A large proportion of people in jails and prisons are in need of acute
psychiatric treatment and should be receiving mental health services in the
community, according to information presented at APA's annual meeting in
Toronto in May.
According to Henry Weinstein, M.D., chair of APA's Corresponding Committee
on Jails and Prisons, people with mental illness fell under the auspices of
the criminal justice system as state psychiatric hospitals emptied in the
1970s and 1980s and began to fill prisons and jails.
"In addition to being inhumane, it is also very costly to incarcerate
people with serious mental illness," said Weinstein, a clinical
professor of psychiatry at New york University and director of the Program in
Psychiatry and the law at New york University Medical Center and Bellevue
Though deinstitutionalization was originally driven by state budget
concerns, incarcerating people with mental illness is costly due to a number
of factors. For instance, "these inmates are usually incarcerated for
longer periods of time" than are people without mental illness,
APA committee members have studied the costs of incarcerating people with
serious mental illness and have urged legislators to shift adequate funds into
corrections to treat them, he
Erik Roskes, M.D., said that some prisoners experience "gate
fever," in which they have trouble adjusting to life outside of prison.
This may be especially true for ex-inmates with mental illness.
"It's in the interest of state legislatures and corrections for these
patients to receive treatment in the community rather than behind bars,"
Weinstein and his co-presenters emphasized the importance of mental health
courts as one way to divert offenders from incarceration to treatment.
"The resources of the mental health system need to be greatly
expanded, with priority given to treating those who are in danger of becoming
mentally ill offenders," said H. Richard Lamb, M.D., one of the
Lamb, a professor of psychiatry and director of the Division of Psychiatry,
Law, and Public Policy at the University of Southern California, conducted a
study of the characteristics of 104 randomly sampled men confined to the Los
Angeles County Jail.
The inmates had been identified by jail personnel as having mental illness
and housed on a 1,500-bed unit designed for offenders with mental illness.
Based on his findings, Lamb determined that 80 percent of the sample had a
serious mental illness, including schizophrenia, schizoaffective disorder,
bipolar disorder, or major depressive disorder.
Lamb and his colleagues determined that 73 percent of the sample was more
appropriate for community mental health treatment, while 27 percent were
appropriately placed in the criminal justice system because of "lengthy
criminal histories of drug possessions and sales and serious property and
Offenders with mental illness can present unique problems for treatment in
or out of the criminal justice system, Lamb noted, due to behavioral problems
and treatment noncompliance.
Over 90 percent of the sample had a history of being noncompliant with
psychotropic medications, 94 percent had prior arrests, and 79 percent had
been arrested for violent crimes.
Tom Hamilton, Ph.D., the past president of the National Alliance on Mental
Illness (NAMI)-Texas and NAMI liaison to APA's Corresponding Committee on
Jails and Prisons, was involved in research on Texas inmates, which showed
that incarcerating people with mental illness was far more expensive than
Hamilton highlighted findings from a government study of 100 inmates
entering state prisons and county jails in Texas, which found that 1 in 4
inmates had serious mental illness based on matching jail and mental health
Those with mental illness had twice the number of jail episodes and three
times the number of jail days per episode as the average offender, Hamilton
In addition, inmates with mental illness were charged with more infractions
per offense than the average nonmentally ill offender.
Hamilton noted that a 2004 cost analysis of inmates in Harris County,
Texas, showed that by diverting offenders with mental illness to the community
for treatment instead of incarcerating them, there is a potential 40 percent
savings per consumer.
Under a program run by the Mental Health and Mental Retardation Authority
of Harris County called New Start, offenders with mental illness are mandated
to receive outpatient treatment once released from jail.
In 2004, the recidivism rate for offenders who received treatment through
the program was 5 percent, according to Hamilton.
"The most unsafe thing you can do is to place [people] with mental
illness in prison and not treat them, and then release them to the community
without linking them to treatment," he said.
Prerelease mental health services for inmates are crucial to ensure their
success in the community, said Erik Roskes, M.D., director of forensic
treatment at Springfield Hospital Center in Sykesville, Md., and a member of
APA's Task Force on Forensic Outpatient Services.
"It's important that we realize that transition in this context is
extremely difficult for many inmates and especially those with mental
illness," Roskes said. However, postrelease treatment planning can also
pose unique challenges, Roskes noted.
For instance, since jail inmates are usually not detained for a lengthy
period and may have little notice before their release, it can be difficult to
arrange community mental health services for them.
Although prison sentences are longer, and prison staff may have more time
to make arrangements for postrelease mental health services, prisons are often
located several hours from inmates' homes, which can present problems
regarding treatment planning and access to services.
Treatment planning may include psychoeducation regarding medications,
addiction, and mental illness, as well as relapse prevention, life-skills
education, assertiveness training, and vocational preparation and job
placement, Roskes said.
In addition, the days and weeks preceding release can provoke anxiety about
being accepted back in the community, he noted. Parole officers and clinicians
should be aware that although stress levels may level off after release, they
may increase again after "a few months, once they realize it's not so
easy being on the outside."
It is vital that forensic psychiatrists "honestly believe that
[offenders with mental illness] can and do recover and change their lives, and
we can help them do that," Roskes emphasized.
Cassandra Newkirk, M.D., noted that it is also important for corrections
staff and case managers in particular to note that after spending 30 days in
jail or prison, Medicare and Medicaid benefits stop. This can be especially
problematic for people who bounce in and out of jail for short periods of
Newkirk is director of mental health services for Geocare Inc., a Boca
Raton, Fla., company that provides mental health services to people in jails
and prisons, and a member of APA's Committee on Jails and Prisons.
"We must advocate for court diversion so that people with serious
mental illness never get into the correctional system to begin with,"
she stated. ▪