Mentally ill people are overrepresented in United States jail and prison populations relative to the general population. There are three times more seriously mentally ill persons in jails and prisons than in hospitals in the United States. The exact cause of this overrepresentation is disputed by scholars; proposed causes include the deinstitutionalization of mentally ill individuals in the mid-twentieth century; inadequate community mental health treatment resources; and the criminalization of mental illness itself. The majority of prisons in the United States employ a psychiatrist and a psychologist. While much research claims mentally ill offenders have comparable rates of recidivism to non-mentally ill offenders, other research claims that mentally ill offenders have higher rates of recidivism. Mentally ill people experience solitary confinement at disproportionate rates and are more vulnerable to its adverse psychological effects. Twenty-five states have laws addressing the emergency detention of the mentally ill within jails, and the United States Supreme Court has upheld the right of inmates to mental health treatment.
There is broad scholarly consensus that mentally ill individuals are overrepresented within the United States jail and prison populations. In the 2010 study titled "More mentally ill persons are in jails and prisons than hospitals: a survey of the states", researchers concluded that, based on statistics from sources including the Bureau of Justice Statistics and the U.S. Department of Health and Human Services, there are currently three times more seriously mentally ill persons in jails and prisons than in hospitals in the United States, with the ratio being nearly ten to one in Arizona and Nevada. "Serious mental illness" is defined here as schizophrenia, bipolar disorder or major depression. Further, they found that sixteen percent of the jail and prison population in the U. S. has a serious mental illness (compared to 6.4 percent in 1983), although this statistic does not reflect differences among individual states. For example, in North Dakota they found that a person with a serious mental illness is equally likely to be in prison or a jail versus hospital, whereas in states such as Arizona, Nevada and Texas, the imbalance is much more severe. Finally, they noted that a 1991 survey through the National Alliance for the Mentally Ill concluded that jail and/or prison is part of the life experience of forty percent of mentally ill individuals.
A separate research study "The Prevalence of Mental Illness among Inmates in a Rural State" noted that national statistics like those previously mentioned primarily pull data from urban jails and prisons. In order to investigate possible differences in rural areas, researchers interviewed a random sample of inmates in both jails and prisons in a rural northeastern state. They found that in this rural setting, there was little evidence of high rates of mental illness within jails, "suggesting the criminalization of mental illness may not be as evident in rural settings as urban areas." However, high rates of serious mental illness were found among the rural prison inmates.
A 2017 report issued by the Bureau of Justice Statistics used self-report survey data from inmates to assess the prevalence of mental health problems among prisoners and jail inmates. They found that 14% of prisoners and 25% of jail inmates had past 30-day serious psychological distress, compared to 5% of the general population. In addition, 37% of prisoners and 44% of jail inmates had a history of a mental health problem.
In 2015 lawyer and activist Bryan Stevenson claimed in his book Just Mercy that over fifty percent of inmates in jails and prisons in the United States had been diagnosed with a mental illness and that one in five jail inmates had a serious mental illness. As for the gender, age, and racial demographics of mentally ill offenders, the 2017 Bureau of Justice Statistics report found that female inmates when compared to male inmates had statistically significant higher rates of serious psychological distress (20.5% of female prisoners and 32.3% of female jail inmates had serious psychological distress, versus 14% of male prisoners and 25.5% of male jail inmates) and a history of a mental health problem (65.8% of female prisoners and 67.9% of female jail inmates compared to 34.8% of male prisoners and 40.8% of male jail inmates). Significant differences between race and ethnicity were also observed. White prisoners and jail inmates were more likely than black or Hispanic inmates to have serious psychological distress or a history of a mental health problems. For example, in local jails, 31% of white inmates compared to 22.3% of black inmates and 23.2% of Hispanic inmates had serious psychological distress. Finally, with regards to age, there were virtually no statistical differences between age groups and the percentage who has serious psychological distress or a history of a mental health problem .
