Fact Sheet: Incarceration and Mental Health

Limited Availability of Mental Health Treatment

Most people in the United States with serious mental illnesses , including substance disorders, do not receive treatment. 10

• A steady elimination of psychiatric hospital beds since 1955 has dramatically reduced the availability of inpatient services.
  • In 1955, there were 339 occupied state psychiatric beds per 100,000.11
  • In 1998, there were 21 occupied state psychiatric beds per 100,000.12
    
  • From 1955 to 1998, the population in state mental hospitals dropped from approximately 559,000 to fewer than 60,000, a decline of nearly 90%.

  Community resources intended to replace inpatient care have not kept pace with the affected population, nor have they been adequately funded to do so.

  • The Community Mental Health Centers Act of 1963, which established federal support for a new system of outpatient care, envisioned a system of supportive community-based resources anchored in health centers, but did not receive needed political support or full appropriations.13
    
    • By 1975, there existed only 675 funded community mental health centers, with 800 unfunded cachements remaining. 14
    • Few CMHCs successfully coordinated the aftercare services and entitlements necessary for patients with severe and long-term mental illness.15
      
      • Services that were poorly coordinated or omitted altogether included psychiatric care, medication, education and housing support, fuel assistance, after care services, foster care arrangements, and access to medications.
      • Failure to integrate these resources continues to impact patients today. 16
      • Cuts have continued on a state-by-state basis in the 21st century.
      • Between 2009 and 2012, states cut nearly $4.5 billion in funding for services for the mentally ill, despite increases of nearly 10% in patient intake in the aftermath of the 2007 financial crisis.19
      • Many reductions occurred through cuts to Medicaid, the largest source of funding for public mental health services for youth and adults.
      • Taken together, the reductions represent the single largest decrease in mental health spending since the Vietnam-era cuts of the late 1960s.20
      • Prisons and jails are some of the only places in the United States where health care is guaranteed by law. Thus, c orrectional facilities in the United States are widely held to be the largest provider of mental health services in the nation.22
        • 1976, the US Supreme Court ruled in Estelle v Gamble that failure to provide basic health care in correctional facilities violated the constitutional prohibition against cruel and unusual punishment. The ruling mandated that prisons and jails provide services for medical care.24

        Criminalization of Mental Illness

        The term “criminalization of the mentally ill” was coined in 1972 to describe the increasing arrest and prosecution rate of individuals with mental disorders.26
        

        • The National Alliance on Mental Illness estimates that between 25% and 40% of all mentally ill Americans will be jailed or incarcerated at some point in their lives. By contrast, about 6.6% of the general population will experience this.27
        • 8% of prisoners with mental illnesses have an arrest that is directly attributable to symptoms of psychosis. 28

        Mental illness is not associated with an elevated rate of violence or violent crime.

        • Only 4% of violence in the United States can be attributed to people diagnosed with mental illness.29
        • Alcohol and drugs are associated with a far greater risk of violence than any major mental disorder.30
          
        • Between 3% and 5% of US crimes involve people with mental illness.31
          
        • Fewer than 5% of the 120,000 gun-related killings that occurred between 2001 and 2010 in the United States involved individuals known to be mentally ill.32
          
        • People who are mentally ill are more likely to be the victims of violent crime than the perpetrators of it.
          • Individuals with schizophrenia have victimization rates 65% to 130% higher than those of the general public.33
            
          • Arrests of those who are mentally ill commonly involve minor crimes, such as trespassing, loitering, public lewdness, and other forms of behavior recognized as bizarre or aggressive.34
            
          • More commonly, arrests of those with mental illness are associated with substance use disorders, which are themselves criminalized or else associated with criminal behaviors.
          • Individuals struggling with mental illness often have co-occurring substance use disorders. Estimated rates of substance use disorders include:
            • 2% of the general public35
              
            • 15% of people with anxiety36
              
            • 20% of people with depression37
              
            • 7% of people with any mental illness38
              
            • People treated for bipolar disorder and schizophrenia have been found to be 12 and 20 times more likely to be treated for alcohol abuse, and 35 and 42 times more likely to be dependent on illegal drugs.39

            The “War on Drugs” initiated in 1971 accompanied a policy shift toward more punitive sentencing practices in the United States, including reduced tolerance toward the use and sale of illegal substances. These policies dramatically increased the population of drug offenders in carceral settings.

