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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.