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On any given day, it is estimated that about 70,000 inmates in U.S. prisons are psychotic. Anywhere from 200,000 to 300,000 male and female prison inmates suffer from mental disorders such as schizophrenia, bipolar disorder and major depression. Prisons hold three times more people with mental illness than do psychiatric hospitals, and U.S. prisoners have rates of mental illness that are up to four times greater than rates for the general population.

These are the findings of a report by Human Rights Watch, released Oct. 22, 2003. Many of the statistics cited by the organization have been released by various organizations and agencies, but the 215-page report provides a more complete picture of the U.S. prison system as the nation's primary mental health care facilities. The complete report is available on their Web site at <www.hrw.org/reports/2003/USA1003/USA1003.pdf>.

"Ill Equipped: U.S. Prisons and Offenders with Mental Illness" resulted from two years of research and hundreds of interviews with mental health care experts, prisoners, correction officials and attorneys. It reported that few prisons offer adequate mental health care services and that the prison environment is dangerous and debilitating for prisoners who have mental illness. These prisoners are victimized by other inmates, punished by prison staff for behaviors associated with their illnesses and often placed in highly restrictive cells that exacerbate their symptoms.

The U.S. prison system is "not only serving as a warehouse for the mentally ill, but, by relying on extremely restrictive housing for mentally ill prisoners, it is acting as an incubator for worse illness and psychiatric breakdowns," according to the report.

The high prevalence of mental illness in the criminal justice system is related to several factors that psychiatrists should care about, Fred Osher, M.D., director of the Center for Behavioral Health, Justice and Public Policy at the University of Maryland, told Psychiatric Times.

The factors that contribute to a person being in jail in the first place relate to inadequate access to quality behavioral health services, Osher told PT. Without these services, people with mental illnesses often engage in behaviors that capture the attention of law enforcement and lead to arrests.

The majority of people with mental illness in the criminal justice system are there for misdemeanors and crimes of survival, according to Osher. He said, "There's a whole host of folks who land in the criminal justice system because of their behavioral disorders." The problem primarily affects people on the margins of society. They are often minorities, almost always impoverished and disabled by their illness.

The federal government's war on drugs has swept up people with mental illness at higher rates than those for the general population because more people with mental illness use and abuse drugs, Osher said. He added, "I think we want to watch the policy around punishment versus treatment, and we want to be advocates for treatment first."

There is also a high prevalence of people coming into the mental health care system with a history of involvement with criminal justice. Mental health care professionals need to be aware of this and think about the necessary communications with law enforcement and correctional supervision officials. "I think the issue is that many folks in mental health care don't want to work with people who have a criminal justice history, but they do anyway," Osher said. "They're just not looking for it."

The general consensus within the criminal justice system is that people with serious mental illness should not be there. It is a bad situation for both the prisoners and the facilities.

"We hear that everywhere," Chris Koyanagi, policy director at the Washington, D.C.-based Bazelon Center for Mental Health Law, told PT. "From jails all over the country, from prison administrators, from senior correctional administrators."

Inmates with mental illness are often punished for their symptoms. Being disruptive, refusing to obey orders, and engaging in acts of self-mutilation and attempted suicide can all result in punitive action. As a result, the report noted, prisoners with mental illness often have extensive disciplinary histories.

Frequently, the prisoners end up in isolation units. "In the most extreme cases, conditions are truly horrific," the report stated, adding:

Mentally ill prisoners locked in segregation with no treatment at all; confined in filthy and beastly hot cells; left for days covered in feces they have smeared over their bodies; taunted, abused, or ignored by prison staff; given so little water during summer heat waves that they drink from their toilet bowls. ... Suicidal prisoners are left naked and unattended for days on end in barren, cold observation cells. Poorly trained correctional officers have accidentally asphyxiated mentally ill prisoners whom they were trying to restrain.

Root Causes

The report found that the high incarceration rate for people with mental illness is a direct result of underfunded and fragmented services. "Chronically underfunded, the existing mental health system today does not reach and provide mental health treatment to anywhere near the number of people who need it," it explained.

Public mental health care systems are stretched for money, according to Koyanagi. And they have people within their priority population who demand services and are responsive to less expensive treatments. "Those folks tend to get their needs met," she said.

People with serious mental illness who are left out of services are more difficult to reach and more difficult to treat because of the nature of their illnesses, she said. They may be dually diagnosed or already homeless.

Koyanagi noted that, from a cynical perspective, it can be said that criminalization is to the advantage of public mental health care systems. "The system can pretend they're not there."

