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Post by Former NIMH Director Thomas Insel: Turning the Corner, Not the Key, in Treatment of Serious Mental Illness

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There are several facts about mental illness in the United States that always seem to surprise those who are not directly involved:

  • Each year, there are nearly twice as many suicides (33,000) as homicides (18,000).1
  • The life expectancy for people with major mental illness is 56 years (the average life expectancy in the U.S. is 77.7 years).2
  • Mental disorders and substance abuse are the leading cause of disability in the United States and Canada.3

Statistics like these attest to the high morbidity and mortality of mental disorders and were the rationale for a new NIMH strategic plan in 2008.

To this list we can now add another statistic—according to the Treatment Advocacy Center (TAC), based on an analysis of data provided by the Substance Abuse & Mental Health Services Administration (SAMHSA), people with mental illness are three times more likely to be in the criminal justice system than hospitals. In some states, such as Nevada and Arizona, the ratio is closer to 10 times more people with mental illness in jails and prisons.

In part, this reflects a 90% decrease in the number of state hospital beds over the past half century while the general population and the numbers in this population with mental illness were increasing. In part, this reflects a true increase in the number of people with mental illness being sent to jails and prisons, due to broad policy changes. For example, mandatory sentencing requirements for drug crimes increased incarceration overall, but also increased incarceration of people with mental illness specifically, because people diagnosed with mental disorders are twice as likely to have co-occurring problems with substance abuse.4 Most of all, however, this statistic reveals a failure to provide alternatives in the mental health care system for people requiring hospitalization. The criminal justice system is not seeking out people with mental illness. Rather, in many places where there are no beds and no outpatient continuity of care program, “America’s jails and prisons have become our new mental hospitals,” as the TAC report says.

What can be done to address this problem? SAMHSA’s Community Support Programs Branch has been a leader in developing criminal justice diversion programs as well as re-entry strategies for non-violent offenders with serious mental illness. NIMH has collaborated with the Bureau of Justice Statistics over the past several years to document the unmet mental health needs in incarcerated populations. NIMH-funded studies are examining the effectiveness of special training to help police officers take appropriate action when responding to calls that involve people with mental illness, such as directing them to mental health care services.5 Other studies are identifying opportunities and challenges in implementing a program to facilitate community re-entry after incarceration, which may help reduce jail and prison recidivism.6 NIMH is designing an initiative to develop and test strategies for making effective mental health treatment available to people while incarcerated and upon re-entry to the community.

Two centuries ago, French physician Philippe Pinel spoke of “moral” treatment as opposed to the incarceration and enchainment of mentally ill people. Today, given all we know about these disorders, when people with mental illness are sent to jails and prisons rather than treated in the health care system, the error is even more egregious. One of the challenges we face in correcting this problem is the absence of an institution for longer-term, evidence-based care for people with severe mental illness. The advent of parity and health care reform may open a window of opportunity to create some new options for this population in need.

1 Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS):; accessed May 2010.

2 Heron MP, Hoyert DL, Murphy SL, Xu JQ, Kochanek KD, Tejada-Vera B. Deaths: Final data for 2006. National vital statistics reports; vol 57 no 14. Hyattsville, MD: National Center for Health Statistics. 2009.

3 The World Health Organization. The global burden of disease: 2004 update, Table A2: Burden of disease in DALYs by cause, sex and income group in WHO regions, estimates for 2004. Geneva, Switzerland: WHO, 2008.

4 Substance Abuse and Mental Health Services Administration. (2009). Results from the 2008 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-36, HHS Publication No. SMA 09-4434). Rockville, MD.

5 Watson AC, Ottati VC, Morabito M, Draine J, Kerr AN, Angell B. Outcomes of Police Contacts with Persons with Mental Illness: The impact of CIT. Adm Policy Ment Health. 2009 Aug 25. [Epub ahead of print] PubMed PMID: 19705277.

6 Draine J, Herman DB. Critical time intervention for reentry from prison for persons with mental illness. Psychiatr Serv. 2007 Dec;58(12):1577-81. PubMed PMID: 18048559.