Position Statements

Mental Health Services in Correctional Settings

Background
Each day in the United States approximately 1.2 million men and women are incarcerated in jails and prisons throughout the country. The average daily population for both jails and prisons has been increasing at an average of 9.2% and 8.5% respectively since 1983 (U.S. Department of Justice, Bureau of Justice Statistics, 1991). A recent report from the General Accounting Office (1991),  projects that anywhere between 6 to 14% of the incarcerated population may have a major psychiatric disorder. Using these estimates to calculate incidence, up to 123,240 people in state and federal prisons and 64,851 people in jails had a severe psychiatric disorder in 1990 (based on the average daily population of prisons and jails).

In 1991 it was reported that 82.2% of prison inmates used alcohol or other drugs and/or had other mental disorders (Regier et al., 1990). This rate was found to be more than twice the rate found in the general population outside of corrections or other institutional settings (e.g., psychiatric hospitals, nursing homes). Fifty-six (56)% of the population was found to have an alcohol disorder and 53.7% had another drug disorder. Other mental disorders were found in 55.7% of the prisoners in this study. In the same study, approximately 90% of the prisoners with schizophrenia, bipolar disorder, and antisocial personality disorder were also diagnosed with addictive disorder. Other studies have demonstrated that among those inmates with a severe mental illness, as many as 72% (Abram & Teplin, 1991) suffer from more than one disorder (e.g., alcohol and other drug use).

In addition to psychiatric disorders, it has also been estimated that between 2 and 10% of the incarcerated population are people with mental retardation (Anno, 1991). The President's Committee on Mental Retardation estimates that there are approximately 14,000 inmates with mental retardation in federal and state prisons nationwide (1991). This represents an increase of 10% since 1988. The Committee also estimates that another 14,000 people with mental retardation have been convicted of crimes but sent to treatment facilities rather than jails or prisons.

Treatment for people with mental retardation as well as those with psychiatric disorders was at one time primarily relegated to hospitals. Beginning in the 1960s, an effort was made to deinstitutionalize these people. This effort was a result of both a desire to provide better treatment and rehabilitation to this population and the economic burden that institutionalization placed on society.

According to the Task Force on Homelessness and Severe Mental Illness (1992), there are approximately 600,000 people that are "literally homeless" on any given day. Of these, it is estimated that one-third suffer from severe mental illness and do not benefit from formal or informal sources of income, social support systems, or healthcare. Indeed, a recently published study suggests that the homeless population is more likely to be mentally ill and are being arrested with greater frequency than the general population (Michaels, Zoloth, & Braslow, 1992). Today, many of those with mental illnesses, who would have been cared for in institutional settings in the past, are sent to correctional facilities around the country as a result of criminal activity. In many instances, the "crime" committed is a direct result of a mental or psychiatric disorder.  The result of this is the criminalization of the mentally ill.

In addition to the increase in people held in correctional facilities as a result of deinstitutionalization, there has been a sharp increase in the number of people held with alcohol and other drug use disorders. In a study conducted by the General Accounting Office in 1991, nearly three quarters of all state inmates and two thirds of all federal inmates have substance abuse problems requiring some level of treatment. Although treatment was seen as necessary, few facilities provided substance abuse treatment to their inmates (American College of Physicians, National Commission on Correctional Health Care, & American Correctional Health Services Association, 1992). In the 1980s, mandatory sentencing for drug offenses increased the number of people serving time in correctional facilities rather than entering  treatment programs. Indeed, although it is estimated that a large percentage of prison inmates have a substance abuse problem, very few prisons actually have a sufficient number of treatment slots within their treatment programs to meet the facility's need.

Once arrested and detained, preexisting mental illnesses may be exacerbated. In other instances, arrest and detention may precipitate mental illness. The conditions of incarceration, including prolonged idleness, the constant threat of violence, and social isolation as well as feelings of guilt, hopelessness, and helplessness may contribute to psychological disorders including suicidal ideation.

Regardless of whether psychiatric disorders are preexisting or precipitated by detention, in most instances the person will eventually return to the community. Therefore correctional facilities must be an integral part of the community mental health and public health system. Efforts must be made to provide quality intervention and treatment to assist the individual in his/her reintegration into the community. Advocacy groups for the mentally ill, such as the National Coalition for the Mentally Ill in The Criminal Justice System, have made an important start to providing assistance for those released from correctional institutions.

Access to needed mental health services by inmates is protected under the Eighth Amendment of the U.S. Constitution. In Ruiz vs. Estelle (1980), the court ruled that the minimum requirements for mental health services in correctional settings must include:

• screening and evaluation to identify those needing mental health care;
• a treatment plan for identified problems;
• qualified mental health staff sufficient to treat the population;
• a health records system;
• a suicide prevention and treatment program; and,
• the appropriate use of behavior-altering medications.

