Most people in the mental health community are aware of how prevalent serious mental illness is: one in 10 is living with either schizophrenia, major depressive disorder or bipolar disorder. And as arresting as this statistic is, it is a conservative figure.
However, what may be less well known is that serious mental illness is as treatable as cardiovascular disease. Advances in psychotropic medication and behavioral therapy have been of inestimable value in the treatment of these chronic illnesses that disrupt the lives of so many.
So, what’s the problem?
The problem is that access to treatment is sorely lacking. And instead of helping people who need it the most, we are sending them to prisons and jails.
The Root of the Problem
How many of us have found, when confronted with a psychiatric crisis, that it can take weeks, if not months, to get an appointment with a psychiatrist or to find a psychiatric bed? There was a time when there was an abundance of psychiatric beds, in very large hospitals that were basically warehouses for people with serious mental illness.
In the 1960s, when psychotropic medications first became available, large numbers of patients were discharged from psychiatric hospitals. The idea, which was encoded in the Community Mental Health Act of 1963, was to create many smaller facilities in communities to continue treatment, largely on an outpatient basis, of people being discharged by deinstitutionalization. Splendid idea! But this was not even close to what happened.
From the beginning, funding for community mental health centers was lacking, and this inadequate funding has continued to this day. The result has been that there are not enough community mental health centers. And the ones that do exist are running on fumes.
The tragic result is that roughly half of people in the population who are living with serious mental illness are not receiving treatment for their illness. And behavior from untreated mental illness can be troublesome and in some cases result in criminal behavior. And, while it is possible to divert people whose criminal case was ruled less serious or violent into treatment rather than jail, the scarcity of treatment facilities all too often makes this impossible.
As a result, there has been a massive trans-institutionalization (transfer from one large institution to another large institution) into our jails and prisons. There now are significantly more people living with serious mental illness in our jails and prisons than there are in our psychiatric facilities. The Los Angeles County Jail, the Cook County Jail and Rikers’s Island are the largest facilities in the nation responsible for treating serious mental illness.
It would be difficult to argue that this is an acceptable situation. When my state legislators have been approached on this topic, the typical response I have found is that there is agreement that change is needed, but, regrettably, funding for doing this simply can’t be found.
What legislators need to understand is that the funds are there, but that they’re being used ineffectively. These funds are going toward housing people with serious mental illness in our jails and prisons, not toward treatment. The costs continue adding up with inadequate or absent treatment: without proper treatment, illnesses can worsen and behavior can deteriorate — therefore, time off for good behavior is unlikely to happen — and they end up staying in prison longer, which costs more money.
On discharge, not having been treated adequately, their behavior is most likely still problematic, making recidivism likely. These human tolls are difficult to monetize, but they are, nonetheless, considerable. But costs can be estimated: On average, in 2018, the cost of holding people in federal custody was $102.60 per day per adult, or $37,449 a year. The monetary cost for juvenile detention is staggering: $588 per day per youth, or $214,620 a year.
The average cost for psychiatric treatment in a community hospital ranges from $3,616 to $8,509, depending on the type of illness being treated. A simple calculation reveals that for an adult, the cost of 35 to 83 days in prison would provide the financing of a hospitalization that would have a better chance of bringing about recovery. For a juvenile, a sentence of just six to 15 days would cover the cost of a psychiatric hospitalization.
It is clear that an inordinate amount of money is being spent on mental illness, but spent in an inordinately wasteful manner. In addition to the incalculable human loss incurred by incarceration’s harmful effect on mental health, there is the easily estimated great fiscal cost that could be spent on treatment that actually helps people with serious mental illness.
Joseph Vanable is a Professor Emeritus of Purdue University’s Department of Biological Sciences. He has long been active in NAMI, as a member of NAMI Indiana’s Board of Directors, serving five years as President, and on its Public Policy Committee. See jvmentalillnesspublicpolicy.com for more details.