            • “Three-strikes laws” mandated life imprisonment for third felony offences, including drug offences.
            • Mandatory minimum sentences, stripped judges of much of their discretion on how to sentence drug users.
            • Incarceration rates across all populations rose sharply after the inception of the war on drugs.40
              • In 1950, the US incarceration rate was 175 per 100,000 residents41
                
              • 1985: 312 per 100,000
              • 2005: 743 per 100,000
              • 2009: 749 per 100,00042
                
              • In 2011, approximately 2,300,000 individuals were incarcerated in the United State, a higher incarceration than any other nation.43
                
              • The existence of a criminal record may influence subsequent interactions with the police, reinforcing a tendency to choose the criminal justice system over the mental health system.45
                
              • A criminal record may also weigh negatively in court, where a long “criminal” history of minor violations is likely to influence further jail sentencing, even when directly related to poorly-controlled mental illness.46
                

              Is incarceration pathogenic?

              Some have considered whether the conditions of incarceration in the United State themselves generate mental illness.47

              • Prison conditions such as crowded living quarters, lack of privacy, increased risk of victimization, and exposure to punitive segregation are strongly correlated with emerging and worsening psychiatric symptoms (including self-harm).48
                • In 2015, 18 states and the Bureau of Prisons met or exceeded standards for overcrowding.
                • In 2015, 26 states and the Bureau of Prisons met or exceeded their minimum number of beds.49
                  
                • Disorders likely to deteriorate during incarceration include major depression, posttraumatic stress disorder, anxiety, and psychosis.50
                  
                  • Incarceration more than doubles the odds of 12-month dysthymia.51
                    
                  • Incarceration increases the odds of 12-month major depression by nearly 50%.52
                  • In prison as in the wider community, psychiatric symptoms may be difficult to distinguish from aggressive or deviant behavior, resulting in further punishment. This pattern is enhanced by the limited treatment options available in incarceration settings.
                    • Prison inmates with mental illness commit from 1.5 to 5 times as many infractions as other inmates.53
                      
                    • A national survey found that among state prisoners, 24% of those with a mental health disorder had been charged with physically or verbally assaulting correctional staff or other inmates, compared to 10.4% of those without a mental health disorder.54
                      
                      • The same survey found that 58% of those with a psychiatric disorder had been charged with rule violations of some stripe, compared to 43% of non-disordered inmates.55
                        
                      • Those who were “acutely mentally ill” made up 6% of the jail population, but were involved in 16% of misconduct incidents.57
                        

                      Mental Health and Punitive Segregation (Solitary Confinement)

                      • It is estimated that 100,000 prisoners in the United States are being held in solitary confinement at any given time.58
                      • Inmates diagnosed with mental illness are disproportionately represented in the isolation units.59
                      • Punitive segregation has serious short-term and long-term repercussions on mental health.60
                        • Protracted isolation, inactivity, and lack of mental health treatment within isolation units can exacerbate symptoms or provoke recurrence.61
                        • Symptoms can include anxiety, depression, anger, cognitive disturbances, perceptual distortions, obsessive thoughts, paranoia, and psychosis, often tending toward further infraction of rules.62
                          
                        • Suicides occur disproportionately more often in segregation units than elsewhere in prison.63
                          
                          • In New York, suicide rates are 5 times as high among prisoners in solitary confinement as among those in the general prison population.64

                          Treatment in Carceral Settings

                          American correctional systems have been roundly criticized for failing to provide even minimally appropriate mental health services for prison inmates.65

                          • Some of this failure may be due to the rapid group of incarceration rates in the United States, which have strained the capacity of jails and prisons to respond to the health needs of inmates.66
                            
                            • The federal prison population has expanded by an average of 3.9% annually since 2000 (0.8% increase for state prison facilities) without a corresponding increase in prison personnel.67
                              
                            • The availability and quality of that care may be deficient or sporadic, despite court mandates for access to adequate health care in prisons,.
                              • The U.S. Bureau of Justice reported that in 2000, only 51% of state prisons provided with 24-hour mental health care.68
                                
                              • A 2009 survey found that most prisoners, including those with chronic medical conditions, had limited access to health care while incarcerated.69
                                
                              • The situation is particularly challenging in the case of inmates with serious mental illnesses, who require specialized treatment and services.71
                                
                              • Due to budget shortfalls and lack of political support, psychologists and psychiatrists who may properly diagnose disorders are in short supply.72
                                
                              • Prison administrators are disincented from investigating and reporting mental health needs due to the difficulty of providing additional resources and services, including special housing and treatment program needs.73
                                
