Incarceration of Mentally Ill: Can Trend Be Reversed?

The ever-growing number of people with mental illness caught up in the criminal justice system and different approaches to address that problem were the focus of several articles in the June Psychiatric Services.

The series comes at a time when society has reached a “crisis point” on the issue, according to John Talbott, M.D., the corresponding author of a commentary in the journal on behalf of the Committee on Psychiatry and the Community of the Group for the Advancement of Psychiatry (GAP). Talbott is the former editor of Psychiatric Services and a former APA president.

The size and scope of the problem were clarified in a report by Henry Steadman, Ph.D., Fred C. Osher, M.D., and colleagues (see Original article: Education, Funding Crucial to Reduce Number of Mentally Ill Inmates). The researchers concluded that more than 2 million jail admissions of the total of 13 million in the 12 months ending by mid-year 2007 represented individuals with a serious mental illness.

Those findings confirmed widespread fears that prisons and jails nationwide have become de facto holding pens for the many Americans with mental illness.

“It's worse and it's awful, but it's not new,” Talbott told Psychiatric News.

The deepening recession and related budget deficits have led many state and local governments to make deep cuts in their public mental health programs, which in turn may be resulting in many more people with untreated psychiatric conditions ending up in jails and prisons, according to Talbott. Moreover, policymakers seem unable or unwilling to address the root causes of the problem.

One of the strongest recent indicators of the extent of the problem came when GAP requested that the “Dear Abby” advice columnist solicit letters from people who had become entangled in the criminal justice system as a result of their mental illness or their families.

GAP received nearly 3,000 letters, including one from a mother whose story of her son's incarceration was retold in Psychiatric Services. The mother, Carol Genengels, wrote that her son, John, became suicidal in 2002 so she called her county mental health office for help. Police officers responded, planning to take her son to a psychiatric hospital. After a brief scuffle, John, who was in a confused state, was charged with assault and jailed for several months. The extended jail time greatly worsened his mental illness, and after his release John required inpatient treatment.

“This country desperately needs mental health reform where the criminal justice system is concerned,” Genengels wrote.

The letters revealed other powerful themes, Talbott noted in his GAP committee commentary in Psychiatric Services. There were “many painful stories of men and women with complex co-occurring conditions—mental illnesses, substance abuse, trauma-related symptoms, developmental problems, brain injury, and even general medical conditions—whom the service system had failed and who wound up in jail. A series of minor offenses that could have been handled outside the criminal justice system instead led to long periods of incarceration. It is particularly distressing to know that for many of these individuals, simple and inexpensive interventions by a well-organized local care system could have prevented these tragic outcomes.”

Alternatives Examined

Among the reform ideas that have evolved in recent years are programs that aim to divert people with mental illness from jail and prison before they become entangled in the legal system.

One such program—for homeless individuals in Miami-Dade County, Fla.—was reported on by Rafael Rivas-Vazquez, Psy.D., and colleagues in the June Psychiatric Services. They found that the program, which sends eligible arrestees to “relationship-based care,” resulted in a “highly significant reduction” in arrest rates, compared with the arrest rates for the same people in the year before their latest arrest. Low rearrest rates correlated with length of time in the diversion program and the number of “psychiatric contacts” they had, among other factors.

The Rivas-Vazquez study is an example of the data-collection efforts on jail diversion for people with mental illness promoted by the Substance Abuse and Mental Health Services Administration.

Another approach promoted by federal mental health officials has been the development of innovative tactics and training for police to use in situations involving people with mental illness to avoid unnecessary arrests and violent escalations of incidents.

A study in the same issue examined correlations between the number of officers trained in Crisis Intervention Teams (CITs)—which focus on deescalating confrontations with people in a psychiatric crisis—and the number of responses by Special Weapons and Tactics (SWAT) teams.

The study, which was conducted in Atlanta, undermined the theory that SWAT team use would decline when CITs were available, as the researchers found no decline in SWAT team activity in the city as the number of CIT-trained officers grew. However, the authors noted that a larger multisite study might get a different result because the relatively small number of SWAT calls in their city related to a psychiatric crisis made identifying subtle changes in response difficult.

“Further research is needed to explore the relationship between CIT and SWAT, particularly in light of the increasing number of publicized cases in which individuals with mental illness have either been injured or killed during SWAT interventions,” wrote Michael Compton, M.D., M.P.H., and colleagues.

Program Shows Some Success

Another study in Psychiatric Services examined participants in a forensic assertive community treatment (FACT) program, which aims to prevent criminal recidivism and identify predictors of future arrest. The study found that although 64 percent of participants were not rearrested during the treatment program, some significant risk factors for recidivism among those who were arrested included a history of arrests for violent crimes before treatment, eviction from residential placement during treatment, and the presence of antisocial traits.

Identifying the extent to which youth with mental illness are over-represented in the criminal justice system was the focus of another Psychiatric Services study. Niranjan Karnik, M.D., Ph.D., and her colleagues used SCID interviews of 790 youths incarcerated for at least nine months in the California Division of Juvenile Justice and determined that 88 percent of boys and 92 percent of girls had a psychiatric disorder. More than 80 percent of the sample met criteria for some type of substance use disorder.

The authors hope that their findings will influence incarceration policy in the state.

“Juvenile-detention facilities must evaluate patients for these disorders and incorporate adequate treatment into the rehabilitation plan for their wards,” wrote Karnik and colleagues.

ThePsychiatric Servicesseries can be accessed at<http://ps.psychiatryonline.org/content/vol60/issue5/index.dtl>.▪