Prison Mental Health Crisis Continues to Grow

Federal support is needed to reverse the increasing“ criminalization” of mental illness and drug addiction, according to APA and federal health officials.

A growing body of evidence demonstrates that the criminal justice system has taken over from the public health system as the destination for many with mental illness and addictions. That was the message delivered to members of Congress and their staffs last month at the annual Mental Illness Awareness Week event sponsored by APA and the National Alliance on Mental Illness (NAMI).

“With the reduction of psychiatric beds in past years, there is only one place that can't say `no' when you need someone kept away from society: the criminal justice system,” said Richard Nakamura, Ph.D., deputy director of the National Institute of Mental Health.

Nakamura and others cited statistics such as those from 1996 research by Linda Teplin, Ph.D., that found that 1 million, or 8 percent, of jail bookings annually involve persons with severe mental illness. A more recent study of the Chicago jail found that 6 percent of males and 12 percent of females entering the system had severe mental disorders, including schizophrenia, mania, and major depression. A 2005 study by H. Richard Lamb, M.D., and Linda Weinberger, Ph.D., concluded that as much as 24 percent of the prison population has a severe mental illness.

More recently, the Department of Justice's Bureau of Justice Statistics (BJs) reported that more than half of all prison and jail inmates have mental health problems (see Original article: page 6). Tom Hamilton, Ph.D., NAMI's liaison to APA's Committee on Jails and Prisons, said that the report was flawed, however, because it did not address the number of inmates suffering from severe and persistent mental illness.

“I suspect if most of us spent much time in these places, we would all develop mental health “problems,'” Hamilton said.

Generally, discrepancies in the number of inmates with mental illness identified by researchers are likely due to differences in the ways they define mental illness, he said. But despite the varying percentages of prisoners with mental illness, people with mental illness are more than twice as likely to be incarcerated.

The cause of the burgeoning number of prison inmates with mental illness in recent decades appears linked to the falling number of state psychiatric beds since the 1960s, Hamilton said. He presented data from Texas to illustrate“ transinstitutionalization” of inmates from state psychiatric hospitals to the criminal justice system. Jail data from Harris County, Texas, which includes Houston, showed that 37 percent of inmates had a serious mental illness, based on a matching of jail and county public mental health records.

The nationwide deinstitutionalization of patients with mental illness, which led to the loss of 90 percent of state psychiatric beds over the last 50 years, was supposed to be replaced with a system of 2,000 community mental health centers. But most states viewed the closure of psychiatric hospitals as a chance to save money, Hamilton said, which resulted in the creation of fewer than 700 “underfunded” community-based mental health facilities.

Also contributing to the problem is the prevalence of substance abuse among people charged with or convicted of crimes. Nearly 6 in 10 mentally ill offenders reported they were under the influence of alcohol or drugs at the time of their latest offense, according to a 1999 BJS report. It also found that one-third of offenders identified as mentally ill were alcohol dependent.

“Just locking up addicts so they can't feed their addictions sounds good, but the problem is that it just doesn't work,” said Wilson Compton, M.D., director of the Division of Epidemiology, Services, and Prevention Research at the National Institute on Drug Abuse, about the high recidivism rates research has found among inmates with untreated addictions.

Although the problems are severe, evidence is mounting that specific programs and approaches can reduce the number of inmates with mental illness and drug addictions, the speakers noted.

Research has found significant progress in reducing addiction rates among inmates when public-health efforts are combined with those of the criminal-justice system, Compton said. The combination takes advantage of the person's incarceration to provide consistent addiction treatment over several months, an approach likely to prevent drug relapses and recidivism. The efficacy of jail-based treatment was reported by a 2006 Maryland study that found that 69 percent of heroin-addicted inmates who received counseling and drug therapy in the months before their release continued treatment one month after leaving prison, and only 29 percent tested positive for heroin.

“This study and others have led to major changes, where treatment is at least being talked about as part of incarceration for those who need it,” Compton said.

Nakamura pointed out that research has found jail-diversion programs for suspects with serious mental illness and co-occurring substance use conditions reduce the time they spend incarcerated without increasing the public-safety risk. Studies have also found that the costs for jail diversion are no higher than those for imprisonment of those with mental illness, who often languish in jail on minor charges because they lack the understanding or funds to fight their incarceration.

Other programs that deserve federal support are Crisis Intervention Training for police officers and postincarceration programs to eliminate recidivism, speakers pointed out.

Rep. Grace Napolitano (D-Calif.) told attendees that she supported their goals of reduced incarceration and improved care for those with mental illness, but that better national cost/benefit data are needed to convince Congress to support these programs.

“The Republican majority understands cost/benefit, so you have to show how these programs can save the government money,” Napolitano said.

Until the nation develops a “safety net” to treat everyone with mental illness, she added, the criminalization of mental illness and drug addiction will continue to plague society.

The report “Mental Health Problems of Prisons and Jail Inmates” is posted at<www.ojp.usdoj.gov/bjs/abstract/mhppji.htm>.▪