                              • Many prisons do not offer medication therapy as a treatment option for mental health conditions, or else offer a restricted range of medications due to cost.74
                              • 1. Prins, S. J. (2014). Prevalence of mental illnesses in US state prisons: a systematic review. Psychiatric Services, 65(7), 862-872.
                              • 2. Swank, G. E., & Winer, D. (1976). Occurrence of psychiatric disorder in a county jail population. The American Journal of Psychiatry; 133:1331- 1333; Stelovich, S. (1979). From the hospital to the prison: A step forward in deinstitutionalization? Psychiatric Services, 30(9), 618-620; Whitmer GE. (1980). From hospitals to jails: the fate of California's deinstitutionalized mentally ill. American Journal of Orthopsychiatry, 50:65-75.
                              • 3. Teplin, L. A. (1990). The prevalence of severe mental disorder among male urban jail detainees: comparison with the Epidemiologic Catchment Area Program. American Journal of Public Health, 80(6), 663–669; Cook County Sherriff Thomas Dart, quoted in Matt Ford, “America’s Largest Mental Hospital is a Jail,” Atlantic Monthly, June 8, 2015.
                              • 4. Council of State Governments Justice Center, 2013, cited in Prins, SJ, "Why Determine the Prevalence of Mental Illnesses in Jails and Prisons?" Psychiatric Services, 65(8), p. 1074.
                              • 5. National Commission on Correctional Health Care: The health status of soon‐to‐be‐released inmates: a report to Congress. Washington, DC: National Commission on Correctional Health Care, 2002; James, D. J., & Glaze, L. E. (2006). Mental health problems of prison and jail inmates. Bureau of Justice Statistics Special Report, NCJ 213600. Washington, DC: Department of Justice.
                              • 6. Substance Abuse and Mental Health Services Administration (SAMHSA) “Revised Estimates of Mental Illness from the National Survey on Drug Use and Health,” November 19, 2013. ; Elizabeth Ford, NYC Health and Hospitals Corporation, Correctional Health Services. Personal communication, April 25, 2017.
                              • 7. Lamb, H. R., & Weinberger, L. E. (2005). The shift of psychiatric inpatient care from hospitals to jails and prisons. Journal of the American Academy of Psychiatry and the Law, 33(4): 529.
                              • 8. Abramsky, S.; Fellner, J. Ill equipped: U.S. prisons and offenders with mental illness. Human Rights Watch; New York: 2003.
                              • 9. Prins, S. J. (2014). Prevalence of mental illnesses in US state prisons: a systematic review. Psychiatric Services, 65(7), 862-872.
                              • 10. Demyttenaere, K., Bruffaerts, R., Posada-Villa, J., Gasquet, I., Kovess, V., Lepine, J., . & Polidori, G. (2004). Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. JAMA, 291(21): 2581-2590; Mojtabai, R. (2005). Trends in contacts with mental health professionals and cost barriers to mental health care among adults with significant psychological distress in the United States: 1997–2002. American Journal of Public Health, 95(11): 2009-2014;. Kessler, R. C., Demler, O., Frank, R. G., Olfson, M., Pincus, H. A., Walters, E. E., . & Zaslavsky, A. M. (2005). Prevalence and treatment of mental disorders, 1990 to 2003. New England Journal of Medicine, 352(24): 2515-2523.
                              • 11. Lamb, H. R. (1998). Deinstitutionalization at the beginning of the new millennium. Harvard Review of Psychiatry, 6(1): 1-10.
                              • 12. Lamb, H. R. (1998).
                              • 13. Grob, G. N. (1995). The Paradox of Deinstitutionalization. Society, 32(5): 51-59; Bassuk, E. L., & Gerson, S. (1978). Deinstitutionalization and mental health services. Scientific American.
                              • 14. Sharfstein, S. S. (1978). Will community mental health survive in the 1980s? The American Journal of Psychiatry, 135(11), 1363-1365.
                              • 15. Grob, G. N. (2000). “Mental health policy in 20th-century America,” in Manderscheid, Ronald W., Ed.; Henderson, Marilyn J., Ed. Mental Health, United States, 2000.
                              • 16. Grob, ibid. Congress repeatedly approved spending on CMHC's and each time failed to make appropriations. In FY 1976, for instance, $37.3 million in approved projects received no funding
                              • 17. “Funding for Mental Health Services and Programs,” Bazelon Center for Mental Health Law.
                              • 18. Bazelon, ibid.
                              • 19. Ford, M. (2015). America’s Largest Mental Hospital is a Jail. Atlantic Monthly, June 8, 2015; Honberg, R., Diehl, S., Kimball, A., Gruttadaro, D., & Fitzpatrick, M. (2011). State Mental Health Cuts: A National Crisis: National Alliance on Mental Illness.
