Severe mental illnesses, like schizophrenia and bipolar disorder, are brain diseases—biological conditions like heart disease or epilepsy. Yet in this country, the institutions most likely to be treating people with these illnesses are not hospitals, but rather jails and prisons.
According to a new report from the Treatment Advocacy Center (TAC), a nonprofit advocacy organization, the United States has fully returned to the 18th-century model of incarcerating the mentally ill in correctional institutions rather than treating them in health care facilities like any other sick people. In 2012, there were roughly 356,268 inmates with severe mental illnesses in prisons and jails, while only 35,000 people with the same diseases were in state psychiatric hospitals.
The numbers of incarcerated mentally ill have been growing, and TAC reports that their treatment in the corrections system is nothing less than abominable. Mentally ill inmates are more likely to become the victims of sexual assault and abuse. They're also overrepresented in solitary confinement, and they are much more likely than other prisoners to commit suicide.
Putting the mentally ill in jails instead of hospitals isn't saving the government any money. In Washington state, for instance, in 2009, the most seriously mentally ill inmates cost more than $100,000 a year to confine, compared with $30,000 for others. One reason for the disparity: According to the report, mentally ill people tend to stay in jail longer than other prisoners because they aren't likely to get bail and also because they are often chronic rule-breakers. For example, according to the report, in Florida's Orange County jail most inmates stay an average of 26 days, but mentally ill inmates are there for 51 days on average. Even worse is New York's Rikers Island jail, where last month a homeless, mentally ill veteran, who'd been arrested for sleeping on the roof of a public housing project, "basically baked to death" in his cell. The average stay for an inmate at Rikers is 42 days. Mentally ill inmates get stuck there for an average of 215 days.
The costs of housing mentally ill inmates don't include the eventual lawsuit payouts when prisons and jails fail to treat them, and they get killed, assaulted, or hurt themselves—which seems to be happening more frequently. Last year, Mother Jones chronicled the story of Andre Thomas, a schizophrenic man on Texas's death row who gouged out his eye while in prison, and then later gouged out the other one and ate it. His story, horrific as it is, isn't especially rare.
The TAC report has a laundry list of horror stories of self-mutilation by mentally ill inmates, many of whom were in jail for minor offenses. Take the story of Florida jail inmate, Mark Kuzara, who cut open his abdomen in 2007. After it was stapled back together, Kuzara took out the staples with his mouth and ate them. "Inmates gave Kuzara pen caps, bolts, and paper that he would shove into the open wound. Kuzara also made himself vomit up meals, throwing up into the open wound," the Lakeland Ledger reported.
For the report, researchers surveyed sheriffs, police chiefs, and other corrections officials about the shift of the mentally ill from hospitals to prisons. They describe a horrific and unmanageable job of managing hundreds of mentally ill inmates cycling in and out of jail, taking up space and also getting sicker because of the lack of proper medical care.
One Mississippi deputy at the Hinds County detention center described his facility: "They howl all night long. If you're not used to it, you end up crazy yourself." An inmate in the jail "tore up a damn padded cell that's indestructible, and he ate the cover of the damn padded cell. We took his clothes and gave him a paper suit to wear and he ate that. When they fed him food in a Styrofoam container, he ate that. We had his stomach pumped six times, and he's been operated on twice.”
The failure to treat the mentally ill properly in hospitals is directly related to recent violent crimes. Take the case of Virginia, where the largest mental institution is the largest state prison and the state's jails hold three times more people with serious mental illnesses than the state hospitals do. The problem is so bad that in 2011, a Virginia Beach sheriff offered to transfer part of his jail budget to the mental-health system to try to get some of the sick people out of his institution and into proper care. Last year, the son of Virginia state Sen. Creigh Deeds (D) stabbed his father before killing himself. Barely 24 hours earlier, he'd seen mental-health professionals under an emergency custody order due to his deteriorating mental state, but he was released because no hospital beds were available.
The obvious solution is to create more hospital beds for treating the mentally ill, but the TAC recognizes that in the current political climate, this isn't going to happen any time soon. So they've offered some sensible interim recommendations. Among them is allowing jails and prison staff to treat mentally ill people with medication against their will. It sounds awful and in the context of a prison, potentially a tool for abuse, and TAC's recommendation is that involuntary medication should be heavily regulated. But many of the sickest mentally ill jail inmates don't recognize that they're sick, and thus, they're unable to seek the help they need to get better. Forcing medication to help people get better seems like a more reasonable alternative to letting them gouge their eyes out.
Another more creative solution is to expand the use of Assisted Outpatient Treatment (AOT), a court-ordered outpatient treatment that keeps people out of jail in the first place. AOT allows the mentally ill to live in the community—so long as they stay on their meds. Violating the court order can result in a participant's being involuntarily committed to a hospital. The results in some states have been promising. A pilot project in Nevada County, California, cut jail time for mentally ill people in the program from 521 days to 17; a North Carolina study of people in AOT found a reduction in arrests from 45 percent to 12 percent. These programs seem a lot more sane, and cost-effective, than putting every homeless person hearing voices in jail.