Out of Sight, Out of Mind; Psychiatry Behind Bars

Steven K. Hoge, MD

Director, Division of Forensic Psychiatry, Bellevue Hospital Center, Clinical Professor, New York University School of Medicine

This interview was conducted by Peter Cook, on July 28, 2006.

In the 1950s there were 500,000 institutionalized mentally ill in the United States. Now the number is roughly 30,000. Unfortunately, deinstitutionalization, which took off in the early 1970s, is not the product of improving mental health—we’ve just decided to put our mentally ill people in a different sort of institution: prison. According to Dr. Steven Hoge, Clinical Professor at NYU School of Medicine and Director of the Division of Forensic Psychiatry, at Bellevue Hospital, there are roughly 1 million mentally ill people in the correctional system in the US at any one time. The mental health services available to this population are almost wholly inadequate, and Dr. Hoge believes that needs to change.

Incarceration Rates

“In America, 700 out of every 100,000 people are incarcerated,” Dr. Hoge says. “For most industrialized nations—and in America before the 1970s—the number is much closer to 100 per 100,000. Even Russia has only 500 or so incarcerated people per 100,000. As a society we have a policy, whether articulated or not, of punishment, and the mentally ill are suffering because of this.” Rates of serious mental illness in jails and prisons are in the neighborhood of 10%–15%. Rates of schizophrenia and bipolar are at 7% and 6% respectively, a much greater prevalence for both than that found in the general population.

A Difficult Patient Population

How are all these mentally ill people ending up in jails? And what can be done to keep them out? “It’s a complex problem,” Dr. Hoge admits. “It would be nice to think that if states just devoted more time and money to treating the mentally ill, less of them would commit crimes and go to jail. However, the evidence doesn’t support this. There was a fortuitous legal experiment in Massachusetts, where, for some time, half of the state sunk twice as much money into treatment of the mentally ill as the other half of the state. The rates of incarceration of mentally ill people remained exactly the same.” Dr. Hoge’s take on this is that the people who tend to end up in jails and prisons aren’t representative of the normal mentally ill population. Half to two thirds of incarcerated mentally ill people are substance abusers. As many as two thirds of them, according to studies, may have antisocial personality disorder comorbid with another, often serious, mental illness, and the homelessness rate is 20%–30%. “These are all markers of a difficult patient population to treat,” Dr. Hoge says. “Not only can they be treatment refractory, but many psychiatrists are understandably uncomfortable working with patients with a history of violence. Aside from fear, there are also liability issues involved. Finally, many of these people do not seek out treatment, and often go out of their way to avoid it.”

Treatment in Correctional Facilities

The numbers on treatment rates of the incarcerated mentally ill are disheartening. 22% of drug and alcohol users are treated and 57% of the mentally ill receive any kind of treatment according to a study by the federal Bureau of Justice. Further, 84% of jails report that fewer than 10% of their inmates receive treatment, and over 50% of jails (not prisons) won’t provide psychiatric medications to their inmates. There are also very few crisis intervention programs in place. “The quality and availability of treatment in correctional settings is not good,” Dr. Hoge says. “There’s inadequate funding, little training, and, often, though obviously not always, the health professionals attracted to these settings aren’t the best. To make matters worse, there’s no privacy. To get treatment you have to self-identify in front of your peers, and that marks you out as an easy target.”

Re-entry

Often, things get no better for the mentally ill on their being released from prison. “By law,” Dr. Hoge explains, “supplemental security income (SSI) and social security disability (SSDI) benefits are suspended on release from prison, which means no Medicaid. A violent history can get you excluded forever from section 8 housing, and drug-related felons have a life-time ban on foodstamps. Someone being released from prison may be hundreds of miles from their home, with no way to get back. 80% of jails have no discharge planning. Released inmates are not well prepared to be reintegrated into the community, and we’re not giving them very much support. This all contributes to the astronomical recidivism rates in this population.” Dr. Hoge cites one study following mentally ill felons released from state prison. Within the first year, only 25% received cash assistance, 5% received drug and alcohol services, and only 1 out of 6 was the recipient of mental health services.

Solutions

“We need specialized programs to address this patient population,” Dr. Hoge says. “We need programs that are geared to spanning the correctional and mental health systems and mental health professionals who are committed to this population. These patients have a propensity toward violence, and community providers have to worry about liability. We need clinicians who have sophisticated risk-assessment skills, and who are comfortable using coercive measures to enforce treatment when necessary.”

Ambitious programs of the sort Dr. Hoge believes necessary have begun to crop up. In California, for example, the Board of Corrections funded a research project in which counties received a lump sum to devote toward the end of providing better psychiatric treatment and reducing recidivism. “The results, as far as treatment goes, were exceptional. The patients in those counties had better clinical outcomes and reduced likelihood of alcohol problems and homelessness. However, the recidivism rates dropped, on average, only a couple of percentage points. We’re making progress, but more innovative solutions need to be examined, and a greater commitment needs to be made to treating this population.”

Disclosure: Dr. Hoge reports no affiliations with or financial interests in any organization that may pose a conflict of interest.