The voices of Urban Institute's researchers and staff
April 7, 2015

The revolving door: mental illness, incarceration, inadequate care, and inadequate evidence

While the incarceration rate in New York has dropped in recent years, the proportion of mentally ill inmates in city jails has risen to nearly 40 percent. In an effort to take responsibility for these individuals, New York recently enacted a law that extends mental health services to more than 3,000 additional inmates discharged from correctional facilities annually who received mental health treatment at some point during the previous three years.

Prior to this law’s enactment, only 3,500 to 4,000 inmates with serious mental health problems were receiving discharge planning services upon release, including medication, enrollment in Medicaid, and initial clinic appointments. Thousands of others who had been stabilized while incarcerated were not eligible for these services, and New York lawmakers believe that this caused inmates to backslide upon release, feeding the cycle of arrest, incarceration, and release.

We recently released a study that takes this issue beyond New York, and provides a national portrait of mentally ill individuals involved in the criminal justice system. An estimated 56 percent of state prisoners, 45 percent of federal prisoners, and 64 percent of jail inmates suffer from a mental health problem. These individuals have a unique set of circumstances and needs; however, all too often, they cycle through the criminal justice system without the appropriate care to address their mental health.

Scope of the problem

Today, the largest US jails and prisons hold more people with mental illness and co-occurring substance use disorders than most inpatient psychiatric facilities. Prisoners suffering from mental illness are more likely to have experienced homelessness, prior incarceration, and substance abuse than those without mental illness. In turn, these factors common among offenders also predispose them to mental illness.

Unfortunately, many prisons and jails are not equipped to address the needs of this population. In a 2006 study by the Bureau of Justice Statistics, only one in three state prisoners and one in six jail inmates who suffered from a mental health problem reported having received mental health treatment since admission.

Clearly, laws that expand mental health treatment in prisons and jails are much needed. New York’s new law could even pave the way for other states to expand their correctional mental health services as well.

An expensive undertaking 

Our new report highlights the fact that mentally ill prisoners tend to have higher recidivism rates than those without mental health problems. This is concerning not only because it indicates that people who suffer from mental illness may have trouble establishing a self-sustaining and law-abiding life after release from prison, but also because it has a direct impact on economic and societal costs. On the economic side, these include criminal justice costs (such as those incurred by the police, courts, jails, parole, probation, and prisons). Societal costs include things like victimization and reduced educational or employment opportunities.

The inadequate treatment of mentally ill persons in the criminal justice system contributes to these costs. One common justification for not providing adequate mental health services to incarcerated individuals is that these services are expensive. But if treatment leads to tangible benefits that exceed the costs (such as employment or lower crime rates), that could be a pretty good deal for the government.

What is being done?  What needs to be done?

Our report includes significant findings on the effectiveness of various programs and practices that target mentally ill inmates both while incarcerated and when they return to communities.

The most promising programs we reviewed provided structured continuation of care from prison to the community setting, as well as multidisciplinary teams to help mentally ill ex-offenders adapt to life outside of prison without having to go back and forth between multiple different agencies to receive services. (For example, an effective multidisciplinary team might include a mental health case manager, a psychiatrist, a substance abuse counselor, a community corrections officer, and a residential housing manager.)

There is also great potential in the expansion of Medicaid eligibility and enrollment for this population. We expect positive results from the extension of coverage to millions of low-income people under the Affordable Care Act, many of whom may have been involved with the criminal justice system.

We also recommend expanding diversion programs like mental health courts in jurisdictions throughout the country. Existing research, including a rigorous study by our colleagues in the Justice Policy Center, shows that mental health courts could stem the tide of criminal justice involvement for mentally ill people and get them into treatment facilities instead of jails and prisons.

Finally, our report shows that the existing body of research on practices and costs associated with mental health in the criminal justice system is fragmented at best, and lacking in quantity and rigor. Even so, the data remain clear about one thing: individuals with mental illness are still largely overrepresented in the criminal justice system. With such high numbers, their care and treatment is not just a humanitarian concern; it is a critical economic issue with broad societal implications.  

As an organization, the Urban Institute does not take positions on issues. Experts are independent and empowered to share their evidence-based views and recommendations shaped by research.

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