Why send mentally ill to prison?

Since 2000, Maine’s prison population has increased by 20 percent. Maine led the nation in 2002 with an increase in its prison population of 11.5 percent. In contrast, the number of inmates nationwide under state jurisdiction increased by only 1.2 percent and many states saw decreases in their prison populations.

Maine has the fifth lowest crime rate in the country and ranks third from the bottom in violent crimes. How do we reconcile our rapidly rising rate of incarceration with the fact that in the same period of time crime in Maine went down by .6 percent? (BDN, Oct. 30)

The community mental health movement that began in the 1960s resulted in many state mental hospitals downsizing or closing with the expectation that patients’ mental health needs could be met within their local communities. Statistics show an inverse relationship between declining rates of institutionalizing of the mentally ill and the increase in incarceration rates. The country’s prison system, in marked contrast to the mental health system, has quadrupled over the past 20 years.

As noted by Human Rights Watch, prisons have become the nation’s default mental health system. It is estimated that one in five prisoners is seriously mentally ill and that up to 5 percent are psychotic at any given moment. The rate of mental illness among female inmates is even higher, ranging from 22 to 29 percent.

It has become increasingly difficult to commit the chronically mentally ill to long-term psychiatric facilities. Generally, commitment requires that a person pose a danger to himself or others. In addition, there are now few facilities that provide anything beyond short-term care for the mentally ill. Many of the people who once resided in state hospitals are now homeless or living in shelters. The community mental health system has not lived up to its promise.

Furthermore, those who receive care in a community mental health facility often fall through the cracks. For instance, they may fail to keep appointments or discontinue the medications, which have stabilized them, without conferring with their psychiatrists. When they relapse, they may end up in the criminal justice system even though their crimes were committed when they were hallucinating, manic or delusional. If deemed competent to stand trial and criminally responsible, they are then treated like any other criminal defendant unless their mental illness is determined to have been a mitigating factor, in which case it might have bearing on the length of their sentence.

What becomes of the mentally ill once they are incarcerated? Many of them have difficulty controlling their behavior and following regulations. They may become targets of aggression or harassment from other inmates or they may become disruptive or violence. Mentally ill inmates are put in solitary confinement, disproportionately to other inmates. Once there, they may regress, become self-abusive or psychotic. Nationwide, mental health care for inmates is inadequate. Maine is no exception. We used to have one psychiatrist who covered almost 2,000 inmates in five correctional facilities across the state. For almost six months we have had none other than a locum tenans psychiatrist who recently filled in for one month.

The cost to the state of incarcerating the mentally ill is considerable. The base rate nationwide for an average prisoner is $22,000 a year. If one adds the cost of psychiatric care and medication, the cost ranges between $30,000 to $50,000. In contrast, the same mentally ill individual could be cared for in the community for about $10,000 a year including food, shelter, housing, supervision and mental health treatment. Mentally ill inmates often serve longer sentences than others because of repeated infractions during incarceration, which extend their sentences. Inadequate psychiatric care in prison may render these inmates more difficult to treat once they return to the community.

The other major factor clogging our prison system is substance abuse, which continues to rise in Maine. Estimates suggest that almost 80 percent of inmates have substance abuse problems. Many of the mentally ill have substance abuse problems, as well, which may get them in trouble with the law. The MacArthur Study found that recently discharged patients from psychiatric hospitals were no more likely to engage in violence than community controls unless they began abusing substances. Many of these people could be treated in outpatient or residential substance abuse programs. Ironically, if they land in prison, substance abuse treatment is often sub-optimal.

The new Maine State Prison, which opened two years ago, anticipated a gradual filling of beds over 10 years. It is already operating close to capacity. Because of overflow conditions in jails, many inmates with short-term sentences are being sent to our prisons instead. Crowding contributes to violence, which is on the rise in our prisons. Staff shortages make it difficult to attend to individual needs of inmates and safety issues.

Where are we heading? What does it say of our country when 1:32 Americans in the year 2000 was either in jail, prison or on probation? No other country incarcerates people at the rate we do. The answer is not building more prisons but looking to the root causes of criminal behavior and finding funds to treat causes such as mental illness and substance abuse.

We need to improve mental health services within our jails and prisons. It is easy not to think about members of our society who are behind walls. However, most will return to society. We should invest in them while they are incarcerated by providing mental health services, literacy training, education, substance abuse treatment and vocational training so that they may return as better and productive citizens. Yet another measure would be to enact mandatory outpatient commitment for mentally ill and substance abusing offenders as has been done in other states such as Oregon.

On a positive note, the Women’s Center at the Maine Correctional Institute in Windham is a model program, which provides wraparound services to its residents in an atmosphere that is communal and rehabilitative. A one-year followup of discharged residents found a recidivism rate of only 5 percent. However, crime is rising rapidly in women, and this facility is not able to accommodate all of the women now housed within the Maine Department of Corrections.

Diane H. Schetky, M.D. is a forensic psychiatrist in Rockport who has worked in the past as staff psychiatrist at several correctional facilities in Maine. She is currently a hospice volunteer at the Maine State Prison.