Shame on Government

Following President Kennedy’s signing of the 1963 Community Mental Health Centers Act, state hospitals discharged patients with major psychiatric illnesses into our communities. Mental health centers were underfunded from the outset. Inadequate funding has caused existing centers to restrict their care to only the most seriously mentally ill. This story is well known. I call it the homeless story.

Legal rulings limiting involuntary commitment and requiring informed consent from patients before they could receive medications for their psychoses have contributed to the problem. The homeless story has become a jail story. The number of mentally ill people in U.S. jails and prisons grew to 283,000 in 1999 as the number of patients in state and county mental hospitals declined from 600,000 in 1950 to 72,000 in 1994.

Contrary to popular belief, mentally ill inmates are only slightly more likely to have committed violent crimes than inmates with no identified mental illness. In fact, people with severe mental illness are three times more likely to be victims of violent crime. Twenty percent of inmates with psychiatric illness were homeless during the year before their incarceration. More than 75 percent of mentally ill inmates have been sentenced to prison, jail, or probation at least once prior to their current sentence.

A recent Little Hoover Commission study in California revealed that about 1.5 million residents went without needed mental health treatment last year. Prevention and intervention services were practically nonexistent. The jail population included 30,000 inmates in need of psychiatric care, many of whom could have avoided incarceration if they had access to appropriate mental health services. More than 5 million Californians, about 22 percent of the population, experience a psychiatric illness each year. About 57 percent of homeless people are mentally ill. Nearly 16 percent of state inmates are severely mentally ill.

The commission found that although California spends $2 billion a year on community mental health programs, the criminal justice system spends $1.8 billion more as a safety net for the failing mental health system. The L.A. county jail, often referred to as the largest mental hospital in the United States, spends more than $16 million a year, including $5 million on psychotropic drugs alone, to treat 2,300 inmates with psychiatric illnesses. The Correctional Services Division chief opined that the county could provide more cost-effective community-based care to the mentally ill for $1,500 to $3,500 a year in comparison with the $26,800 it costs to jail them.

Stories appear daily in our newspapers pointing out these and other problems. In Oklahoma researchers are examining whether there is a correlation between the growing number of suicides and the downsizing of the state mental hospital. In Minneapolis police fatally shot three delusional people in the previous year. In Colorado the state was sued for failure to implement a judicial order mandating improved care for the chronically mentally ill. While incarcerated at Rikers Island in New York, inmates with mental illness receive psychiatric care and medications. When released, they are dropped off at a bus stop in Queens with nothing more than a subway card. In contrast to psychiatric facilities, jails are not required to provide a discharge plan. It comes as no surprise that jails have become revolving doors. A Soros Foundation study referred to jails as “Hospitals of Last Resort.”

A few states have innovative programs like that in Massachusetts in which the state contracts with the University of Massachusetts Medical School for the treatment of prisoners with psychiatric illnesses. Only 8 percent of those who were involved in treatment have been rearrested for crimes compared with rearrest rates of up to 50 percent among all freed prisoners.

Some states recognize that waiting for a person with a psychiatric illness to become dangerous or incapacitated is too little, too late, and can have dire consequences. Prevention, early intervention, adequate resources, and police training to help them recognize people with psychiatric illnesses are essential. When state governments fail to pass meaningful mental illness legislation, the shame continues. ▪