Revolving-Prison-Door Phenomenon Seen in Mentally Ill Inmates

Inmates With Bipolar Disorder Most Likely to Have Repeat Incarcerations

Marlene Busko

January 16, 2009

January 16, 2009 — Prison inmates with major psychiatric disorders are more likely than prisoners without a psychiatric history to have multiple episodes of repeat arrests and incarceration, in a "revolving-door phenomenon," researchers report.

A 6-year study of close to 80,000 inmates found that those with major depressive disorder, bipolar disorder, schizophrenia, and nonschizophrenic psychotic disorders were much more likely than other prisoners to have had multiple incarcerations.

"The greatest increase in risk was observed among inmates with bipolar disorders, who were 3.3 times more likely to have had 4 or more previous incarcerations compared with inmates who had no major psychiatric disorder," Jacques Baillargeon, PhD, from the University of Texas, in Galveston, and colleagues write.

"Addressing this public-health crisis adequately will require the continued development of novel and integrated interventions," they add. "Given the scale and complexity of this problem, it is likely that a coordinated effort among criminal-justice, mental-health, and public-health systems will be necessary to reduce the widespread criminalization of the mentally ill in America."

The study is published the January issue of the American Journal of Psychiatry.

National Public-Health Crisis

Epidemiologic studies show that up to almost 1 in 4 inmates in US prisons has a severe mental illness, which researchers describe as a "national public-health crisis."

Multiple factors have brought this on, including massive closings of public mental-health hospitals during the late 1960s (when new antipsychotic medications became available), greater restrictions in mental-health insurance coverage, and the "war on drugs" during the 1980s that led to a dramatic increase in the proportion of inmates with psychiatric disorders and substance-abuse problems.

Despite the magnitude of the problem, few studies have looked at this issue of repeat arrest or incarceration in these individuals.

In the first study to examine the association between psychiatric disorders and repeat incarceration, investigators conducted a retrospective cohort study of all 79,211 inmates who began serving a sentence between September 2006 and September 2007 in the Texas Department of Criminal Justice System, the nation's largest state prison system.

They determined the number of incarcerations in the past 6 years among 5 groups of inmates:

  • No psychiatric disorder (the reference group; n=71,333).

  • Major depressive disorder (n=3252).

  • Bipolar disorder (n=2402).

  • Schizophrenia (n=849).

  • Nonschizophrenic psychotic disorders (n=1375).

Inmates with these 4 disorders were 1.6 to 3.3 times more likely to have 4 or more incarcerations during the previous 6 years, compared with inmates with no psychiatric disorder.

Inmates with psychiatric disorders other than depression also had higher rates of violent crimes.

Because of the large study size and high degree of statistical power, the findings are likely to be generalizable to other US prison systems, the authors write.

"Many people with serious mental illness move continuously between crisis hospitalization, homelessness, and the criminal-justice system," they note.

Potential strategies to reduce recidivism in mentally ill prison inmates include diverting individuals with serious mental illness to appropriate community-based mental-health services in lieu of incarceration, linking newly released mentally ill inmates with community-based services, and developing specialized correctional mental-health facilities.

Reversing Criminalization

In an accompanying editorial, H. Richard Lamb, MD, from the University of Southern California, in Los Angeles, says the study provides valuable data and highlights the fact that criminalization in mentally ill prisoners is a serious problem.

"Currently, a large number of people with severe mental illness receive their acute psychiatric inpatient treatment in the criminal-justice system rather than in the mental-health system," he writes.

He proposes that acute inpatient beds should be a high priority in community mental health and lengths of stay should not be unreasonably short.

In addition, Dr. Lamb suggests that at-risk individuals who are resistant to psychiatric treatment could benefit from assisted outpatient treatment (court-ordered civil commitment).

The authors and the editorialist report having no financial disclosures.

Am J Psychiatry. 2009; 166:103-109 Abstract, 8-10. Abstract


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