Researchers commonly cite deinstitutionalization, or the emptying of state mental hospitals in the mid-twentieth century, as a direct cause of the rise of mentally ill people in prisons. In the 2010 study "More mentally ill persons are in jails and prisons than hospitals: a survey of the states," researchers noted, at least in part due to deinstitutionalization, it is increasingly difficult to find beds for mentally ill people who need hospitalization. Using data collected by the Department of Health and Human Services, they determined there was one psychiatric bed for every 3,000 Americans, compared to one for every 300 Americans in 1955. They also noted increased percentages of mentally ill people in prisons throughout the 1970s and 1980s and found a strong correlation between the amount of mentally ill persons in a state's jails and prisons and how much money that state spends on mental health services. In the book Criminalizing the Seriously Mentally Ill: The Abuse of Jails As Mental Hospitals, researchers note that while deinstitutionalization was carried out with good intentions, it was not accompanied with alternate avenues for mental health treatment for those with serious mental illnesses. According to the authors, Community Mental Health Centers focused their limited resources on individuals with less serious mental illnesses, federal training funds for mental health professionals resulted in lots more psychiatrists in wealthy areas but not in low-income areas, and a policy that made individuals eligible for federal programs and benefits only after they'd been discharged from state mental hospitals unintentionally incentivized discharging patients without follow-up.
In the article "Assessing the Contribution of the Deinstitutionalization of the Mentally Ill to Growth in the U.S. Incarceration Rate" researchers Steven Raphael and Michael A. Stoll discuss transinstitutionalization, or how many patients released from mental hospitals in the mid-twentieth century ended up in jail or prison. Using U.S. census data collected between 1950-2000, they concluded that "those most likely to be incarcerated as of the 2000 census experienced pronounced increases in overall institutionalization between 1950 and 2000 (with particularly large increases for black males). Thus, the impression created by aggregate trends is somewhat misleading, as the 1950 demographic composition of the mental hospital population differs considerably from the 2000 demographic composition of prison and jail inmates." However, when estimating (using a panel data set) how many individuals incarcerated between 1980 and 2000 would have been institutionalized in years past, they found significant transinstitutionalization rates for all men and women, with the largest rate for white men.
A related cause of the disproportionate amount of mentally ill people in prisons is criminalization of mental illness itself. In the 1984 study "Criminalizing mental disorder: The comparative arrest rate of the mentally ill", researcher L. A. Teplin notes that in addition to a decline in federal support for mental illness resulting in more people being denied treatment, mentally ill people are often stereotyped as dangerous, making fear a factor in action taken against them. Bureaucratic and legal impediments to initiating mental health referrals means arrest can be easier, and in Teplin's words, "Due to the lack of exclusionary criteria, the criminal justice system may have become the institution that cannot say no." Mentally ill people do indeed experience higher arrest rates than those without mental illness, but in order to investigate whether or not this was due to criminalization of mental illness, researchers observed police officers over a period of time. As a result, they concluded "within similar types of situations, persons exhibiting signs of mental disorder have a higher probability of being arrested than those who do not show such signs."
The authors of the book Criminalizing the Seriously Mentally Ill: The Abuse of Jails As Mental Hospitals claim that nationwide, 29% of jails will hold mentally ill individuals with no charges brought against them, sometimes as a means of 'holding' them when psychiatric hospitals are very far away. This practice occurs even in states where it is explicitly forbidden. Beyond that, according to the authors, the vast majority of people with mental illnesses in jails in prisons are held on minor charges like theft, disorderly conduct, alcohol/drug related charrges, and trespassing. These are sometimes "mercy bookings" intended to get the homeless mentally ill off the street, a warm meal, etc. Family members have reported being encouraged by mental health professionals or police to get their loved ones arrested as a means of getting them treatment. Finally, some mentally ill people are in jails and prisons on serious charges, such as murder. The authors of Criminalizing the Seriously Mentally Ill claim many such crimes wouldn't have been committed if the individuals had been receiving proper care.
