Treatment of Mentally Ill in Prisons and Jails: Follow-up Care Needed

Jay M. Pomerantz, MD



Currently, a good deal of treatment is being provided for mentally ill inmates within the prison system, according to the Bureau of Justice Statistics (BJS) of the US Department of Justice.[1] A prison census conducted in June 2000 found that fewer than 1.8% of all inmates in state-run institutions were held in facilities in which mental health services were not available. Drawing from surveys of inmates conducted in 1997, the BJS found that 10.1% of inmates in state institutions reported having a mental or emotional condition, and 10.7% said they had at least 1 overnight visit to a mental hospital or program.

The year 2000 prison census reported that nearly 13% of inmates in state-run institutions (or about 19% of those inmates who were mentally ill) received some form of mental health care from a trained professional on a regular basis. Also, nearly 10% of all inmates (an estimated 114,400 inmates nationwide) were receiving psychotropic medications. The use of these drugs, including antidepressants, stimulants, sedatives, and tranquilizers, was most common in facilities specializing in mental health confinement (45%), medical treatment facilities (22%), and female-only confinement facilities (22%).

Although these statistics on treatment provided within the prison system are reassuring, they tell us nothing about quality of care. More important is whether the mental health treatment is continued after the inmate returns to the community. Wolff and colleagues[2] surveyed officials of 17 New Jersey jails about release planning for inmates with mental illness compared with other chronic (medical) illnesses (ie, heart disease, HIV/AIDS). When asked to rate the importance of release planning for persons with serious mental illness, 71% of the respondents (12 jails) reported that it is very or extremely important. Yet officials at 10 of the 17 jails reported that they provide after-release care for fewer than 10% of inmates with mental illness.

About half of the jails reported that they never or rarely provide inmates who have serious mental illness with medications or prescriptions once they are released. Eight jails reported having partnerships with community clinics for on-site screening, treatment, case management, release planning, and follow-up aftercare for all inmates with HIV/AIDS. Connections such as these were not found between jails and the community mental health system.

It does not make either clinical or economic sense not to provide follow-up care in the community for mentally ill persons following their release from jails or prisons. Ventura and colleagues[3] documented that the provision of community-based case management was significantly associated with a lower probability of rearrest and a longer period before rearrest for mentally ill offenders. In this study conducted at Lucas County jail in Toledo, Ohio, 261 inmates in whom a mental disorder was diagnosed were tracked for 3 years after their release. Recipients of community-based case management were significantly less likely than nonrecipients to be arrested for any offense (60% vs 77%) or for a violent offense (52% vs 71%).

The issue of the violent mentally ill offender is a valid concern but not nearly as big a problem as it usually is made out to be in the media. Actually, mentally ill offenders rarely commit serious violent offenses. Researchers followed up on 337 mentally ill prisoners who were released from Washington State prisons in 1996 and 1997.[4] Persons with schizophrenia, major affective disorders, and borderline personality disorder made up most of the sample. Although charges for new crimes or supervision violations were common (70% of participants), just 10% committed new felonies against persons, and 2% committed serious violent offenses (homicide, rape, first-degree robbery or assault) over the average follow-up period of 31 months. Although 2% may be considered a rate high enough to justify allocation of more resources for treatment and follow-up services on the grounds of public safety, emphasizing danger to the public may only reinforce public fear and discourage efforts to reach out to mentally ill offenders and keep them engaged in community mental health and other social support services.[4]

More widespread public support for devoting more resources to treating the mentally ill in prisons and jails may come from the application of a public health model. As pointed out by Conklin and colleagues,[5] medical and correctional communities have only recently realized the extent to which mental illness; substance use disorders; chronic disease; and communicable diseases, such as HIV/AIDS, tuberculosis, hepatitis, and sexually transmitted diseases, are concentrated in the correctional system.

In Hampden County Correctional Center, Ludlow, Mass, 20% of the 1800 inmates are receiving psychological services at any given time, with a major mental illness having been diagnosed in 4%. A 14-bed psychiatric unit for evaluation and stabilization of acute emotional problems is fully utilized. Surprisingly, nearly all of the women and many of the men identified as having mental health problems have been victims of some form of physical or sexual abuse.

The key point is that correctional institutions are reservoirs of physical and mental illness, which constantly spill back into the community. If these diseases are to be treated properly, transmission interrupted, and the health of the general public optimized, then effective treatment and education must be provided within the jail system. These conditions are public health problems that demand effective management and close coordination among correctional health, community health, public health, and mental health facilities.

Inmates at Hampden County Correctional Center are followed after discharge for physical illness, mental illness, and substance abuse through a network of 4 affiliated community health centers, all of which have contracted with a mental health clinic in their catchment area to provide aftercare services for inmates who received mental health care while in prison. That way, health care started within the jail can continue after release.

This public health model of intervention comes from a jail, not a prison. Hampden County Correctional Center is a medium-security facility housing 1800 inmates at any one time. The population is constantly in flux, with approximately one third of the inmates remaining 3 days or fewer (persons awaiting court appearances), one third staying for 4 to 90 days, and one third staying for 91 days to 2 years.[6] This kind of revolving-door setting is ideal for diagnosis and initiation of treatment while persons are in jail and continuing the treatment in the community upon their release.

Indeed, as was pointed out in a letter to Psychiatric Services,[7] most persons with mental illness who are involved in the criminal justice system have short stays in local jails rather than long stays in prison. A study conducted in New York State found that female recipients of mental health services are 17.6 times more likely to go to jail than to prison, and that men are 8.9 times more likely.[7] The letter points out that a 1998 national statistic from the BJS finding that 63% of mentally ill offenders were in state prisons and not local jails is misleading. Any point-in-time census does not account for the high volume of persons who enter and exit local jails over time. If most mentally ill persons are really in short-term jails rather than long-term prisons, then a public health, community resource approach makes the most sense.

The same ideas apply to drug offenders. A study conducted in New Haven, Conn, found that after their release, offenders who had participated in a prison-based substance abuse treatment program and work release program were 70% less likely than nonparticipants to return to drug use and be rearrested.[8] If ever there was a cost-effective opportunity to help the mentally ill and drug abusing population, focusing on the inmate population (during incarceration and afterwards) may be it.