The Need for Mental Health and Substance Abuse Services for the Incarcerated Mentally Ill

THE AMERICAN PUBLIC HEALTH ASSOCIATION,

Understanding that the Surgeon General’s report states that “one in five adults during a given year experience a mental disorder,”¹ including adults with serious mental illness, substance use disorder and co-occurring mental and substance use disorders, as defined in the Federal Register;¹ and

Recognizing that compared to the general population, people with mental disorders, substance use disorders, and co-occurring mental and substance use disorders are arrested more frequently for nonviolent crimes or behaviors committed as a direct result of the mental disorders, substance use disorders, and/or homelessness^2-4 or are arrested on “mercy bookings” because of the restrictiveness of psychiatric hospital admission policies and the lack of community based mental health and substance abuse services;⁵ and

Noting that there are nearly two million people incarcerated in the jails and prisons in the United States,^6,7 with an estimated 10-15% of people in the prisons suffering from mental illnesses,⁸ and an estimated 3-11% of the seriously mentally ill prison population diagnosed with co-occurring substance use disorders;⁹ and

Further finding that between 140,000 and 400,000¹⁰ people in prisons and jails have a diagnosable mental disorder, estimated at 16% of offenders in state prisons, 7% of federal prisoners, and 16% of detainees in local jails;¹¹ and moreover, 6 in 10 mentally ill offenders are more likely to be under the influence of alcohol or drugs at the time of the offense;¹² and

Understanding that people with mental disorders are vulnerable to deterioration of their mental condition with incarceration;¹³ and

Realizing the rate of suicide for the incarcerated population compared to the general population is 11 to 14 times greater, with 95% of the suicides within the prisons and jails committed by those persons with mental illnesses;¹⁴ and

Learning that the rate of criminal justice involvement for people of color is high in urban areas, with Black and Latino people comprising more than 50% of the populations of prisons and jails, and that arrests and convictions for drugs have accounted for much of this involvement; and

Believing that the mental health status of prisoners of color is continually at risk because of the lack of substance abuse and mental health treatment;¹⁵ and

Recognizing that there is a need for collaboration between the mental health, the substance abuse treatment, the criminal justice, and the public health systems in formulating policies and programs for the assessment and treatment of these populations within the criminal justice system; and

Affirming that mental health services are unevenly provided in prisons and jails, with less than half of the detainees or offenders, offered separate housing, supportive therapies, and substance abuse treatment;^16,17 and

Acknowledging that those who are incarcerated and have mental disorders have a right to treatment programs that consist of a minimum set of assessment and treatment services, including but not limited to: crisis intervention, psychiatric screening and assessment, short and long-term psychotherapy as appropriate, medication evaluation and management, and, special separate housing,¹⁸ delivered in a culturally competent environment; and

Recognizing that APHA has adopted as policy the diversion from jail for non-violent arrestees who have serious mental illness,* and

Acknowledging that the increased use of mandatory sentencing, particularly for drug offenses, leads to the release of inmates including those with mental disorders with no parole or post-release supervision of any kind by the criminal justice or mental health systems, and that there is a need for continuity of care through discharge/transfer planning,^19,20 and linkage to community mental health and substance abuse services and continuous aftercare,²¹ which can have the effect of preventing relapse and recidivism; and

Recognizing that the delivery of mental health and substance abuse services, both within the larger community and within the prisons and jails is operating in a managed behavioral health care environment, which influences the availability of continuity of care for the mentally ill, including aftercare placement in housing, rehabilitative services, and ongoing therapies; therefore

1. Urges the Administrator of the Substance Abuse and Mental Health Services Administration and the Directors of the National Institutes of Health, the National Institute of Mental Health, the National Institute on Drug Abuse, the National Institute of Justice, and other national health and law enforcement agencies, to study the service needs and create practice and evaluation guidelines for a national model of mental health services and substance abuse treatment services for the incarcerated mentally ill that include discharge plans for mental health patients being released from custody;
2. Encourages state mental health and substance abuse authorities to:

• develop collaborations among mental health, criminal justice, and public health agencies to examine problems for the treatment of the incarcerated mentally ill (by way of example, the most recent collaboration with the State of Maryland);²²
• Adopt standards specifically created by the American Public Health Association, the American Psychiatric Association, and the National Commission on Correctional Health Care for the treatment of inmates with mental disorders and substance use disorders; and
• Appropriate sufficient funds within the budgets of both mental health and corrections agencies and within managed care contracts, to fund in-house and aftercare services for inmates with mental disorders.

