Incarceration and Mental Health

The closing of state psychiatric facilities during the process of deinstitutionalization in the 1960s was intended to improve care for people suffering from mental illness and shift treatment provision to less restrictive settings. People with mental illness left state-funded institutions to return home, to nursing homes, and other community-based residences. However, nearly half of the proposed community-based health centers that were to replace state psychiatric facilities were never built, and those that were completed ran into financial distress when federal money ran out a few years later.

The lack of sufficient community-based treatment options has instead resulted in the drastic increase in the incarceration of the people with mental illness. In fact, correctional facilities in New York, Los Angeles, and Chicago currently act as the three biggest psychiatric facilities in the country. The number of hospitalized persons with serious mental illness (SMI) decreased from 550,000 in the 1950s to 70,000 in 2012; concurrently, the prison population grew from 178,000 in the 1950s to 5.6 million today. The percentage of individuals with SMI in prisons increased from .7% in 1880 to 21% in 2005.

Compounding the aftermath of deinstitutionalization was the War on Drugs, a federal initiative dating back to the 1970s that used “tough-on-crime” rhetoric and mandated long sentences for drug-related offenses, even those involving small amounts of drugs or first-time offenders. The War on Drugs may account for up to two-thirds of the increase in the federal prison population and one-half of the increase in the state prison populations between 1985 and 2000. Given the comorbidity of mental illness and substance dependence, the War on Drugs has made a significant contribution to the increase the number of people with mental illness behind bar.

Compared to the general population, justice-involved individuals are substantially more likely to have a history of mental illness, including psychotic illness and depression, as well as of trauma stemming from abuse. Data from 2005-2006 shows that over half of prison and jail inmates meet criteria for mental illness. Female inmates and older inmates have higher rates of mental illness, and suicide rates in detention facilities are approximately three times greater than in the general population. People with mental illness are 4.5 times more likely to be arrested than those in the general population.

Incarcerating people with SMI raises a number of critical ethical and security issues. Mental illness is associated with high recidivism rates and increased rates of disciplinary infractions in prisons, making incarceration for individuals suffering from mental illness challenging for staff and other inmates. Mentally ill prisoners are disproportionately placed in solitary confinement as a response to behavioral difficulties, which can cause their mental health to deteriorate further. As a vulnerable population, they are also at a higher risk for abuse by other inmates and correctional staff. The use of segregation and medical services associated with inmates that have SMI, as well as the cost of litigation associated with inmate abuse and mistreatment makes them an extremely expensive population to house in correctional facilities. Despite the need for treatment options, only about a third of state prisoners and a sixth of jail inmates who need mental health treatment report receiving it while incarcerated.

More communities are now attempting to keep the people with mental illness out of the criminal justice system by using specialized police- or court-based diversion programs. The Affordable Care Act presents a unique opportunity to get more people into care for the mental health issues, and hopefully stem the tide of incarceration. As awareness grows about the problem of incarcerating people with mental illness, communities will need to once again address the need to expand local resources for treating mental illness.

(Contributed by Anisha Lewis)


Dumont, D., Brockmann, B., Dickman, S., Alexander, N. & Rich, Josiah. (2012). Public Health and the Epidemic of Incarceration. Annual Review of Public Health,33, 325-339.

James, D.J. & Glaze, L.E. (2006). Mental Health Problems of Prison and Jail Inmates. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.

Mumola, C., and M. Noonan. (2008). Deaths in Custody Statistical Tables. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.

Platania, J., Varna Garis, A., & Cerullo, M. (2015). Community and Stakeholder Perceptions of the Rhode Island Criminal Justice System’s Interactions with Persons with Mental Illness.

The research articles included below are intended to provide tools for general readers as well as researchers and students who are interested in learning more about Incarceration and Mental Health. The list is neither comprehensive nor exhaustive, but is intended to help a reader dive deeper into the subject matter at hand. We will be updating articles on a monthly basis.

Measuring suicidality using the personality assessment inventory: a convergent validity study with federal inmates
Patry MW, Magaletta PR. Assessment. 2015 Feb.
“Although numerous studies have examined the psychometric properties and clinical utility of the Personality Assessment Inventory in correctional contexts, only two studies to date have specifically focused on suicide ideation. This article examines the convergent validity of the Suicide Ideation Scale and the Suicide Potential Index on the Personality Assessment Inventory in a large, nontreatment sample of male and female federal inmates (N = 1,120). The data indicated robust validity support for both the Suicide Ideation Scale and Suicide Potential Index, which were each correlated with a broad group of validity indices representing multiple assessment modalities. Recommendations for future research to build upon these findings through replication and extension are made.”