When these individuals do leave the criminal justice system, they often can't get into local community mental health care programs, just as they can't get into public housing. "They're deemed unsuitable for that particular program because of their record," she said.

Over the last several decades, states have emptied their psychiatric hospitals without moving sufficient resources into community-based programs. Meanwhile, overall prison populations have soared.

It is tempting for people to conclude that a causal relationship exists between the decreased number of people in state psychiatric hospitals and the increased number of inmates with mental illness, Osher said, but the data do not support that belief.

Over the last 20 years, the U.S. prison population has experienced an enormous increase, with about 3% of the adult population now under some form of jail or correctional supervision, he said. Consequently, the problem has more to do with the way that people get arrested. People who are visibly homeless or have drug and alcohol problems are landing in jails and prisons with greater frequency.

The jails themselves represent a public health opportunity, according to Osher. Given estimates that about 15% to 17% of people coming into jails have a serious mental illness and that there are 11 million arrests a year, "that's a huge number of folks who are mostly not connected with systems of care." Screening programs could help identify those people so that they can get connected with appropriate treatment programs.

People who are privately insured are not immune from run-ins with the criminal justice system. A privately insured person with bipolar disorder can run into serious problems during a manic episode. In such cases, encounters with the legal system are usually less harmful, Koyanagi said. Often these individuals can be stabilized and returned to services within the community.

The people who tend to get stuck in the criminal justice system usually have long records, she told PT. "It doesn't just happen once, it happens again and again because nothing is done to deal with the underlying problems. And you end up in prison because you have a long rap sheet."

Koyanagi agreed that drug crimes are a major contributor to the growing number of mentally ill in jails and prisons. Whether a user or a seller, people with co-occurring mental illness and substance abuse get swept up by punitive drug penalties, she said.

Efforts to Respond

Koyanagi and Osher both served on the steering committee for the Criminal Justice/Mental Health Consensus Project Report, which was issued in 2002. The project represented an unprecedented national effort to bring together federal policy-makers with criminal justice and mental health care professionals to create a more responsive system for addressing the needs of people with mental illness who are at risk of involvement or are already involved with the criminal justice system.

Jail and prison overcrowding issues are high on the priority lists of wardens and sheriffs in this country, and correction officials are clamoring for improved mental health treatment in communities to deal with this, Osher said. Because of the high rates of people with serious mental illness in the criminal justice system and the problems they create in terms of service utilization and jail management, the mental health care field has partners in law enforcement and the courts and among corrections personnel.

"When you go before a state legislature and advocate for better mental health services as a psychiatrist, it seems self-serving," Osher said. "But when you go before them as a warden or a sheriff or a police officer, folks listen."

The first recommendation in the Human Rights Watch report, which drew upon the work of the Consensus Project, is for enactment of the Mentally Ill Offender Treatment and Crime Reduction Act, which was introduced in 2003 by Sen. Mike DeWine (R-Ohio). On Oct. 29, 2003, the U.S. Senate unanimously passed the bill, which would provide five-year grants to states and localities that could be used for mental health courts, in-jail treatment, transitional services and training. The bill now awaits action in the House, where it was introduced by Rep. Ted Strickland (D-Ohio).

The Bazelon Center is concerned that if the bill passes, the money will be spent to build up mental health services within jails and prisons without focusing on community-based services that would keep people out of the criminal justice system in the first place, Koyanagi said. Nothing in the bill prevents the money being used primarily or exclusively for services in jails and prisons, she said. The Bazelon Center feels that services in these facilities should be the responsibility of criminal justice agencies.

Mental health care systems need to develop evidence-based services such as assertive community treatment, which takes an intensive team approach to helping a person receive treatment and supports, and integrated substance abuse services, Koyanagi said. While funding services within the criminal justice system deals with the immediate problem of what to do with a prisoner who is psychotic, it is a temporary, not a systemic, solution.

"The ultimate goal of people in the criminal justice system is not to have so many of these folks in their facilities," Koyanagi said. "Building up mental health services inside of jails and prisons doesn't encourage judges not to put people there."

A judge may see that someone is not being helped by the community mental health care system and decide that, in jail, that person might be diagnosed, put on the right medications and get better.

"Judges have told us they do that," Koyanagi told PT. However, prisons and jails are not therapeutic environments, and serving time gives a person a record that follows them throughout life.

As of yet, there hasn't been an effective policy response to the problem of keeping people with mental illness out of jails and prisons, Koyanagi said. She added, "If that continues to be true, there may be more and more litigation against both criminal justice agencies and possibly mental health agencies, too."