* APHA Policy Statement 9929: Diversion from Jail for Non-Violent Arrestees with Serious Mental Illness. APHA Policy Statements: 1948 to present. Cumulative Washington, DC: American Public Health Association; current volume.

References

1. US Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999; p. 15.
2. The Ad Hoc Working Group on Persons with Mental Illness in the Criminal Justice System. Double Jeopardy: Persons with mental illness in the criminal justice system. Report to Congress from CMHS/SAMHSA, February 24, 1995.
3. Dennis D and Steadman HJ. The criminal justice system and severely mentally ill homeless persons: An overview. Report prepared for the Task Force on Homelessness and Severe Mental Illness. Dalmar, NY: Policy Research Associates, 1991.
4. Pogebin MR and Poole ED. Deinstitutionalization and increased arrest rates among the mentally disordered. J Psychiatry and the Law. Spring 1987.
5. Torrey, EF. Editorial: Jails and prisons - America’s new mental hospitals. Am J Public Health. 1995;85:1611-1613. 
6. Egan T. Hard time: Less crime, more criminals. New York Times, March 7, 1999, section 4, p.1. 
7. Goldstrom I, Henderson M, Male A, et al. Jail mental health services: A national survey. In Center for Mental Health Services, 1998. Mental Health United States. Manderscheid RW and Henderson MJ (eds.). DHHS Pub. No. (SMA)99-3285. Washington DC:, US Government Printing Office, 1998; p.176-187.
8. Butterfield F. Prisons replacing hospitals for the nation’s mentally ill. New York Times, March 5, 1998, page 1.
9. Lamb HR, and Weinberger LE. Person with severe mental illness in jails and prisons: A review. Psychiatr Serv. 1998, 49(4): 483-492.
10. Position Statement of the American Association of Community Psychiatrists. Received by Email, March 9, 1999. 
11. P.M. Ditton. Mental Health and Treatment of Inmates and Probationers. Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Assistance Special Report, July 1999.
12. Mumola CJ. Substance Abuse and Treatment. Washington, DC: State and Federal Prisoners, 1997. US Department of Justice, Office of Justice Programs, Bureau of Justice Assistance. Special Report, January 1999.
13. Edens JF, Peters RH, and Hills HA. Treating prison inmates with co occurring disorders: An integrative review of existing programs. Behav Sci Law. 1997; 15(4): 439-457.
14. TenCare Partner’s Roundtable. A survey of county jails in Tennessee: A descriptive study to quantify the number of persons in jails who have a mental illness or have substance abuse problems. Nashville, TN, October 1998.
15. Kupers T. Prison Madness: The Mental Health Crisis Behind Bars and What We Must Do About It. San Francisco, CA: Josey-Bass Publishers, 1999, p. 93-94.
16. The Ad Hoc Working Group on Persons With Mental Illness in the Criminal Justice System. Double Jeopardy: Persons with Mental Illness in the Criminal Justice System. Report to Congress from SAMHSA/CMHS, February 24, 1995.
17. Osofsky HJ. Psychiatry behind the walls: Mental health services in jails and prisons. Bull Menninger Clin; Fall 60(4):464-479.
18. National Commission on Correctional Health Care. Position paper: Mental Health Services in Correctional Settings, 1992.
19. See 7.
20. Schnapp WB, and Cannedy R. Offenders with mental illness: mental health and criminal justice best practices. Admin and Policy in Mental Health. March 1998; 25(4).
21. Field G (ed.). Continuity of Offender Treatment for Substance Use Disorders from Institution to Community. Treatment Improvement Protocol Series 30. Washington, DC: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. 1998.
22. Washington Post Center to study inmate mental health. Washington Post. March 2, 2000, p. 3

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