                              • 20. Bazelon ibid.
                              • 21. Council of State Governments/Eastern Regional Conference, & United States of America. (2002). Criminal Justice/Mental Health Consensus Project; Dumont, D. M., Brockmann, B., Dickman, S., Alexander, N., & Rich, J. D. (2012). Public health and the epidemic of incarceration. Annual Review of Public Health, 33, 325-339.
                              • 22. Reingle Gonzalez, JM, & Connell, NM (2014). Mental health of prisoners: Identifying barriers to mental health treatment and medication continuity. American Journal of Public Health, 104(12): 2328-2333; Wilper, AP, Woolhandler, S, Boyd, JW, Lasser, KE, McCormick, D, Bor, DH, & Himmelstein, DU. (2009). The health and health care of US prisoners: results of a nationwide survey. American Journal of Public Health, 99(4): 666-672; Adams, K., & Ferrandino, J. (2008). Managing mentally ill inmates in prisons. Criminal Justice and Behavior, 35(8): 913-927.
                              • 24. Dumont et al. (2012).
                              • 25. Teplin, L. A. (1984). Criminalizing mental disorder: the comparative arrest rate of the mentally ill. American Psychologist, 39(7), 794; Toch, H. (1985). Warehouses for people? The Annals of the American Academy of Political and Social Science, 478(1): 58-72.
                              • 26. Abramson MF. (1972). The criminalization of mentally disordered behavior: possible side-effect of a new mental health law. Hospital and Community Psychiatry, 23: 101-105.
                              • 27. Bonczar, T. P. (2003). Prevalence of Imprisonment in the US Population, 1974-2001. Bureau of Justice Statistics.
                              • 28. Prins SJ., Skeem J. L., Mauro C., & Link BG. (2015). Criminogenic factors, psychotic symptoms, and incident arrests among people with serious mental illnesses under intensive outpatient treatment. Law and Human Behavior, 39(2): 177.
                              • 29. Fazel S, Grann M. (2006). The population impact of severe mental illness on violent crime. Am J Psychiatry, 163(8): 1397–1403.
                              • 30. Friedman, R. A. (2006). Violence and mental illness—how strong is the link? New England Journal of Medicine, 355(20): 2064-2066.
                              • 31. Appelbaum PS. (2006). Violence and mental disorders: data and public policy. Am J Psychiatry, 163(8):1319–1321.
                              • 32. Centers for Disease Control and Prevention. (2013). Leading causes of death reports, national and regional, 1999-2010. Atlanta, GA: CDC.
                              • 33. Brekke JS, Prindle C, Bae SW, Long JD. (2001). Risks for individuals with schizophrenia who are living in the community. Psychiatr Serv, 52(10): 1358–1366.
                              • 34. Abramson MF. (1972).
                              • 35. Patterson E. (2004). Mental Health and Drug Abuse.
                              • 36. Grant BF., Stinson FS., Dawson DA., Chou SP., Dufour MC., Compton W., . & Kaplan K. (2004). Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: Results from the national epidemiologic survey on alcohol and related conditions. Archives of General Psychiatry, 61(8): 807-816.
                              • 37. Grant et al. Ibid.
                              • 38. Patterson E. (2004).
                              • 39. Carney CP, Jones L, Woolson RF. (2006). Medical Comorbidity in Women and Men with Schizophrenia: A Population-Based Controlled Study. Journal of General Internal Medicine, 21(11): 1133-1137.
                              • 40. In 1994, the New England Journal of Medicine reported that the "War on Drugs" resulted in the incarceration of one million Americans each year. Grinspoon L., & Bakalar JB. (1994). The War on Drugs--A Peace Proposal. The New England Journal of Medicine, 330(5): 357-360.
                              • 41. Cahalan MW., Parsons LA. (1986). Historical corrections statistics in the United States, 1850-1984 (pp. 1-27). Washington, DC: US Department of Justice, Bureau of Justice Statistics.
                              • 42. Cahalan & Parsons. (1986).
                              • 43. Walmsley R. (2011). World prison population list. London, UK: International Centre for Prison Studies, King’s College London; 2009; Wildeman C, Wang EA. (2017). Mass incarceration, public health, and widening inequality in the USA, Lancet. 389(10077): 1464-1474.
                              • 44. Baillargeon J, Binswanger IA, Penn JV, Williams BA, Murray OJ. (2009). Psychiatric disorders and repeat incarcerations: the revolving prison door. Am J Psychiatry, 166(1): 103–109.
                              • 45. Lamb & Weinberger (2005).
                              • 46.Ibid.
                              • 47. Wildeman & Wang (2017).
