A new report on the fate of U.S. prisoners with mental illness has earned attention from major newspapers, members of the U.S. Senate, and correctional officials.

The 215-page document, "Ill-Equipped: U.S. Prisons and Offenders With Mental Illness," contains descriptions of the difficulties such individuals face because of prison life and inadequacies in their psychiatric treatment, the responses of correctional staff to people with mental illness, and specific issues such as suicide and the problems of female prisoners.

Human Rights Watch staff spent two years on research for the study, which included hundreds of interviews with prisoners, correction officials, mental health experts, and attorneys; visits to facilities in 13 states; and analyses of legal opinions. (See box for recommendations.)

Jeffrey Metzner, M.D., chair of APA’s Council on Psychiatry and Law, said, "The report provides an excellent overview of the problems facing many inmates with serious mental illness in prisons throughout the United States. The information from numerous experts cited in the report confirms that our principal problem is not lack of information about what is needed, but obtaining resources to provide the essential services."

Jamie Fellner, director of Human Rights Watch U.S. Program and the report’s co-author, told Psychiatric News that the report, which was released on October 22, had led to editorials and op-ed pieces in the New York Times and Chicago Tribune, as well as stories in other newspapers and publications.

On October 28 the Mentally Ill Offender Treatment and Crime Reduction Act of 2003 (S 1194) passed the Senate by unanimous consent. Sen. Mike DeWine (R-Ohio), the bill’s sponsor, mentioned the Human Rights Watch report in the press release announcing the bill’s passage.

The act would provide grants to create or expand mental health courts, train correctional officers and others to identify symptoms of mental illness, promote cooperative efforts to treat mental illness and substance abuse, and promote intergovernmental cooperation concerning prisoners with mental illness.

Eugene Cassel, J.D., acting director of APA’s Division of Government Relations, said, "We are very encouraged by the strong Senate support for the bill and will continue to advocate for it with members of the House of Representatives."

Metzner also urged passage of the bill.

Much of the media’s attention has focused on the numbers of people with mental illness who are prisoners, Fellner said.

The report cites estimates from APA’s 2000 report "Psychiatric Services in Jails and Prisons" that "perhaps as many as 1 in 5 prisoners was seriously mentally ill, with up to 5 percent actively psychotic at any given moment." It also cites estimates by Metzner and his colleagues in the 1998 book Treatment of Offenders With Mental Disorders that "somewhere between 8 percent and 19 percent of prisoners have significant psychiatric or functional disabilities and another 15 percent to 20 percent will require some form of psychiatric intervention during their incarceration."

"We really want people to start paying attention to the problems the numbers represent," Fellner added. Those problems stem both from the prison environment and the lack of adequate mental health services.

Expert witnesses have testified that prisoners with mental illness are victimized by other inmates and are "extremely vulnerable to the manipulations of their peers." Overcrowded prisons take a particularly harsh toll on individuals who are already anxious, depressed, or psychotic and have poor coping mechanisms.

Those prisoners find it difficult to comply with prison rules and are punished for behavior that results from their illness. Mentally ill prisoners have been punished for self-mutilating ("destroying state property"), attempting suicide with a torn sheet ("destroying state property"), yelling and kicking cell doors because of hearing voices ("creating a disturbance"), throwing papers at a guard while delusional ("battery"), and smearing feces on a cell door ("being untidy").

The report noted that only 231 of the nation’s approximately 1,400 prisons have received accreditation from the National Commission on Correctional Health Care (NCCHC), meaning that they adhere to NCCHC’s guidelines concerning mental health care and submit to monitoring.

Among the problems cited were understaffing (in terms of numbers and qualifications of staff), poor screening and tracking of prisoners with mental illness, delayed treatment, inappropriate diagnoses of malingering, limitations on the kinds of medications available, interruptions in medications because of shortages, and inadequate monitoring of medication side effects.

Henry Weinstein, M.D., chair of APA’s Corresponding Committee on Jails and Prisons, pointed out that the Association had been in the forefront of efforts to bring about mental health reform in jails and prisons through development of "APA’s Guidelines for Psychiatric Services in Jails and Prisons," now in its second edition.

The guidelines state that the "fundamental policy goal for correctional mental health treatment is to provide the same level of mental health services to each patient in the criminal justice process that should be available in the community" and offer details about the mental health services that should be provided in jails and prisons.

He added that committee members are working with the National Alliance for the Mentally Ill and the Council of State Governments to develop cost data and analyses that convince legislators that it is cost-effective, as well as humane, to provide access to high-quality, community-based mental health services whose goal is to minimize unnecessary incarceration of people with mental illness.

"Ill-Equipped: U.S. Prisoners and Offenders With Mental Illness" is posted on the Web at www.hrw.org/reports/2003/usa1003/. Information about APA’s Psychiatric Services in Jails and Prisons, which contains APA’s guidelines, is posted at www.appi.org/book.cfm?id=2287. ▪