symptoms wax and wane in response to genetic and congenital vulnerabilities, environmental influences, and individual behavior – public health and safety officials can collaborate in developing more effective and efficient strategies for managing mentally ill inmates in America’s jails and prisons and after release in to their communities.

Perhaps now more than ever has the care and treatment of mentally ill offenders in jails and prisons become a public safety/public health issue.  With individuals coming out of jail or prison having disproportionately high rates of mental illness and substance abuse disorders, the time is propitious for a paradigm shift.  Carpe Diem!

Author’s note: The views and opinions expressed in this article/blog are those of the author and do not necessarily represent any official policy or position of any state or federal agency.