Dr. Lamb, Dr. Weinberger, and Dr. Gross are affiliated with the Department of Psychiatry, Keck School of Medicine, University of Southern California, P.O. Box 86125, Los Angeles, CA 90086-0125 (e-mail: firstname.lastname@example.org). Dr. Marsh was with Jail Mental Health Services, Los Angeles County Department of Mental Health, at the time of the study and is now with the Olive View Urgent Community Services Project for the department.
There is much discussion in the literature about the very large numbers of persons with mental illness in our jails and prisons (1,2,3,4,5,6). Many mental health, law enforcement, and legal professionals are concerned that the criminal justice system has become a predominant disposition for large numbers of persons with severe mental illness who are in need of treatment (7,8,9,10,11). Various reasons have been cited for this phenomenon. They include the lack of access to adequate treatment for persons with mental illness in the community, deinstitutionalization and the limited availability of psychiatric hospital beds, the interactions between persons with severe mental illness and law enforcement personnel, and more formal and rigid criteria for civil commitment (12).
The nation's prisons and jails held over 2.1 million inmates as of June 30, 2004 (13). The latest methodologically sound estimates of the percentages of persons diagnosed as having severe mental illness (schizophrenia, schizoaffective disorder, bipolar disorder, and major depression) range from 10% to 19% of jail populations, 18% to 27% of state prison populations, and 16% to 21% of federal prison populations, as determined by the National Commission on Correctional Health Care (14). By using the lower percentages to avoid overstating this phenomenon, we estimate that as of June 30, 2004, the number of inmates with severe mental illness in jails (10%) was 71,399, in state prisons (18%) was 223,386, and in federal prisons (16%) was 27,099. Thus the total number of persons in jails and prisons diagnosed as having severe mental illness was at least 321,884.
With such a large number of this population incarcerated in the criminal justice system as opposed to being treated in the mental health system, it is important to have more detailed information about their psychiatric and criminal histories and status, what psychiatric services they used while incarcerated, and what challenges they might present in psychiatric treatment after release.
The purpose of this study was to explore these issues in detail in a population of persons with mental illness (particularly individuals with severe mental illness) who were detained in a large, urban county jail. This was a retrospective study of a random sample of male inmates who were identified as mentally ill and placed in the approximately 1,500-bed jail unit set aside for this population. We ascertained their demographic characteristics, diagnoses, psychiatric and legal histories, current psychiatric condition and treatment, and their legal dispositions.
All persons brought to the Los Angeles County Jail are processed through the Inmate Reception Center. The reception center is responsible for booking and assigning all inmates to housing in the jail system that is thought to be the most appropriate for them.
One of the housing options within the Los Angeles County Jail is the Twin Towers Correctional Facility. The facility holds approximately 1,500 men and is designated as the special housing unit for male jail inmates who are considered to be mentally ill. Although the facility also houses female inmates, they were already the subject of an ongoing study. Consequently, the jail authorities invited us to study the male inmates.
With trained sheriff's custody staff the reception center administers a 15-item medical-psychiatric questionnaire to all incoming inmates. If the inmates answer yes to any of the psychiatric questions or if they "appear odd in any way," they are referred to a mental health professional to determine whether they should be admitted to mental health housing. At the time of the study, the inmates designated as needing mental health housing were assigned in rotation to one of nine mental health areas in the Twin Towers Correctional Facility. The psychiatrists and other mental health professionals working in these areas were responsible for evaluating, treating, and developing discharge planning for their inmate-patients.
The mental health area used for this study thus received every ninth inmate from the reception center, regardless of level of acuity. The staff of the study area followed inmates throughout their stay at the Twin Towers facility, from acute to subacute status. Therefore, they were very familiar with the inmates and their course of treatment at the facility; this information was recorded in the inmates' charts.
All persons admitted to the study area, with the exception of those who were diagnosed as malingering, were eligible for selection as participants in this study. All diagnoses were based on DSM-IV criteria and were made by the individual's treating psychiatrist at the Twin Towers facility. The sample consisted of identifying every tenth inmate (excluding those diagnosed as malingering) who was admitted into the study area between March 2002 and August 2002; this process resulted in a total of 106 individuals. Thus this study was a representative sample of male inmates with mental illness admitted to the Twin Towers and involved a review of the inmates' records. Criminal history data could not be found for two inmates; consequently, they were dropped from the study, leaving a total sample of 104. The entire study sample had been released from the correctional facility at the time of data collection.
