By the 1880s, there were 75 psychiatric hospitals in the United States, and a survey estimated that less than 1% of prisoners had mental illness. For the next 90 years, it was widely accepted in the United States that people with mental illness belonged in hospitals rather than prisons.

Then it all came undone.

(Because of firewall issues, this link may not work. A PDF version of this article is attached.)

In this editorial in the current issue of the American Journal of Psychiatry, University of North Carolina’s Dr. David Rubinow considers the unintended consequences of de-institutionalization, the decades long push for the mentally ill to be moved out of hospitals and into the community – and often into the forensic system.

Dr. Rubinow surveys the situation:

  • “In 1955, approximately 560,000 patients occupied state hospital beds; today the number is approximately 35,000.”
  • “It is no mystery where the patients went: In 1880, 0.7% of U.S. prisoners had serious mental illness; in the 1970s, the rate was approximately 5%, and today it is likely more than 20% (an estimated total of almost 360,000 inmates).”
  • “In a rather astonishing yet woefully unsurprising statistic, Torrey et al. estimate that there are 10 times as many mentally ill persons in prisons than in state hospital beds.” !!

The following graph, from The Economist, illustrates the trend:

These numbers are, of course, American – but the trend is the same across the West. A Lancet review involving 23,000 inmates found that “typically about 1 in 7 prisoners in western countries have psychotic illnesses or major depression.” On a personal note, early in my career, I did some jail work and was amazed to find how many mentally ill people were behind bars, and so often for trivial crimes (failure to appear, etc.).

Drawing on the work of Dr. Torrey, the editorial suggests several policy changes.

1) create the conditions that will permit the appropriate treatment of prisoners with mental illness;

2) implement jail diversion programs;

3) promote the use of assisted outpatient treatment for at-risk individuals;

4) get the data – determine the real cost of incarcerating those with mental illness.

This is a big editorial in a big American journal. The policy implications, though, are very relevant north of the 49th parallel.

Reading of the Week. Every week I pick a reading — often an article or a paper — from the world of Psychiatry.