Mental Health Evaluation
Written policies and defined procedures require, and actual practice evidences, post-admission evaluation of all inmates by qualified mental health professionals within 14 calendar days of admission. Results of the evaluation become a part of the inmate's medical record. Inmates found to be suffering from serious mental illness or developmental disability are immediately referred for care. Those who require acute care mental health services beyond those available at the jail (prison) or whose adaptation to the correctional environment is significantly impaired are transferred to an appropriate facility as soon as the need for such treatment is determined by qualified mental health professionals. A written list of referral sources, and a protocol for referral, exists.

Position Statement
The National Commission on Correctional Health Care recognizes that the number of inmates with mental illness, alcohol or other drug addiction, and mental retardation is large and is growing annually.  Therefore, the Commission recommends the following:

1. All correctional institutions should be required to meet recognized community standards for mental health services as promoted by standards set by organizations such as the National Commission on Correctional Health Care, the American Psychiatric Association, and the American Public Health Association.
2. Correctional health services and community mental health systems, including diversion programs for the seriously mentally ill who are charged with minor crimes, should collaborate to provide leadership for the development of community-wide assessment and triage programs to assist in the disposition of mentally ill persons who violate the law.  Multi-specialty expertise should be available to assess both organic and functional disorders as well as to provide case management services. Community mental health systems should be required to have a "no decline agreement" that states that they will evaluate and treat persons with mental illness and mental retardation upon referral from the court.  In addition, agreements should be in place to continue treatment after discharge from the correctional institution.
3. Correctional institutions should identify the mentally ill and those with mental retardation among their populations and, where legally permissible and clinically appropriate, refer these people to treatment programs in the community for intervention services. Where this is not possible, intervention services should be provided by the facility. In either case, correctional facilities and community based programs should work together to assure continuity of care for the inmate after release. Case management services should be available to assure access to mental health and substance abuse treatment programs as well as to integrate family oriented treatment where possible.
4. Comprehensive services that may be used in aftercare for people released from correctional institutions should be available in the community including: 1) outreach programs, 2) medical management of mental disorders, 3) medically supervised detoxification, 4) toxicology screening, 5) hospitalization, 6) diversion programs, 7) individual and group psychotherapy, 8) milieu-based programs, 9) self help groups, 10) family therapy, 11) assistance with housing, funding, and clothing, and 12) legal aid. Community mental health systems should provide cross-training for those staff members that are involved in the treatment of the mentally ill in the correctional setting.

Adopted by the National Commission on Correctional Health Care Board of Directors
September 27, 1992

References
Abram, K. M., & Teplin, L. A. (1991, October). Co-occurring disorders among mentally ill jail detainees.  American Psychologist, 1036-1045.

American College of Physicians, National Commission on Correctional Health Care, and American Correctional Health Services Association. (1992, July). Position paper. The crisis in correctional health care: The impact of the national drug control strategy on correctional health services.  Annals of Internal Medicine, 117(1).

Anno, B. J.  (1991). Prison health care: Guidelines for the management of an adequate delivery system. Washington, DC: National Institute of Corrections, 125-126.

General Accounting Office. (1991, April). Mentally ill inmates: Better data would help determine protection and advocacy needs.

Michaels, D., Zoloth, S. R., & Braslow, C. A. (1992). Homelessness and indicators of mental illness among inmates in New York City's correctional system. Hospital and Community Psychiatry, 43, 2, 150-151.

President's Committee on Mental Retardation, Information provided by George Bouthilet, Coordinator for the Subcommittee for Full Citizenship and Justice for People with Mental Retardation. (1991). Statistics drawn from the draft report on mental retardation and correctional settings.

Regier, D. A., Farmer, M. E., Rae, D. S., Locke, B. Z., Keith, S. J., Judd, L. L., &  Goodwin, F. K.  (1990). Comorbidity of mental disorders with alcohol and other drug abuse. Journal of the American Medical Association, 264(19).

Standards resources include:

• the National Commission on Correctional Health Care's Standards for Health Services in Juvenile Detention and Confinement Facilities, Standards for Health Services in Jails, and 
• Standards for Health Services in Prisons
• the American Psychiatric Association's principles and guidelines for psychiatric services as described in Psychiatric Services in Jails and Prisons, APA Task Force Report 29, 1989
• the American Public Health Association's Standards For Health Services In Correctional Institutions, Part 5 - Mental Health Services, 1986.

The Task Force on Homelessness and Severe Mental Illness. (1992). Executive summary.  Outcasts on main street: Report of the task force on homelessness and severe mental illness.

U.S. Department of Justice, Bureau of Justice Statistics. (1991). Sourcebook of criminal justice statistics - 1990.