Psychologists report that one in every eight prisoners were receiving some mental health therapy or counseling services by the middle of the year in 2000. Inmates are generally screened at admission and depending on the severity of the mental illness they are placed in either general confinement or specialized facilities. Inmates can self report mental illness if they feel it is necessary. In the middle of the year in 2000, inmates self reported that State prisons held 191,000 mentally ill inmates. A 2011 survey of 230 correctional mental health service providers from 165 state correctional facilities found that 83% of facilities employed at least one psychologist and 81% employed at least one psychiatrist. The study also found that 52% of mentally ill offenders voluntarily received mental health services, 24% were referred by staff, and 11% were mandated by a court to receive services. Although 64% of providers of mental health services reported feeling supported by prison administration and 71% were involved in continuity of care after release from prison, 65% reported being dissatisfied with funding. Only 16% of participants reported offering vocational training, and the researchers noted that although risk/need/responsivity theory has been shown to reduce the risk for recidivism (or committing another crime after being released), it is unknown whether it is incorporated into mental health services in prisons and jails. A 2005 article by researcher Terry A. Kupers noted that male prisoners tend to underreport emotional problems and don't request help until a crisis, and that prison fosters an environment of toxic masculinity, which increases resistance to psychotherapy. A 2017 report from the Bureau of Justice Statistics noted that 54.3% of prisoners and 35% of jail inmates who had past 30-day serious psychological distress has received mental health treatment since admission to the current facility; and 63% of prisoners and 44.5% of jail inmates with a history of a mental health problem said they had received mental health treatment since admission.
Finally, the book Criminalizing the Seriously Mentally Ill: The Abuse of Jails As Mental Hospitals points out that 20% of jails have no mental health resources. In addition, small jails are less likely to have access to mental health resources and are more likely to hold individuals with mental illnesses without charges brought against them. Jails in richer areas are more likely to have access to mental health resources, and jails with more access to mental health resources also dealt less with medication refusal.
Research shows that rates of recidivism, or re-entry into prison, are not significantly higher for mentally ill offenders. A 2004 study found that although 77% of mentally ill offenders studied were arrested or charged with a new crime within the 27-55 month follow-up period, when compared with the general population, "our mentally ill inmates were neither more likely nor more serious recidivists than general population inmates." In contrast, a 2009 study that examined the incarceration history of those in Texas Department of Criminal Justice facilities found that "Texas prison inmates with major psychiatric disorders were far more likely to have had previous incarcerations compared with inmates without a serious mental illness." In the discussion, the researchers noted that their study's results differed from most research on this subject, and hypothesized that this novelty could be due to specific conditions within the state of Texas.
A 1991 study by L. Feder noted that although mentally ill offenders were significantly less like to receive support from family and friends upon release from prison, mentally ill offenders were actually less likely to be revoked on parole. However, for nuisance arrests, mentally ill offenders were less likely to have the charges dropped, although they were more likely to have charges dropped for drug arrests. In both cases, mentally ill offenders were more likely to be tracked into mental health. Finally, there were no significant differences in charges for violent arrests.
A broad range of scholarly research maintains that mentally ill offenders are disproportionately represented in solitary confinement and are more vulnerable to the adverse psychological effects of solitary confinement. Due to differing schemes of classification, empirical data on the makeup of inmates in segregated housing units can be difficult to obtain, and estimates of the percentage of inmates in solitary confinement who are mentally ill range from nearly a third, to 11% (with a "major mental disorder"), to 30% (from a study conducted in Washington), to "over half" (from a study conducted in Indiana), depending on how mental illness is determined, where the study is conducted, and other differences in methodology. Researchers J. Metzner and J. Fellner note that mentally ill offenders in solitary confinement "all too frequently" require crisis care or psychiatric hospitalization, and that "many simply won't get better as long as they are isolated." Researchers T. L. Hafemeister and J. George note that mentally ill offenders in isolation are at higher risk for psychiatric injury, self-harm and suicide. A 2014 study that analyzed data from medical records in the New York City jail system found that while self-harm was significantly correlated with having a serious mental illness regardless of whether or not an inmate was in solitary confinement, inmates with serious mental illness in solitary confinement under 18 years of age accounted for the majority of acts of self-harm studied. When brought before federal courts, judges have prohibited or curtailed this practice, and many organizations that deal with human rights, including the United Nations, have condemned it.
In addition, scholars argue the conditions of solitary confinement make it much more difficult to deliver proper psychiatric care. According to researchers J. Metzner and J. Fellner, "Mental health services in segregation units are typically limited to psychotropic medication, a health care clinician stopping at the cell front to ask how the prisoner is doing (i.e., mental health rounds), and occasional meetings in private with a clinician." One study in the American Journal of Public Health claimed that health care professionals must "frequently" conduct consultation through a slit in a cell door or an open tier that provides no privacy.
