Structural Racism in American Psychiatry and APA: Part 8

The number of individuals in the United States who are confined against their will is remarkable: about 2.3 million people on an average day. The majority are in state prisons (1.291 million), local jails (631,000), and federal prisons and jails (226,000). While prisons hold twice as many inmates as jails, prisons admit 600,000 people a year, while jails admit 10.6 million. In jails, only about 25% of inmates have been convicted of a crime, usually a misdemeanor with up to a one-year sentence, while 75% of inmates are awaiting trial.

Racial/Ethnic Differences in Prisons and Jails

Black and Latino individuals are disproportionately incarcerated in prisons and jails. Overall, 56% of the U.S. incarcerated population are Black and Latino individuals, who represent 32% of the population. If we look at just those serving sentences in federal and state prisons, data from 2017 indicate that Blacks represented 12% of the adult population but 33% of the inmates, Hispanics represented 16% of the adult population but 23% of inmates, and whites represented 64% of the adult population but only 30% of inmates. Moreover, there were 1,549 Black prisoners for every 100,000 Black adults—nearly double the rate for Hispanics (823 per 100,000) and nearly six times the imprisonment rate of whites (272 per 100,000).

In jails, the disproportionate rate of incarcerated Black people reflects, in part, at the front end, that Black people are 2.17 times more likely to be arrested than white people and that prosecutors are more likely to grant pretrial diversion to white defendants than to Black or Latino defendants with similar legal characteristics. At the back end, Black people serve longer sentences than do whites and are more likely to recidivate.

It’s clear that the racial and ethnic makeup of U.S. prisons and jails continues to look substantially different from the demographics of the country as a whole.

People With Mental Illness in Prisons and Jails

The number of people who are incarcerated in correctional facilities and have mental illness is equally remarkable. The Treatment Advocacy Center (TAC) estimates that 15% of the state prison population and 20% of the state jail population have a serious mental illness. TAC, joined by the National Sheriffs’ Association, reported that in 44 states and the District of Columbia, at least one prison or jail holds more people with serious mental illnesses than the largest state psychiatric hospital.

In a more nuanced look at the incarcerated population, the Bureau of Justice Statistics (BJS) reported on mental health problems using data from 2002 to 2004 and applying the criteria of a recent history or symptoms of a “mental health problem.” A recent history meant that within the previous 12 months a mental health professional had made a clinical diagnosis or provided treatment based on DSM-IV. The outcome was that 56% of state prisoners, 45% of federal prisoners, and 64% of jail inmates were determined to have a mental health problem. BJS estimated that 15% of state prisoners and 24% of jail inmates reported symptoms that indicated a psychotic disorder, results quite similar to TAC’s. And those with mental health problems had disproportionate rates of co-occurring factors that negatively impacted health: 74% of state prisoners and 76% of jail inmates with a mental health problem had a co-occurring substance use disorder; 13% had been homeless before incarceration (compared with 6% without mental health problems); and 24% had a history of physical or sexual abuse (compared with 8% without mental health problems). While the need for treatment is apparent, only about 1 in 3 state prisoners and 1 in 6 jail inmates who had a mental health problem had received treatment since admission.

Black People With Mental Illness in Prisons and Jails

The BJS report indicated that among state prisoners, 62% of white inmates, compared with 55% of Blacks and 46% of Hispanics, were found to have a mental health problem. Among jail inmates, whites (71%) were also more likely than Blacks (63%) and Hispanics (51%) to have a mental health problem. But these data may be misleading.

The methodology used to determine the presence of any mental illness may underrepresent the prevalence of psychiatric disorders in Black and Latino inmates. In a study of two jails in Maryland and three jails in New York state using the Brief Jail Mental Health Screen (BJMHS), Blacks and Latinos had lower odds than whites of screening positive. Blacks and Latinos had somewhat lower odds than whites of endorsing two or more symptom items but had appreciably lower odds of endorsing items regarding prior mental health service utilization. The authors concluded that racial differences in BJMHS screening results likely reflect the reproduction of racial disparities in previously obtaining and using services for mental illness rather than valid differences in prevalence of mental illness.

Even if Black inmates in correctional facilities have a somewhat lower prevalence of all mental health problems, the overrepresentation of incarcerated Black people means Blacks with mental illness are being disproportionately held in jails and prisons, which is not the place they need to be.

Data on serious mental illness in Black inmates show an even starker picture. In a study of the L.A. County Jail in 2014, Black people with severe mental illness—schizophrenia, bipolar disorders, and other psychoses—were more likely to be incarcerated than people of other races. Black people made up 9.6% of the population in Los Angeles, but they constituted 31% of L.A. County jail prisoners and 43.7% of those diagnosed with serious mental illness requiring special jail housing.

Moreover, with only about 30% of state prison inmates and 17% of jail inmates getting any treatment, and, as some have reported, with Blacks getting less treatment than whites, prisons and jails have become wastelands for mentally ill Black people.

The negative effects of incarceration for Black men do not end with release from confinement. A multisite study found that compared with other Black men in the community, those who had been incarcerated had a 14% higher severity of depression, a 13% higher severity of distress, and a 16% higher severity of discrimination.

Addressing the Problem

These inequities should come as no surprise as the United States has a long history of differentially incarcerating Black people, previously through Jim Crow laws and more recently through racial profiling and racial profiling by proxy (when white individuals call police because they think a person of color is at a location the person doesn’t belong due to skin color). And this country has a long history of ignoring the psychiatric treatment needs of Black people by first not hospitalizing them; then by segregating them in hospitals in shameful neglect as I have described in a previous column (see Psychiatric News); and over the last 50 years, by locking them up in correctional facilities and public psychiatric hospitals, both of which have been ill equipped to treat them.

There are two complementary ways to address these racial inequities that would provide treatment for Black individuals in settings more appropriate to their needs than the jails and prisons they are now in. One way is through improved diversion, such as pre-arrest diversion through racially informed education and training of police officers, or post-arrest diversion through mental health courts equally available to all. Mental health courts have been shown to reduce recidivism and violence by people who have mental disorders and are involved in the criminal justice system.

The second way is through having an adequate number of psychiatric beds to meet the population’s need so that jails don’t become repositories for people who are waiting to be transferred to a hospital, as occurs in some states, or who need psychiatric treatment but end up in jail or prison because there are no psychiatric hospital beds available. An adequate number of beds would help stem the criminalization of people with serious mental illness and would address longstanding racial inequities in mental health care in this country.

As previously described in Psychiatric News, I have created a presidential task force to develop a methodology to determine psychiatric bed requirements in any jurisdiction. The model, while meeting many needs, will address a long-standing injustice—the disproportionate incarceration of Black people with mental illness who too often languish there without treatment. Rather, they need to be in appropriately funded and staffed psychiatric hospitals in which culturally competent clinicians can treat Black patients, and rehabilitation and recovery can truly occur for these individuals. ■