                              • 48. Olley MC., Nicholls TL., & Brink J. (2009). Mentally ill individuals in limbo: Obstacles and opportunities for providing psychiatric services to corrections inmates with mental illness. Behavioral Sciences & the Law, 27(5): 811-831; l Kaba F, Lewis A, Glowa-Kollisch S et al. (2014). Solitary confinement and risk of self-harm among jail inmates. Am J Public Health. 104(3): 442–447.
                              • 49. Carson EA., & Anderson E. (2016). Prisoners in 2015. Bureau of Justice Statistics. Office of Justice Programs. US Department of Justice.
                              • 50. Wildeman C, Wang EA. (2017); 4; K Turney, C Wildeman, J Schnittker. (2012). As fathers and felons: explaining the effects of current and recent incarceration on major depression. J Health Soc Behav, 53: 465–481; Kays JL, Hurley RA, Taber KH. (2012). The dynamic brain: neuroplasticity and mental health. J Neuropsychiatry Clin Neurosci. 24: 118–124.
                              • 51. Turney et al. (2012).
                              • 52. Turney et al. Ibid.
                              • 53. O'Connor FW., Lovell D., & Brown L. (2002). Implementing residential treatment for prison inmates with mental illness. Archives of Psychiatric Nursing, 16(5): 232-238.
                              • 54. James & Glaze (2006).
                              • 55. James & Glaze Ibid.
                              • 56. Dora B. Schriro, Commissioner, NYC DOC, “Statement to the New York City Council Committee on Fire and Criminal Justice Services,” March 7, 2013.
                              • 57. Schriro ibid.
                              • 58. Baumgartel S., Guilmette C., Kalb J., Li D., Nuni J., Porter DE., & Resnik J. (2015). Time-In-Cell: The ASCA-Liman 2014 National Survey of Administrative Segregation in Prison.
                              • 59. Lovell, D. (2008). Patterns of disturbed behavior in a supermax population. Criminal Justice and Behavior, 35(8): 985-1004.
                              • 60. Haney, C. (2003). Mental health issues in long-term solitary and “supermax” confinement. NCCD News, 49(1): 124-156.; Andersen HS, Sestoft DD, Lillebæk, TT, et al. (2000). A longitudinal study of prisoners on remand: psychiatric prevalence, incidence and psychopathology in solitary vs. non-solitary confinement. Acta Psychiatr Scand, 102(1): 19–25; Steinbuch AT. (2014). The movement away from solitary confinement in the United States. New Eng. J. on Crim. & Civ. Confinement, 40, 499.
                              • 61. Metzner JL & Fellner J. (2010). Solitary Confinement and Mental Illness in U.S. Prisons: A Challenge for Medical Ethics. Journal of the American Academy of Psychiatry and the Law Online, 38 (1): 104-108.
                              • 62. Smith PS. (2006). The effects of solitary confinement on prison inmates: a brief history and review of the literature. Crim Just, 34:441–568.
                              • 63. White, T. W., Schimmel, D. J., & Frickey, R. (2002). A comprehensive analysis of suicide in federal prisons: a fifteen-year review. Journal of Correctional Health Care, 9(3): 321-343.
                              • 64. Way BB, Sawyer DA, Barboza S, Nash R. (2007). Inmate suicide and time spent in special disciplinary housing in New York State prison. Psychiatr Serv, 58(4): 558–560.
                              • 65. Human Rights Watch. (2003) Ill-equipped: US prisons and offenders with mental illness. HRW; New York.
                              • 66. Solomon AL, Osborne JWL, LoBuglio SF, et al. (2008). Life After Lockup: Improving Reentry From Jail to the Community. Washington, DC, Urban Institute.
                              • 67. Reingle Gonzalez & Connell. (2014).; Washington, DC: The Pew Charitable Trusts. (February 14, 2007). Prison growth could cost up to $27.5 billion over next 5 years [press release].
                              • 68. Beck, A. J., & Maruschak, L. M. (2001). Mental health treatment in state prisons, 2000. Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.
                              • 69. Wilper AP, et al. (2009).
                              • 70. Moore S. (2007). Using muscle to improve health care for prisoners. New York Times. August 27.
                              • 71. Lamb HR, Weinberger LE, Marsh JS, et al. (2007). Treatment prospects for persons with severe mental illness in an urban county jail. Psychiatric Services, 58:782–786.
                              • 72. Hills H, Siegfried C, Ickowitz A. (2004). Effective Prison Mental Health Services: Guidelines to Expand and Improve Treatment. Washington, DC: US Department of Justice, National Institute of Corrections; p. 93.
                              • 73. Reingle Gonzalez & Connell. (2014).
                              • 74. Hills et al. (2004).; Adams & Ferrandino. (2008).; Beck & Maruschak (2001).

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