Data collected included the inmates' demographic characteristics and psychiatric (including diagnoses) and legal characteristics and history before and during the arrest associated with their incarceration. The presence or absence of severe mental illness (defined in this study as schizophrenia, schizoaffective disorder, bipolar disorder, and major depressive disorder with psychotic features) was determined by the individual's current psychiatric diagnosis in jail.
The inmates' treatment at Twin Towers and the court's disposition were charted in the jail psychiatric records. Additional sources of information for this study included inmates' past mental health treatment as obtained from the Los Angeles County Department of Mental Health's electronic records and arrests and convictions as found in the state's electronic Consolidated Criminal History Reporting System.
Approval to conduct this study was given by the Los Angeles County Department of Mental Health Human Subjects Research Committee, as well as by the Bureau of Criminal Information and Analysis of the State of California Department of Justice, which provided the criminal history records. The Los Angeles County Sheriff's Department also approved this study.
Table 1 presents the psychiatric diagnoses of the 104 persons in the study. Seventy-five percent had a severe mental illness, as previously defined.
Table 2 presents the demographic data for inmates who were identified as having a severe mental illness. Of note, 36% were homeless at the time of the current arrest.
Table 3 shows that 92% of the inmates with severe mental illness had a history of nonadherence to psychiatric medications that were prescribed for them in the community before the arrest for which they were being jailed. This information, found in the jail records, was obtained from collateral sources, such as family and mental health professionals who had treated them previously. In addition, 95% of the inmates with severe mental illness had prior arrests. Of these, 72% had been arrested previously for violent crimes against persons (at least one of the following: assault, armed robbery, rape, corporal abuse of a spouse or child, kidnapping, and attempted murder). Seventy-six percent were known to have a history of substance abuse. Moreover, 41% of those with severe mental illness had a history of incarceration in state prison, and with respect to the current offense, 24% were sent to state prison.
As shown in Table 4, there were three levels of jail housing for the inmates: the acute psychiatric inpatient unit within the jail, the lockdown area, and the general treatment area for inmates who were not believed to need acute inpatient care. The lockdown area is a highly staffed, highly structured area for people whom the mental health staff believe need acute psychiatric hospitalization. It was used only when there were no available beds in the acute inpatient unit and was not used for any other purpose. Persons with mental illness were sent to the lockdown area for the same criteria used for admission to the jail's acute inpatient unit. That is, as a result of their mental illness, they were judged to be a danger to self or others (or both) or were unable to use food, clothing, or shelter as provided by the sheriffs. Each person in this unit was checked at least once every 15 minutes and was often housed alone in a single cell for safety reasons.
Of the 78 inmates who had a severe mental illness, 32% required acute hospitalization in the jail inpatient unit and 44% were placed in the lockdown area for a part of their time in jail (for 72 hours or more). Thus 76% of those who had a diagnosis of severe mental illness required inpatient care or its equivalent during their incarceration for the current offense.
The discharge treatment plan was also noted for the inmates when possible. This information, however, is not included in the tables because 24 (31%) persons were sentenced to prison or committed to a forensic state hospital and nine (12%) were released unexpectedly from jail before a treatment plan could be formulated.
This study examined a sample of 104 men with mental illness who were arrested in a major, urban county and placed in a special housing unit in the jail for inmates with mental illness. We found that of the 78 inmates who had a severe mental illness, 59 (76%) required acute hospitalization or its equivalent for a part of their time in jail. Clearly, a large percentage of the study sample of male inmates with severe mental illness were receiving their acute psychiatric inpatient treatment in the criminal justice system and not in the mental health system. Other key findings were that of the male inmates diagnosed as severely mentally ill, 92% were known to be nonadherent to psychiatric medications before the current arrest, 95% had prior arrests, 72% had prior arrests for a violent offense against persons, and 76% were known to have a history of substance abuse.
We note that some of the male inmates with severe mental illness had committed serious crimes, both on the current arrest and in the past. Some also had lengthy criminal histories of drug possession, drug sales, and property and weapons charges; two-fifths also had a history of incarceration in state prison. Much attention has been paid in recent years to the increasing number of persons with severe mental illness in jails and prisons, and rightly so. The findings of this study, however, suggest that some may well be appropriate to be under the jurisdiction of the criminal justice system.
