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, according to a report released Tuesday by the Treatment Advocacy Center and the National Sheriffs’ Association.
Across the country, an estimated 356,268 people with mental illnesses including bipolar disorder and schizophrenia are in prisons and jails, compared to just 35,000 in state hospitals — a tenfold difference.
That’s similar to the mental health system in 1830, before Dorothea Dix and other advocates pushed to shift people with mental illnesses out of the prisons and into hospital care instead, says Dr. E. Fuller Torrey, a psychiatrist and lead author of the report.
“We’ve basically gone back to where we were 170 years ago,” says Torrey, a prominent critic of the widespread effort to deinstitutionalize psychiatric patients beginning in the 1960s. “We are doing an abysmal job of treating people with serious mental illnesses in this country. It is both inhumane and shocking the way we have dumped them into the state prisons and the local jails.”
The report includes a survey of each state’s mental illness treatment laws in prisons, as well as background on the percentage of prisoners with mental illnesses in each state. Since 1970, Torrey says that percentage has risen from an average of about 5 percent to 15-20 percent.
“There is not a single state in the United States where you want to go to a jail or prison and be severely mentally ill,” says Torrey. He adds that many jails and prisons are trying to improve their care of prisoners with mental illnesses, but they are hampered by state laws that make forced treatment difficult.
In 31 states, prisons can administer treatment over a prisoner’s objections by requesting a special treatment review committee, but the process is often difficult and the report calls such efforts “grossly underutilized.” Some people with mental illness refuse treatment, often because they are not aware that they are sick.
“This causes major problems,” the authors write in the report. “Jail officials can thus be legally sued in many states if they forcibly medicate mentally ill prisoners without their consent, yet can also be held legally responsible for the consequences of such prisoners’ psychotic behavior,” including suicide.
Torrey adds that there is often a fundamental mismatch between guards and prisoners with mental illnesses. “People who work in jails and prisons signed up because they wanted to take care of bad people. So you get some personality types that are not compatible with taking care of people with serious mental illnesses,” he says.
Prisoners with mental illnesses often are put in seclusion for long periods of time, remain incarcerated longer than other prisoners, and are disproportionally abused, beaten and raped by other inmates. In addition, prisoners with mental illness who are not treated often become sicker.
The solution to the problem, according to the authors of the report, is to create a public mental health system that helps people with serious psychiatric problems “before they are so disordered they commit acts that result in their arrest.” This includes court-ordered outpatient treatment and jail diversion programs such as mental health courts.
The authors also recommend reforming jail and prison treatment laws to more easily allow staff members to administer involuntary medication for inmates with mental illnesses who are gravely disabled, deteriorating or pose a likelihood of serious harm to themselves or others.
The issue of court-ordered outpatient treatment divides the mental health community with organizations like The Bazelon Center for Mental Health Law and Mental Health America opposing it on the grounds that it violates the civil liberties of people with serious mental illnesses.
Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.