The United States has the highest incarceration rate in the world, and it has been documented that at one time or another over 20 million people have been incarcerated. Individuals with mental illness represent two to four times of the national average rate in jail and prison settings. Individuals with severe mental illness (SMI) represent more than ten times the average rate of people in jails or prisons. These statistics are higher than individuals with severe mental illness that are currently in state hospitals (Al-Rousan, Rubenstein, Sieleni, Deol, & Wallace, 2017).
Of individuals that are currently incarcerated, 48% are diagnosed with mental illness, and 29% have an SMI, whereas 26% have some form of addiction. These statistics rise when reviewing statistics on females. Of females that have been incarcerated 60% are diagnosed with a mental illness. Similar trends are witnessed in multiple countries. (Al-Rousan, Rubenstein, Sieleni, Deol, & Wallace, 2017; Ibishi, Musliu, Hundozi & Citaku 2015; Kumar, Viswanath, Sebestian, Holla, Konduru, Chandrashekar & Math, 2014). In Kosovo and India over 70% of individuals in inpatient psychiatric facilities were diagnosed with a SMI diagnosis of psychosis. Other prevalent diagnoses included substance abuse and personality disorders. A multi country literature review of 24 countries similarly showed increased rates of psychiatric diagnoses, substance abuse, and personality disorders (Fazel & Seewald 2012).
There have been multiple plausible explanations of the rise of incarceration of individuals with mental illness including: reduction in psychiatric beds, laws aimed at protecting the public which has resulted in increased incarceration of individuals with mental illness for minor offenses, and a rise in SMI individuals in low and middle income countries due to limited resources to provide mental health services, amongst other factors (Fazel & Seewald, 2012). This trend also indicates increased incarceration of individuals with mental illness for minor offenses and highlights an opportunity for the jails and prisons to provide comprehensive mental health services (de Tribolet-Hardy, & Habermeyer, 2016).
The burden of mental illness and economic costs are well documented in various countries as recent trends indicate a rise in incarceration of individuals with mental illness and suggest a need for specialized services to treat this population. In addition to the need to provide specialized services a related issue is providing training to involved stakeholders that work with this population, and the need for specialized training and identification of rehabilitation services to improve success and integration in the community, reduce recidivism rates, and increase public safety.
In a study conducted by Sarteschi (2013), incarcerated individuals with mental illness have a constitutional right to receive basic mental health services, however this right is not being met. Individuals with mental illness were frequently being deprived of their right for mental health and medical services due to prisons operating at twice their capacity. This resulted in a release of over 33,000 inmates in California in 2011. The trends towards increased incarceration of individuals with mental illness continues to rise throughout the years. In California, due to a lack of programs, and services, shortages of beds at the state hospitals, individuals with severe mental illness, or those declared to be “incompetent” end up spending extended periods of time in jails as they wait to go the state hospitals/other agencies that have been identified as having the ability to help individuals to be “restored to sanity”. After individuals go through this process they must return to the jail, then wait for more extended time to attend their mental health court date, which many accepted as a so called “lesser charge”. However, they then are returned to jail and wait again until there is a bed available for a program. As a result of their mental illness and agreeing to abide by the terms of the mental health/drug court they spend significantly longer periods of time incarcerated. This is due to a multitude of factors including: the lack of availability of resources, lack of compliance with treatment, limited housing options, lack of support systems, public perception of safety, lack of coordination between systems, and lack of funding.
Individuals that are in low income and middle-income countries that have been remanded or are in pre-trial also face increased incarceration times. The poverty levels of the countries and incarceration of individuals, lack of resources for the criminal and legal system, and lack of ability to afford legal representation, increase incarceration times in these contexts (Lancet, 2019). Lack of education and training about mental health, particularly those that have been incarcerated, stigma of mental health, lack of access to services, and lack of coordination and communication between stakeholders decrease prognosis for incarcerated individuals with mental illness. In addition, vague mental health policies, lack of resources, lack of implementation of services and laws, decrease and worsen prognosis for incarcerated individuals with mental illness.
