Education, Funding Crucial to Reduce Number of Mentally Ill Inmates

Mental health advocates are hopeful that members of Congress may use recent research on the large number of people with serious mental illness incarcerated in the United States to expand federal support for programs that aim to end the role of jails and prisons as default destinations for this inmate population.

Over 2 million jail admissions in the 12 months ending in mid 2007 were of people with serious mental illness, according to research by Henry Steadman, Ph.D., and colleagues. The report was one of a series published in the June Psychiatric Services that focused on quantifying and improving the interactions of people with mental illness with the criminal justice system (see Original article: Incarceration of Mentally Ill: Can Trend Be Reversed?).

The Steadman research, based on clinical interviews of 822 randomly selected jail inmates, produced rates of serious mental illness that were extrapolated out to the jail population nationwide. The study authors concluded that 15 percent of men and 31 percent of women in U.S. jails suffer from serious mental illness, which was defined to include major depressive disorder; depressive disorder not otherwise specified; bipolar disorder I, II, and not otherwise specified; schizophrenia spectrum disorder; schizoaffective disorder; schizophreniform disorder; brief psychotic disorder; delusional disorder; and psychotic disorder not otherwise specified. The rates jumped to 17 percent of male inmates and 34 percent of female inmates when posttraumatic stress disorder was included.

“These findings scream out for more screening and treatment,” said Fred Osher, M.D., director of health systems and services policy at the Council of State Governments (CSG) Justice Center and a co-author of the Steadman study, in an interview with Psychiatric News.

The findings differ from some previous research on mental illness among incarcerated people, including a 2006 Bureau of Justice Statistics (BJS) report that 64 percent of all jail inmates had a “mental health problem” within the prior year. The BJS study provided “imprecise estimates,” Osher said, because the presence of psychiatric problems was based on whether inmates reported one of several symptoms of mental illness listed in DSM-IV.

“All of us were saying 'Whoa, that does not mean that [these inmates] have a mental illness,'” Osher said.

Osher said the methodology used in their study was more academically rigorous than BJS's because it included the use of the Structured Clinical Interview for DSM-IV by trained clinical research interviewers of inmates at five jails during two separate time periods. The jails were in Maryland and New York.

The rates of serious mental illness among jail inmates in the Steadman research were higher than those in another prominent study in the 1980s that used an approach with similar “methodological rigor,” according to Osher. The study by Linda Teplin, Ph.D., and colleagues of inmates in Cook County, Ill., found the rate of “severe mental disorders” was 6.4 percent among male inmates and 12.2 percent among females. The Teplin criteria for severe mental illness excluded many of the psychiatric conditions that the Steadman study included as “serious mental illness.”

The high rates of serious mental illness among prisoners and the rigorous academic approach used to measure them has spurred some interest in Congress for further examination of the issue and possible legislation to address the problem, according to Osher. He was invited to describe the Steadman study findings this month at a congressional briefing that could result in new legislation.

One prominent piece of legislation already introduced to address the issue is the National Criminal Justice Commission Act of 2009 (S 714), which seeks to quantify the extent of the problem of both jails and prisons serving as de facto psychiatric wards nationwide. The bill was introduced in March.

The legislation, according to its sponsor, Sen. Jim Webb (D-Va.), has 28 cosponsors and broad bipartisan support because more people are recognizing that prisons and jails nationwide have become “warehousing” facilities for people with mental illness. In a Senate floor speech in March, Webb cited earlier statistics that an estimated 350,000 men and women with serious mental disorders are in prisons and jails, and four times as many people with mental illness are incarcerated than there are in psychiatric hospitals.

“There is a complex set of reasons for that, but the main point for all of us to consider is, these people who are in prison are not receiving the kind of treatment they would need to remedy the disabilities that have brought them to that situation,” Webb said.

The legislation would direct a commission to examine the effectiveness and availability of alternatives to incarceration and make recommendations on changes in policies and laws to improve the treatment of mentally ill people both within the criminal justice system and in the larger society.

Another measure is the Juvenile Crime Reduction Act (HR 1931), which was introduced by Rep. Patrick Kennedy (D-R.I.) in April. It would provide grants to fund diversion efforts for mentally ill juveniles who become entangled with law enforcement.

In addition to legislative attempts to remedy the issue of excessive incarceration of people with mental illness, private organizations have sought to educate state and local government officials and politicians about the problems and ways to mitigate them.

One recent example of this educational outreach is a guide from the CSG's Justice Center, “Improving Outcomes for People With Mental Illnesses Under Community Corrections Supervision: A Guide to Research-Informed Policy and Practice,” released in March. This 44-page guide translates research on improving the correctional system's treatment of people with mental illness. The guide summarizes current research on effective “supervision strategies” and treatment approaches for inmates with mental illness.

Other areas where more research is needed, according to the guide, include screening and assessing new inmates for mental illness.

“Prevalence of Serious Mental Illness Among Jail Inmates” is posted at<http://ps.psychiatryonline.org/cgi/content/full/60/6/761>. The text of the incarceration-related legislation can be accessed at<http://thomas.loc.gov> by searching on the bill numbers, HR 1931 and S 714. The CSG publication,“ Improving Outcomes for People With Mental Illnesses Under Community Corrections Supervision: A Guide to Research-Informed Policy and Practice,” is posted at<www.nicic.org/Library/023634>.▪