Compiled by Megan J. Wolff, PhD MPH
Last updated: May 30, 2017
Individuals with mental illness and substance use disorders are significantly overrepresented in American jails and prisons, a development that has attracted the concern of clinicians, researchers, policymakers, and corrections personnel.
- The rate of mental disorders in the incarcerated population is 3 to 12 times higher than that of the general community.
- This is true across the full spectrum of diagnoses, including schizophrenia, anxiety disorders, mood disorders, and impulse control disorders.
- These rates have been increasing.
- Reports of large numbers of mentally ill persons in jails and prisons began appearing in the 1970s.
- These numbers accelerated dramatically in the 1990s and 2000’s, a trend particularly evident in urban centers such as Chicago and New York City.
- In 1990, 1 in 15 prisoners at Cook County Jail had some form of mental illness. In 2015, the estimated prevalence was 1 in 3.
- At Rikers Island in New York City the average daily population dropped 12% from 2005 to 2012, but the prevalence of mental illness rose 32%.
The high rate of serious mental illness, including major depression, bipolar disorder, schizophrenia, and other psychotic disorders in incarceration settings has been the subject of particular alarm.
- The rate of severe mental illness in jails and prisons is estimated to fall between 16% and 24%.
- By contrast, the rate of severe mental illness in the general community falls between 3.9% and 5.0%.
- Using the 16% estimate, there were at least 310,000 (113 per 100,000 population) severely mentally ill inmates in jails and prisons in 2000.
- In 2003, the number of individuals with severe mental illness in American prisons was 3 times higher than the number in psychiatric hospitals.
- Differences in data collection and reporting methods make it difficult to ascertain the rates of specific disorders. Nevertheless, an investigation of 28 studies on the prevalence of mental illnesses in prisons, identified estimates in the following ranges:
- Current major depression from 9% to 29%
- Current bipolar disorder from 5.5% to 16.1%
- Current panic disorder from 1% (women) to 5.5% (men and women) to 6.8% (men)
- (The rate in the general community was 0.5% to 3.0%)
- Current schizophrenia from 2 to 6.5%
- (The rate in the general community was 0.5% to 0.8%)
- Current Attention Deficit and Hyperactivity Disorder (ADHD) from 10% to 25%
- (The rate in the general community was 4.0% to 5.0%)
The increased rates of mental illness and substance abuse in American incarceration settings draw from a series of factors.
Limited Availability of Mental Health Treatment
Most people in the United States with serious mental illnesses, including substance disorders, do not receive treatment.
- 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.
- In 1998, there were 21 occupied state psychiatric beds per 100,000.
- 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.
- By 1975, there existed only 675 funded community mental health centers, with 800 unfunded cachements remaining.
- Few CMHCs successfully coordinated the aftercare services and entitlements necessary for patients with severe and long-term mental illness.
- 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.
- Federal spending on mental health initiatives has decreased dramatically since President Reagan’s 1981 Omnibus Budget Reconciliation Act, which shifted control back to the states in the form of block grants and reduced federal expenditures by 25%.
- In 2006, mental health spending by states was less than 12% of the $8 billion spent in 1955.
- 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.
- 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.
- For many individuals, contact with the criminal justice system may represent the first occasion for any treatment services..
- Prisons and jails are some of the only places in the United States where health care is guaranteed by law. Thus, correctional facilities in the United States are widely held to be the largest provider of mental health services in the nation.
- 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.
- Scholars note that the criminal justice system has become the system that “cannot say no.”
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.
- 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.
- 8% of prisoners with mental illnesses have an arrest that is directly attributable to symptoms of psychosis.
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.
- Alcohol and drugs are associated with a far greater risk of violence than any major mental disorder.
- Between 3% and 5% of US crimes involve people with mental illness.
- 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.
- 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.
- 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.
- 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 public
- 15% of people with anxiety
- 20% of people with depression
- 7% of people with any mental illness
- 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.
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.
- In 1950, the US incarceration rate was 175 per 100,000 residents
- 1985: 312 per 100,000
- 2005: 743 per 100,000
- 2009: 749 per 100,000
- In 2011, approximately 2,300,000 individuals were incarcerated in the United State, a higher incarceration than any other nation.
- Incarcerated persons with mental health disorders are more likely than the general population to be re-incarcerated.
- Rates of recidivism are between 50% and 230% higher for persons with mental health disorders regardless of diagnosis.
- 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.
- 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.
Is incarceration pathogenic?
Some have considered whether the conditions of incarceration in the United State themselves generate mental illness.
- 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).
- 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.
- Disorders likely to deteriorate during incarceration include major depression, posttraumatic stress disorder, anxiety, and psychosis.
- Incarceration more than doubles the odds of 12-month dysthymia.
- Incarceration increases the odds of 12-month major depression by nearly 50%.
- 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.
- 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.
- 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.
- In 2013 in New York City, prisoners with mental health disorders made up 38% of the jail population but were involved in 60% of all “incidents.”
- Those who were “acutely mentally ill” made up 6% of the jail population, but were involved in 16% of misconduct incidents.
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.
- Inmates diagnosed with mental illness are disproportionately represented in the isolation units.
- Punitive segregation has serious short-term and long-term repercussions on mental health.
- Protracted isolation, inactivity, and lack of mental health treatment within isolation units can exacerbate symptoms or provoke recurrence.
- Symptoms can include anxiety, depression, anger, cognitive disturbances, perceptual distortions, obsessive thoughts, paranoia, and psychosis, often tending toward further infraction of rules.
- Suicides occur disproportionately more often in segregation units than elsewhere in prison.
- In New York, suicide rates are 5 times as high among prisoners in solitary confinement as among those in the general prison population.
Treatment in Carceral Settings
American correctional systems have been roundly criticized for failing to provide even minimally appropriate mental health services for prison inmates.
- 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.
- 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.
- 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.
- A 2009 survey found that most prisoners, including those with chronic medical conditions, had limited access to health care while incarcerated.
- In 2007, federal judges removed California prison health care from the state's control, citing deplorable conditions.
- The situation is particularly challenging in the case of inmates with serious mental illnesses, who require specialized treatment and services.
- Due to budget shortfalls and lack of political support, psychologists and psychiatrists who may properly diagnose disorders are in short supply.
- 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.
- 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.