Mental Illness and Prisoners: Concerns for Communities and Healthcare Providers

Samantha Hoke, MSN, PMHNP-BC, RN


Online J Issues Nurs. 2015;20(1) 

In This Article

Factors Affecting Mental Healthcare in Prisons

Characteristics of the Prison Population

Rates of mental illness within prison systems across western countries are very high. A systematic review of 62 studies of mental health disorders within western countries found the following diagnoses among male prisoners: 3 to 7% psychotic disorder, 10% major depression, 47% antisocial personality disorder, and 65% personality disorder, including antisocial personality disorder (Fazel & Danesh, 2002). The same review yielded higher results for women. Among the female prisoners, diagnoses included: 4% psychotic disorder, 12% major depression, 21% antisocial personality disorder, and 42% personality/antisocial disorder (Fazel & Danesh, 2002). In addition to these diagnoses, a significant number had anxiety disorders, organic disorders, traumatic brain injuries (TBI), suicidal behaviors, distress associated with all forms of abuse, attention-deficit hyperactivity disorder (ADHD) and other developmental disorders, including mental retardation and Asperger's syndrome (Daniel, 2007).

Rates of mental illness in the U.S. alone are burdensome. The U.S. Department of Justice (USDOJ) found that more than half of all inmates, or over than 1 million individuals, have a mental illness compared to 11% of the general population; and yet only 1 of 3 prison inmates and 1 of 6 jail inmates receive any form of mental health treatment (Daniel, 2007; James & Glaze, 2006). Thus 56% of state, 46% of federal, and 64% of jail prisoners have either a current or recent history of mental health problems (James & Glaze, 2006). The USDOJ also studied the distribution of mental health problems and found that 43% of state prisoners and 54% of jail inmates reported symptoms that met criteria for mania; 23% of state and 30% of jail inmates reported symptoms of major depression; and 15% of state and 24% of jail inmates reported symptoms that met criteria for a psychotic disorder (James & Glaze, 2006). Furthermore, approximately 70% had a primary or comorbid substance abuse disorder (James & Glaze, 2006). The high amount of mental health disorders alone constitutes but one of the many limitations to appropriate healthcare presented in correctional settings.

Social Policy and Increased Incarceration Rates

Many question why rates of mental illness are so high among incarcerated individuals. The answer is complex as several synergistic factors related to social policy have contributed to high rates of persons with mental illness behind bars. The first factor was the mass closing of public mental health hospitals in the 1960s. This national movement followed the availability of new antipsychotic medications, such as Olanzapine®. Movement leaders believed moving patients into a community-based setting was a humane alternative to overcrowded and understaffed institutions (Baillargeon et al., 2009). Unfortunately, resources fell short, coordination lacked, and promised clinics and halfway houses were not provided to care for released hospital patients (Baillargeon et al., 2009; FRONTLINE, 2005). Following this movement, health insurers restricted mental health coverage; private hospitals restricted enrollment of psychotic patients; and civil commitment laws became more restrictive (Baillargeon et al., 2009). As these changes occurred, another policy change ensued that resulted in dramatic increases in rates of incarcerations of persons with mental illness(es). The 1980s "war on drugs" led to an increase in drug-related arrests and mandatory sentencing laws (Baillargeon et al., 2009). These arrests resulted in an increase in the proportion of inmates with psychiatric disorders and substance abuse problems (Baillargeon et al., 2009). Prison sentences and substance abuse remain significant contributing factors to the increased population of prisoners with mental health concerns.

Mentally Ill and Prison Sentences. Policy changes have increased the length of time served for mentally ill inmates. State prisoners who had a mental health problem served an average sentence of four months longer than those without a mental health problem (James & Glaze, 2006). In general, studies have found that individuals with a mental health problem serve an average sentence of 15 months longer than those without (Baillargeon et al., 2009; FRONTLINE, 2005). There was little variation noted in expected time served for jail inmates (approximately 55% with a mental health problem and 54% without one both expecting to serve 6 months or less) (James & Glaze, 2006).