However, some researchers disagree with the scope of claims surrounding the psychological effects of solitary confinement. For example, in 2006 researchers G. D. Glancy and E. L. Murray conducted a literature review in which they claimed that many frequently-cited studies have methodological concerns, including researcher bias, the use of "volunteer nonprisoners, naturalistic experiments, or case reports, case series, and anecdotes" and concluded "there is little evidence to suggest the majority...kept in SC...experience negative mental health effects." However, they did support claims that inmates with preexisting mental illnesses are more vulnerable and do suffer adverse effects. In their conclusion they claim "we should therefore be concerned about those with pre-existing mental illness who are housed in segregation because there is nowhere else to put them within the correctional system."
One major area of legal concern is the emergency detention of the non-criminal mentally ill in jails while waiting for formal procedures for involuntary hospitalization. Twenty-five states and the District of Columbia have laws that specifically address this practice; eight of these states as well as D. C. explicitly forbid it. Seventeen states, on the other hand, explicitly allow it. Within this set, the criteria and circumstances necessary differ by state, and most states limit the detention periods in jails to one to three days. One distinguishing factor of this practice is that it is often initiated by a non-medical professional such as a police officer. In many states, especially those in which a non-public official such as a medical health professional or concerned citizen can initiate the detention, a judge or magistrate is required to approve it before or soon after the initiation.
When emergency detention in jails has been brought to court, judges have generally agreed that the practice itself is not unconstitutional. One notable exception was Lynch v. Baxley; however, later cases, particularly Boston v. Lafeyette County, Mississippi, have connected the ruling of unconstitutionality in that case with the conditions of the jails themselves rather than the fact that they were jails. That being said, the Supreme Court of Illinois has stated that this practice is unconstitutional if the person being detained doesn't pose an imminent threat to himself or others.
Several landmark Supreme Court cases, notably Estelle v. Gamble, have established the constitutional right of prison inmates to mental health treatment. Estelle v. Gamble determined that "deliberate indifference to serious medical needs" of prisoners was a violation of the Eighth Amendment to the U.S. Constitution. This case was the first time the phrase "deliberate indifference" was used; it is now a legal term. In order to determine "serious medical need" later cases would use tests such as the treatment being mandated by a physician or an obvious need to a layman. On the other hand, other cases, notably McGukin v. Smith, used much stricter terms, and in 1993 researchers Henry J. Steadman and Joseph J. Cocozza commented that "serious medical need" had little definitional clarity. Langley v. Coughlin involved a prisoner "regularly isolated without proper screening or care" and clarified that a single, distinctive act is not necessary to constitute deliberate indifference but rather "if seriously ill inmates are consistently made to wait for care while their condition deteriorates, or if diagnoses are haphazard and records minimally adequate then, over time, the mental state of deliberate indifference may be attributed to those in charge."
The landmark case Washington v. Harper determined that although inmates do have an interest in and the right to refusal of treatment, this can be overridden without judicial process even if the inmate is competent provided there this act is "reasonably related to legitimate penological interest". Washington's internal process for determining this need was seen as affording due process. In contrast, in Breads v. Moehrle, the forcible injection of drugs in a jail was not upheld because sufficient procedures were not taken to ensure "substantive determination of need".
George Daniel, mentally ill man on Alabama's death row was arrested and charged with capital murder. In jail, George became acutely psychotic and couldn't speak in complete sentences. Daniel, had been on death row until several years later, Lawyer Bryan Stevenson uncovered the truth of the doctor who lied about the examination of Daniels mental illness. Daniel's trial was then overturned and has been in a mental institution. Another mentally ill man, Avery Jenkins, was convicted of murder and sentenced to death. Throughout Jenkins's childhood, he had been in and out of foster homes and developed a serious mental illness. Jenkins erratic behavior didn't change, so his foster mother decided to get rid of him by tying him to a tree and left him there. Around the age of sixteen he was left homeless and started to experience psychotic episodes. At the age of twenty, Jenkins had wandered into a strange house, and stabbed a man to death as he perceived it to being a demon. He then was sentenced to death and spent several years in prison as if he had been sane and responsible for his actions. Jenkins the got off death row and was put into a mental institution.