Factors that could improve the success rate and reduce recidivism of individuals with severe mental illness is to have the ability to provide comprehensive mental health services in jail and prison settings. Providing these services in the jail settings requires coordination with correctional officers, leadership in jails, medical personnel, adequate staffing, training, and working as multidisciplinary teams within the jail settings. An increase in services would necessitate involvement of the buy in of multiple stakeholders including law enforcement, legal system, healthcare policies, criminal system, and most importantly political and financial support.
The World Health Organization (WHO) reports the increased cost of the burden of mental health disorders and addiction. They state that up to 35% of individuals from high income countries do not receive the care they need. In low income and middle-income countries these statistics increase to 75% of the population. Individuals that have mental illness and are incarcerated are vulnerable groups that are stigmatized by various contexts. Funding for services are often governed by public interest and politics.
Countries have different standards and services in the treatment of forensic individuals, treatment, and laws and resources governing the needs of those that have mental illness. In Europe there is no standard protocol for the provision of forensic services for individuals with mental illness. The needs of forensic patients and individuals that are mentally incarcerated in other countries and the development of forensic psychiatry are in its infancy. In Kosovo forensic psychiatry and its importance is in its infancy (Salize, Lavikainen, Seppanen, & Gjocaj, 2014). In 2013, there were approximately 11 beds that were available for individuals that had mental illness, in a three-person unit, in a psychiatric hospital, a trend that was criticized along with the committee on torture. In addition, prior to 2004, individual’s mental health diagnosis was not taken into consideration when evaluating crimes. In 2005 the Kosovo rehab centre for torture victims (KRCT) noted that 28% of the population had significant mental illness and about 65% of the population had traumatic experiences during the war. However, there is not data on individuals with mental illness that are incarcerated in Kosovo.
Forensic psychiatry and implementing the mental health needs of incarcerated individuals is imperative in national policies. Due to the high burden of cost in prison systems, on societies, in health disparities, in discrimination, and on the public safety it is imperative that countries evaluate their laws, policies, structures, resources, funding, and assess politics and public perceptions of mental health stigma. Comprehensive services involving all stakeholders and including prevention, education, recidivism services, and need for advocacy are imperative when addressing the forensic and mental health needs of individuals with mental illness that have been incarcerated. Proper rehabilitative and mental health services could be beneficial to the individual, society, family, community, and the country and is a needed program. Implementing forensic psychiatry services has much benefit to countries on multiple levels including: reducing economic costs, reducing impacts on families, decreasing recidivism, improving health, reducing disparities, decreasing the prison and jail population, increasing opportunities for individuals to participate and contribute to society, preserve families, decrease impact on families, and assist countries in meeting the United nations sustainable development goals.
References
Al-Rousan, T., Rubenstein, L., Sieleni, B., Deol, H., & Wallace, R. B. (2017). Inside the nation’s largest mental health institution: A prevalence study in a state prison system. BMC public health, 17(1), 342.
de Tribolet-Hardy, F., & Habermeyer, E. (2016). Schizophrenic patients between general and forensic psychiatry. Frontiers in public health, 4, 135.
Fazel, S., & Seewald, K. (2012). Severe mental illness in 33 588 prisoners worldwide: systematic review and meta-regression analysis. The British Journal of Psychiatry, 200(5), 364-373.
Ibishi, N. F., Musliu, N. R., Hundozi, Z., & Citaku, K. (2015). Prevalence of the hospitalisation of mentally ill offenders in the Forensic Unit of the Clinic of Psychiatry in Pristina over a three-year period and long-term strategy implications for the management of the Forensic Mental Health System Service. Medicine, Science and the Law, 55(3), 201-207.
Kumar, D., Viswanath, B., Sebestian, A., Holla, B., Konduru, R., Chandrashekar, C. R., & Math, S. B. (2014). Profile of male forensic psychiatric inpatients in South India. International journal of social psychiatry, 60(1), 55-62.
Salize, H. J., Lavikainen, J., Seppänen, A., & Gjocaj, M. (2014). Developing forensic mental healthcare in Kosovo. Frontiers in public health, 2, 26.Sarteschi, C. M. (2013). Mentally ill offenders involved with the US criminal justice system: A synthesis. Sage open, 3(3), 2158244013497029.