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Post by Former NIMH Director Thomas Insel: A Misfortune Not a Crime

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Despite careful monitoring and daily insulin, many people with type I diabetes experience emergencies like diabetic coma that require hospital care. Imagine a dystopic world where this care was not given in hospitals but in jails alongside inmates convicted of violent crimes. Imagine that, for lack of hospital beds, people requiring longer-term care for often disabling diabetic complications had to be housed in state prisons, where medical care was not a priority and personal safety was not assured.

If you think this sounds like a far-fetched premise for an apocalyptic movie or health care parable, check out a new report from the Treatment Advocacy Center on the treatment of people with serious mental illness. According to this report, there are now 10 times more people with serious mental illness in state prisons (207,000) and county jails (149,000) than there are in state mental hospitals (35,000). The report includes a state-by-state assessment of treatment of people with mental illness in jails and prisons. In 44 of the 50 states, the largest single “mental institution” is a prison or jail. The Cook County Jail in Chicago, Shelby County Jail in Memphis, and Polk County Jail in Des Moines each hold more individuals with serious mental illness than do all the state mental hospitals combined in those states.

How can this be possible? In the 1830’s Dorothea Dix revolutionized the care of people with mental illness by taking them out of jails and caring for them in asylums, later known as state hospitals. In the last 50 years, we have reversed this trend, resulting in a 90 percent reduction in public hospital beds for people with serious mental illness. While this reversal came about as the result of good intentions, it has resulted in unintended consequences. Many, but not all, people with serious mental illness can be treated effectively with the less restrictive care offered in outpatient settings. Sometimes patients with serious mental illness, just as with other serious medical illnesses, require hospitalization. In the absence of available public or private hospital beds, there are few options. Some patients are housed in emergency room holding areas; some return home, where family and friends struggle to provide care; and some—at considerable risk to themselves—become homeless. For those who do not realize they are ill and therefore resist treatment, or those whose behavior may be disruptive or aggressive, jails and prisons have become the de facto mental hospitals. Of course, this new report begs the question of whether racial and ethnic minorities, young men, or poor people are more likely to end up in jails and prisons rather than a bona fide health care setting. Indeed, a 2012 report on a study of patients in the San Diego County public health system found that risk factors for incarceration among the mentally ill included being male and African American; being homeless doubled the risk. 1

As this new report demonstrates, those who run the jails and prisons did not sign up for this role, are not trained medically to provide appropriate care, and face legal restrictions in many areas when they attempt to provide treatment. And for the inmates who are acutely ill with hallucinations and paranoid delusions, the prison environment can hardly be an ideal setting for recovery. When I visited mentally ill inmates at the DC Jail a few years ago, they were kept in solitary confinement for 23 hours each day, many for months at a time. How can this be acceptable care for people with mental illness?

What should be done? Returning to the asylum system—which could be regarded as turning away from the goal of recovery—is not the answer. The new report suggests several remedies, including ensuring better treatment within the prison system, jail diversion programs, assisted outpatient treatment, and release planning. Surely our nation can do better than assigning the criminal justice system the responsibility for delivering care to the mentally ill. In an era of mental health parity and health care reform, how can we allow hundreds of thousands of people with a brain disorder to be treated in our justice system—if that can be called treatment—rather than our healthcare system? Abraham Lincoln, no stranger to serious mental illness, once lamented, “a tendency to melancholy… is a misfortune not a fault.” Our current system, if these new numbers are accurate, treats mental illness, for many, not as a misfortune but a crime, with little promise of recovery.


1 Hawthorne WB et al. Incarceration among adults who are in the public mental health system: rates, risk factors, and short-term outcomes. Psychiatr Serv. 2012 Jan;63(1):26-32. doi: 10.1176/