Often the reason individuals with mental illness serve longer sentences is related to the inability to follow the strict rules of prison life. Individuals with a mental health problem tend to obtain conduct violations. Statistics estimate that among state prisoners, 58% with a mental health problem (compared to 43% without) had been charged with rule violations (James & Glaze, 2006). Depending on the violation level, this may result in revoked privileges and changed security level and/or release date. For example, the resulting disciplinary record may lead to more difficulty achieving parole. Parole boards are also reluctant to release individuals with a mental health disorder back into the community due to inadequate community services available for them to obtain treatment (Rossman, 2001; FRONTLINE, 2005).

Mentally Ill and Substance use. It is a common misperception that people with mental illness are dangerous. Two recent studies revealed illegal drugs as the primary contributor to violence, not mental illness (Dolan, Castle, & McGregor, 2012; Fazel, Gulati, Linsell, Geddes & Grann, 2009). The studies examined the potential link between mental illness and risk of violence and found violence risk was not significantly increased when compared to the general public. The studies also indicated that the risk of violence in persons with mental illness combined with substance use was not different than the risk of violence for individuals with a diagnosis of solely substance use.

There is a high rate of substance abuse among prisoners, but especially among those also diagnosed with mental illness. At the time of arrest, over a third of inmates who had a mental health diagnosis were under the influence of substances compared to a quarter of inmates without mental illness (James & Glaze, 2006). An assessment of nonviolent crimes found persons with schizophrenia or non-schizophrenia psychotic disorders had lower rates of driving under the influence, but higher rates of drug possession (Baillargeon et al., 2009). Dual diagnosis was common; 74% of prisoners who had a mental health problem met criteria for substance dependence or abuse, compared to 56% without a mental health problem (James & Glaze, 2006).

An individual who has both an alcohol or drug problem and an emotional/psychiatric problem has a dual diagnosis (Mental Health America, 2013). Dual diagnoses are common, but this concept has not always been accepted. However, research has demonstrated that simultaneous treatment of mental illness and substance abuse supports better outcomes, which has furthered the acceptance of dual diagnoses. Approximately 50% of the mentally ill population also has a substance abuse problem (National Alliance on Mental Illness, 2013a). Additionally, 6 of 10 people with a substance use disorder also suffer from another mental illness (National Institute on Drug Abuse, 2007). Of those individuals who are incarcerated, the number increases to almost 70%, or nearly 3 of 4 persons (Daniel, 2007; Skeem, Manchak & Peterson, 2010).

These statistics beg the question: why are individuals with mental illness more prone to substance abuse over those without a mental health problem? Self-medicating and social factors are viewed as common contributors to substance abuse amongst mentally ill individuals. Like their healthy counterparts, individuals with mental illness may begin to use drugs or alcohol for recreational use. Continued use has often been attributed to a misguided attempt to treat symptoms of their mental illness. In the short term, individuals may find they can reduce their level of anxiety or depression by self-medicating. Genetic vulnerabilities are hypothesized as a reason for continued use as well. Genetic factors predispose individuals to both mental disorders and addictions, or to having a greater risk of the second disorder once the first appears. (National Alliance on Mental Illness, 2013a; National Institute on Drug Abuse, 2007; McKean & Ransford, 2004).

Other factors contribute to substance abuse in this population. Mentally ill persons are often socially disenfranchised. Poverty situates them to live in neighborhoods endemic with illicit substances, unemployment, and other marginalized citizens. Research has also demonstrated that mentally ill individuals are more likely to have a history of victimization. Individuals who have difficulty developing social relationships, often as a consequence of mental illness, find themselves more easily accepted by groups whose social activities is based on drug use. Some believe that an identity based on drug addictions is more acceptable than one based on mental illness. (National Alliance on Mental Illness, 2013a). Together, social stresses and traumas and early exposure to drugs are common factors that can lead to addiction and mental illness (James & Glaze, 2006; National Alliance on Mental Illness, 2013a; Skeem et al., 2010).

Finally, some areas of the brain are affected by both drug abuse and mental disorders. For example, brain circuits linked to reward processing, as well as those implicated in the stress response, are affected by substance abuse and also abnormalities in specific mental disorders. With the commonality of dual diagnoses, it is naïve to discount the evidence and fail to address both issues of substance use and mental illness when addressing mental health concerns and care for prisoners. (National Institute on Drug Abuse, 2007).