Oxford Textbook of Correctional Psychiatry

The first comprehensive textbook on correctional psychiatry will be released next month in an effort to improve the quality of care given to inmates with mental illnesses. Kenneth L. Appelbaum, MD, a co-editor of the textbook, sheds light on the need for mental health services in both correctional facilities and the community. Appelbaum is clinical professor of psychiatry at UMass Medical School and director of correctional mental health policy and research at its Center for Health Policy and Research, a unit within Commonwealth Medicine.

1.  What percentage of inmates in jails and prisons have a mental illness? Has that percentage increased or decreased? Are there differences in the rates by gender or age?

Estimates of the prevalence of mental disorders among jail and prison inmates have significant limitations, in part due to inconsistencies in how studies define and identify those disorders. Commonly cited national percentages for male inmates range from 12 to 15 percent having psychotic or major mood disorders and double those rates if other disorders, except for substance use and personality disorders, are included. Studies often find that female inmates have prevalence rates twice as high as their male peers. We have to view these numbers with caution because studies vary greatly in how they screen and identify cases. What we can say with good confidence, however, is that inmates have a higher prevalence of mental disorders than people in the general population, female inmates have higher rates than male inmates, and the numbers have been steadily increasing for many years.

2.  Does the mental illness usually lead to the arrest or are the symptoms more likely to manifest once the individual has been incarcerated?

Criminal behavior has complex causes, most of which have nothing to do with mental illness. For some individuals with inadequately treated disorders their resulting behaviors, substance use, and impairments in social and occupational functioning increase the likelihood of arrest and incarceration. After incarceration, screening and evaluation in jail or prison sometimes identifies serious mental illness and treatment needs that went undetected and unmet in the community.

3.  Is there a correlation between those who have a mental disorder and substance abuse? Were inmates with a mental disorder more likely to have been homeless before their arrest?

Having a mental illness does increase the risk of substance use and homelessness at time of arrest. A 2006 study by the U.S. Department of Justice, for example, found that among jail inmates with a “mental health problem” 34 percent had been using drugs at the time of arrest and 17 percent had been homeless within the year before their arrest compared to 20 percent and 9 percent of the rest of the jail population, respectively. Other studies have also found higher rates of substance use and homelessness among jail and prison inmates with mental illness. These studies, too, have methodological limitations despite the apparent precision in the numbers they report. In the DOJ study, the determination that an inmate had a mental health problem did not necessarily include a formal diagnosis or treatment by a mental health professional. Some of the inmates deemed to have a mental health problem would likely not qualify for a diagnosis of a serious disorder after careful clinical evaluation. The rates of substance use and homelessness might be even greater if we focused exclusively on inmates with reliable diagnoses of illness. Although inmates with mental disorders undoubtedly have higher rates of these problems, we need to take the precise numbers with a grain of salt.

4.  What symptoms of mental illness are seen in jails and prisons?

Mental illness presents with the same symptoms whether in jail, prison, or out in the community, but the setting can affect how those symptoms get expressed. Some individuals benefit from access to food, shelter, supervision, structure, and health care, but jails and prisons are not the best settings for providing these services. Many individuals with serious mental illness have difficulty coping with the stresses found in correctional settings. Their symptoms can interfere with their ability to follow institutional rules, and the behaviors associated with their disorders can get them into trouble. As a result, they have a greater likelihood of incurring disciplinary sanctions and punishment, including placement in isolation in segregation units, and they generally spend more time than comparable inmates incarcerated before parole or release.

5.  Is there an increasing awareness among correctional officials of mental illness in the inmate population? Are correctional officers being trained to recognize signs of mental illness and what to do?

Correctional administrators are among the first to acknowledge the problem. Officers get training in what to look for and when and how to make referrals to mental health, but how well this happens in practice can vary. Some correctional facilities lack the capacity to adequately meet the need for mental health services, which can discourage officers from making referrals. Even under the best of circumstances, the overall mission and culture of jails and prisons differs from clinical settings. We can’t realistically expect correctional systems and personnel to provide the same level of care found in exclusively clinical settings. Few, if any, jail and prison officials welcome their role as administrators of de facto mental health institutions. Nevertheless, they increasingly fill the void left by the ongoing shrinkage in state hospital beds and community-based treatment services.

6.  Is the recidivism rate higher among inmates with mental illnesses?

The answer is not straightforward. Most of the research has not found significantly higher recidivism rates among inmates with mental illnesses, especially when controlling for other factors. More robust predictors of recidivism include a longer history of past criminal activity, substance use problems, and antisocial beliefs and attitudes. Inmates with mental illness are more likely to have co-occurring problems with substance use, and their functional impairments could interfere with interventions that target substance use and antisocial thinking. Thus, mental illness can interact negatively with more important causes of recidivism.

7.  How does releasing inmates with untreated mental illness back into the community affect the community?

 As noted, lack of treatment can hinder interventions that reduce the likelihood of recidivism. Untreated illness also increases risks for unemployment, homelessness, substance use, and disrupted interpersonal relationships. These circumstances add to the risk of recidivism and cause disability that has societal costs in addition to causing individual suffering and distress. Ninety-eight percent or more of inmates eventually return to the community. If they leave jail or prison with untreated disorders, public health and safety is compromised.

 8.  What can be done to treat inmates with mental illnesses to prepare them to go back into the community?

Simply put, we need to ensure the availability and adequacy of clinical services in correctional facilities and in the community. Either one by itself won’t suffice. We have a moral and constitutional obligation to provide clinical services for inmates, but incarceration should not be the first opportunity for a person to receive comprehensive health care. Disparity in community access to health care remains far too common, and in the past several decades, we have increasingly abandoned the neediest of our fellow citizens with serious mental illnesses. Jails and prisons have, in effect, become our mental health facilities of first resort for too many people. This needs to change.