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The Burden of Mental Illness Behind Bars

Peter van Agtmael / Magnum Photos

A lthough people in correctional facilities are mostly excluded from national health surveys, an extensive literature review reveals that this population has dramatically higher rates of disease—especially mental illness and substance use disorders—than the general population, and that correctional facilities too often serve as ill-equipped treatment providers of last resort for medically underserved and marginalized people.

Mental Illness

For nearly a century, state psychiatric hospitals were the primary institutions for treating people with mental health problems. These state asylums were established as the result of a 19th-century national crusade to decrease the extent that people with mental illness were being housed and abused in jails and poorhouses. Unfortunately, these institutions created additional problems, often warehousing patients in deplorable living conditions against their will. In the late 1950s, states began closing their asylums in large numbers with the promise that they would be replaced with a robust network of behavioral health care centers where people could receive the services they needed, while continuing to live in the community—a movement known as deinstitutionalization.

Deinstitutionalization was the result of advances in psychotropic medication, stronger due-process protections against civil commitment, the growing influence of community psychiatry, and the enactment of Medicaid in 1965. The newly created community centers were envisioned to offer a range of services: inpatient, outpatient, emergency, partial hospitalization, and consultation and education on mental health.

The promise of the community mental health movement fell short of its ambitions due to underfunding at the federal and state levels, preventing many people from accessing the services they needed. Dramatic cuts to a variety of social safety-net programs in the 1980s—which led to increases in homelessness and the number of people with untreated mental illness on the street—coincided with massive government spending on the War on Drugs and prison construction.

These changes contributed to a disproportionate number of underserved people with mental health problems becoming entangled in the criminal justice system and correctional facilities becoming their default treatment providers. Today, about 14.5 percent of men and 31 percent of women in jails have a serious mental illness, such as schizophrenia, major depression, or bipolar disorder, compared to 3.2 and 4.9 percent, respectively, in the general population. While estimates vary, the prevalence of serious mental illnesses is at least two to four times higher among state prisoners than in community populations.

Substance Use Disorders

The punitive sentencing laws and aggressive policing practices that emerged from the national War on Drugs were perhaps the single greatest factor responsible for surging prison populations. Starting in the early 1970s and accelerating over the following decades, a series of new state and federal policies led to unprecedented numbers of people being sent to prison to serve long custodial sentences for drug offenses. The concentration of drug arrests in urban communities of color is a primary driver of pervasive racial disparities in the criminal justice system. African Americans are significantly more likely to be arrested, 13 times more likely than whites to go to prison for a drug conviction, and represent 62 percent of people imprisoned for a drug conviction, despite negligible differences in reported drug use. The increase in incarceration following arrest on drug charges accounted for about two-thirds of the increase in the federal prison population and one-half of the increase in the state prison populations from 1985 to 2000.

Today, nearly 68 percent of people in jail overall and more than 50 percent of those in state prisons have a diagnosable substance use disorder, compared to 9 percent of the general population. Moreover, most people who have a serious mental illness also have a co-occurring substance-use diagnosis. For instance, in jails an estimated 72 percent of people with a serious mental illness also have a substance use disorder.

Despite this high need, less than 15 percent of people who are incarcerated receive appropriate treatment. For instance, although a significant body of research shows that pharmacological treatments such as methadone and buprenorphine effectively treat opioid addictions, most correctional facilities choose not to offer them, subjecting people with chronic addictions to higher risk of withdrawal while in custody and of overdose when released to the community.

from Vera’s 2014 report On Life Support: Public Health in the Age of Mass Incarceration, pages 5-10.

For a discussion of how law enforcement can help ensure that the people they encounter with mental illness and substance use disorders get treatment, rather than arrested, see Vera’s 2015 report First Do No Harm: Advancing Public Health in Policing Practices.