In May, the Treatment Advocacy Center (TAC) and the National Sheriff’s Association released a report revealing that people living with severe mental illness are more likely to be in jail or prison than a hospital. The report analyzes previously unreleased data from a 2004 Substance Abuse and Mental Health Services Administration (SAMHSA) survey that tracked admissions to public and private psychiatric hospitals, as well as psychiatric units at general hospitals. This survey found that there were about 100,000 psychiatric beds available in 2004, or about one for every 3,000 Americans. The study uses this new data, combined with previously published data, to calculate that there are approximately 3.2 people with serious mental illness in jail or prison for every one person in a psychiatric bed.
The report takes an historical perspective, tracing the use of jails and prisons to house people with mental illness from the 1800s, when there was only about one psychiatric bed per 5,000 Americans and most people living with serious mental illness were in jail or prison. In response to the horrific conditions in prisons and jails, advocates led by Dorothea Dix pushed for the creation of psychiatric hospitals. At their peak, there was one psychiatric bed per 300 Americans. However, concerns about mistreatment in psychiatric hospitals led to widespread closures. Unfortunately, inadequate community mental health services have taken their place and the pendulum has swung back – with more people entering the justice system.
The study includes a review of literature showing that currently approximately 15-20 percent of prison inmates and jail detainees have serious mental illness; this percentage has risen precipitously with the closure of psychiatric hospitals. As recently as 1983, only 6.4 percent of inmates were reported to live with serious mental illness. Examples from state systems show that high rates of incarceration are a huge burden on local and state correctional systems. Testimony from state and local criminal justice leaders show that these individuals are aware of the scope of the problem and feel they are not adequately trained or resourced to effectively respond to so many people living with serious mental illness in the justice system.
In their analysis of the new psychiatric bed data, the authors of the report found that the ratio of individuals incarcerated versus those hospitalized varied widely across states, with North Dakota having the lowest ratio (1-to-1)) and Nevada the highest (9.8-to-1). Further analysis of state mental health expenditure data from the National Association of State Mental Health Program Directors (NASMPHD) shows that the states with the highest mental health expenditures per capita have the lowest incarceration rates of people living with mental illness and vice versa.
The report reviews some of the tragic and costly outcomes of warehousing people with mental illness in the criminal justice system, which include high use of emergency services and high recidivism rates. In addition, people living with mental illness tend to stay in jails and prisons longer, cost more money to incarcerate and can be more difficult for corrections officers to manage. For the individuals incarcerated the consequences are grave: they face increased risk of abuse, higher suicides rates and, without adequate support on release, a high probability of re-arrest.
The report cites the reason for high incarceration rates as the lack of effective community mental health services to provide treatment in place of the psychiatric hospitals closed over the last 50 years. The report makes several recommendations to help reduce incarceration of people living with mental illness, including increased use of Assisted Outpatient Treatment (AOT) statutes to better connect individuals who are unable or unwilling to comply with treatment to needed outpatient treatment and services. The authors also suggest increased use of mental health courts to divert people from incarceration.
The recommendations also include several ways to manipulate funding streams to decrease incarceration, including tying federal mental health funding to decreased incarceration of people with mental illness. The report proposes requiring state departments of mental health to pay for the housing and treatment of jail detainees with mental illness, and requiring states to shift money saved in psychiatric bed closures to the correctional system. Finally, the study recommends reform of the federal institutions of mental disease (IMD) exclusion that bars federal Medicaid funds from paying for care in institutions with more than 16 beds, of which more than 50 percent are used to treat people with a severe mental illness (the IMD exclusion effectively bars the use of Medicaid funds for most psychiatric hospitals).
Irrespective of how you feel about specific policy recommendations, this report underscores the urgent need for improved access to mental health services as well as for partnerships between mental health providers, criminal justice systems and advocates to implement strategies for diverting people from the justice system and into effective treatment. Download the report from the Treatment Advocacy Center Web site.