Comorbid antisocial and substance misuse proclivity and mental health service utilization by female inmates: Testing the worst of both worlds hypothesis with the PAI
Walters GD, Magaletta PR. Psychol Serv. 2015 Feb.
“The primary purpose of this study was to establish whether female inmates with comorbid proclivity for antisocial behavior and substance misuse, as measured by the Personality Assessment Inventory (PAI; Morey, 2007), use more mental health-related services than female inmates with either antisocial or substance misuse proclivity alone. A second purpose was to determine whether the effect of comorbid antisocial and substance misuse proclivity on mental health service utilization is cumulative or interactive. In a survey of 421 female federal prison inmates, it was noted that proclivity for both antisocial behavior and substance misuse was associated with significantly greater subsequent use of mental health services in female inmates than either proclivity alone, even after preexisting mental health diagnoses and treatment were controlled. In addition, the effect was additive rather than interactive. These findings provide further support for the “worst of both worlds” hypothesis, which holds that comorbid antisocial and substance involvement/proclivity portend poorer future outcomes than either antisocial or substance involvement/proclivity alone. The implications of these results for development of a comprehensive training model that provides mental health professionals with the skills to properly screen and effectively treat female inmates are discussed, along with the need to clarify the theory behind the “worst of both worlds” hypothesis.”

Serious mental illness, criminal risk, parole supervision, and recidivism: Testing of conditional effects
Matejkowski J, Ostermann M. Law Hum Behav. 2015 Feb.
“Adults with serious mental illness (SMI) who are released from prison tend to recidivate more quickly and at higher rates than similarly situated adults who do not have SMI. The current study examined whether this relationship with recidivism is mediated by criminal risk level and whether parole supervision can ameliorate the effects of SMI on recidivism. Findings indicate that SMI did exhibit a significant indirect effect with recidivism when considering its relationship with actuarially assessed risk. However, this indirect effect was not conditioned by whether the individual was released to parole; specifically release status did not moderate the relationship between risk and recidivism. The direct effects of SMI on recidivism were found to be conditioned upon release status. Specifically, we found no relationship between SMI and recidivism for parolees and a negative relationship between SMI and recidivism among nonparolees. Findings indicate a need for paroling authorities to find more effective ways of reducing criminal risk, which can decrease subsequent recidivism, among the individuals they supervise.”

Disciplinary Responses to Misconduct Among Female Prison Inmates With Mental Illness, Substance Use Disorders, and Co-Occuring Disorders
Houser K, Belenko S. Psychiatr Rehabil J. 2015 Feb 9.
“Objective: Most female inmates have mental health, substance use, or co-occurring disorders (CODs), which can create greater difficulty adjusting to incarceration and higher rates of prison misconduct. The response of prison officials to institutional misbehaviors has important implications for female inmates’ experiences while incarcerated, their likelihood of parole, and the clinical course of their condition. This article examined whether disciplinary actions are more severe for women with CODs.
Method: Data were provided by the Pennsylvania Department of Corrections for all female state prison inmates incarcerated between January 1, 2007, and July 30, 2009 (N = 2,279). The final sample of 211 women included those who had committed a minor misconduct during their incarceration. Disorder categories were created based on intake assessments, and multivariate models were estimated to determine the effect of disorder category on whether the prison imposed a severe or minor disciplinary response to the misconduct.
Results: The odds of receiving severe disciplinary responses to minor misconduct was significantly greater for women with CODs than those with the singular disorders of mental illness or substance abuse disorders, or those with no disorders.
Conclusions and Implications for Practice: Findings suggest correctional institutions are responding in a punitive manner to the symptomatic manifestations of CODs in female inmates. These findings suggest the importance of screening instruments in correctional settings that assess for the presence of dual disorders. In addition, correctional administrators must implement training protocols for correctional officers and staff on the complexity of CODs and the ability to identify behavioral and emotional symptoms associated with this vulnerable subset of the offender population.”

Mental Health and Substance Abuse Service Engagement by Men and Women During Community Reentry Following Incarceration
Begun AL, Early TJ, Hodge A. Adm Policy Ment Health. 2015 Feb 8.
“Individuals reentering the community following incarceration are at high risk for experiencing mental health and substance use problems. This longitudinal study explores patterns and barriers for engaging treatment services during early reentry. Seventy-five men and 62 women in jail, prison, or community based correctional facilities (CBCFs) participated in pre- and post-release interviews. Findings indicate that services were engaged at a lower-than-needed rate and barriers were greater for individuals leaving jails compared to prison or CBCF. Exploratory factor analysis of the barriers instrument is presented. Implications for extending service access to this population are discussed, as are future directions for research.”