On the other hand, a number of male inmates with severe mental illness were arrested when it appeared that their offending conduct was due primarily to their illness. We learned the circumstances of the current offense when we reviewed the jail records, and it appeared that these persons should have been hospitalized instead of being taken to jail. The following two cases serve to illustrate this point. A person with psychotic symptoms and a previous diagnosis of schizophrenia was found taking lemons from the property of a private residence and throwing them at trees; he was arrested and charged with burglary. Another person with manic and paranoid symptoms and a previous diagnosis of schizoaffective disorder pummeled an inflatable advertising display of an animal, shouted that the animal was after him, and shoved the owner of the business but did not hurt him; he was arrested and charged with vandalism.
There are extremely difficult challenges in transferring persons with severe mental illness, such as those in our study, from the criminal justice system to the mental health system. For example, most inmates in our study needed acute inpatient hospitalization. This issue is compounded by evidence that these inmates might well present problems in intermediate and long-term treatment and management, as suggested by the large percentages of male inmates with severe mental illness who were known to be nonadherent to psychiatric medications before the current arrest, who had prior arrests in general as well as prior arrests for a violent offense against persons, and who were known to have a history of substance abuse. Given these characteristics, it was our clinical impression that most of these inmates with severe mental illness would present a major challenge in treatment in any setting. In this study, the jail would appear to have acquired the responsibility for many of those who are among the most difficult and expensive to treat.
Our review of the electronic criminal histories proved instructive. We also knew the circumstances of the current offense and often of prior offenses from the inmate's jail psychiatric record. Thus we were able to observe that a series of nonserious offenses committed by many persons with severe mental illness often resulted in a lengthy criminal history with no narrative included in the electronic records as to what really happened. These individuals may have appeared as habitual criminals when they came to the attention of law enforcement and their criminal histories were accessed. In reality, they were persons with serious mental illness who were not receiving adequate treatment, and they acted in an inappropriate and often aggressive manner when stressed.
An example from our study was a disorganized, homeless man with schizophrenia who was arrested repeatedly for various petty thefts, such as taking toys from a department store and aluminum foil from a convenience store to protect himself from imagined X rays. After a number of such episodes, he had a long list of arrests and convictions for theft. Consequently, when the police officer was called to the scene on the current matter for a similar offense and ran the individual's arrest history, the person may well have appeared to be a thief, rather than a person with severe mental illness, whom the police officer believed should be arrested instead of hospitalized. Thus this person with severe mental illness continues to be criminalized.
It should be emphasized that we are not advocating against arresting and incarcerating those individuals who commit serious crimes, even if they have a severe mental illness. An example from this study was a man with schizophrenia who was found by the police in possession of a loaded gun and threatening others. It may well be more appropriate for such an individual to be arrested, treated in the jail, and dealt with by the criminal court.
If we intend to successfully reverse the trend of the criminalization of persons with severe mental illness, diversion from the criminal justice system to the mental health system is only the first step (15,16). There must also be a very large increase in psychiatric treatment and rehabilitation resources in the mental health system to accommodate those persons with severe mental illness who are being diverted. In that we found a large percentage of the study sample had a history of being nonadherent to psychiatric medications, these resources, at least for those in this study, would need to include such measures as assertive community treatment, mental health courts, and assisted outpatient treatment. In addition, we must recruit and retain mental health professionals who can treat and manage a difficult population in the community (17).
There are some limitations of this study that support a cautioned approach for generalizing the findings beyond the study site. It was a retrospective analysis using a small sample. Inasmuch as this was a study of only men, the data and discussion cannot be generalized to women. In addition, the study site has been noted to house the largest number of persons with mental illness in the country (18), which may reflect a greater degree of criminalization than is found in other jurisdictions. The study was conducted in a large metropolitan area where mental health resources are often in short supply. This could influence law enforcement's tendency to arrest and detain persons with severe mental illness who might not be incarcerated in other communities. Finally, this study did not examine persons with severe mental illness who came to the attention of police and were directed to the mental health system rather than being arrested.
An important finding in this study was that 76% of male inmates with severe mental illness in a county jail were receiving their acute psychiatric inpatient treatment in the criminal justice system and not in the mental health system. With the large number of persons with severe mental illness being arrested, it is not surprising to find that jails have become one of the predominant settings for providing acute psychiatric inpatient treatment.
Further, the persons with severe mental illness in this study would present a major challenge in treatment in any setting and are among the most difficult to treat. If we intend to address the criminalization of persons with severe mental illness and overcome the challenges to their treatment, the resources of the mental health system need to be greatly expanded, with priority given to those who are, or who are in danger of becoming, subject to the jurisdiction of the criminal justice system.