Inmate Health - Mental Illness In Prison

Beginning in the 1970s, there was a movement to de-institutionalize the mentally ill and reintegrate them into society. This widespread trend resulted in the closing of many large-scale mental hospitals and treatment centers. With fewer options open to them, the mentally ill more often came into contact with law enforcement authorities. Morris L. Thigpen, Director of the National Institute of Corrections, wrote in Effective Prison Mental Health Services: Guidelines to Expand and Improve Treatment (Washington, DC: National Institute of Corrections, May 2004): "Since the early 1990s, an increasing number of adults with mental illness have become involved with the criminal justice system. State and federal prisons, in particular, have undergone a dramatic transformation, housing a growing number of inmates with serious mental disorders. Complicating this situation is the high proportion of mentally ill inmates who have co-occurring substance use disorders."

According to the National Institute of Mental Health (NIMH), about 22.1% of the American public suffer from a diagnosable mental disorder. The U.S. prison population, at least as measured by looking at its largest component, the state prison population, experiences a prevalence of mental illness very much in line with that of the general population. Beck and Maruschak reported in Mental Health Treatment in State Prisons, 2000 (Bureau of Justice Statistics, July 2001) that the prevalence of mental illness, broadly defined, was between 22% and 24% in the prison population.

Effective Prison Mental Health Services reported in 2004 that, of state public and private prisons, 95% provided some sort of mental health services to their inmates, with 84% providing professional therapy or counseling. Most (78%) screened newly arrived inmates for mental problems.

Prisoner Characteristics

The most recent comprehensive survey of the prison population's mental health was issued in 1999 (Mental Health and Treatment of Inmates and Probationers, BJS, July 1999). It was based on the 1997 Survey of Inmates in State and Federal Correctional Facilities, the 1996 Survey of Inmates in Local Jails, and the 1995 Survey of Adults on Probation. Although the data are now aging, they bring into focus the differences between prison inmates with mental problems and those who do not have them.

TABLE 6.7
State and federal inmates known to be HIV-positive, 2000

	Total known to be HIV positivea			HIV/AIDS cases as a percent of total custody populationb
Jurisdiction	2002	2001	2000	2002	2001	2000
U.S. total
Reportedc	23,864	24,147	25,333	1.9%	1.9%	2.0%
Comparable reportingd	23,848	24,011	25,198
Federal	1,547	1,520	1,302	1.1%	1.2%	1.0%
State	22,317	22,627	24,031	2.0	2.0	2.2
Northeast	7,620	8,136	8,721	4.6%	4.9%	5.2%
Connecticut	666	604	593	3.6	3.5	3.6
Maine	f	15	11	f	0.9	0.7
Massachusetts	290	307	313	2.9	3.0	3.0
New Hampshire	16	17	23	0.6	0.7	1.0
New Jersey	756	804	771	3.2	3.4	3.2
New York	5,000	5,500	6,000	7.5	8.1	8.5
Pennsylvania	800	735	900	2.0	2.0	2.4
Rhode Island	86	148	90	2.5	4.4	2.6
Vermont	6	6	20	0.4	0.4	1.5
Midwest	2,133	2,135	2,252	1.0%	1.0%	1.1%
Illinois	570	593	619	1.3	1.3	1.4
Indiana	f	f	f	f	f	f
Iowa	33	27	27	0.4	0.3	0.3
Kansas	48	41	49	0.5	0.5	0.6
Michigan	591	584	585	1.2	1.2	1.2
Minnesota	37	33	42	0.5	0.5	0.7
Missouri	262	262	267	0.9	0.9	1.0
Nebraska	24	24	18	0.6	0.6	0.5
North Dakota	4	4	2	0.4	0.4	0.2
Ohio	417	398	478	1.0	0.9	1.1
South Dakota	6	5	4	0.2	0.2	0.2
Wisconsin	141	164	161	0.8	0.9	1.0
South	10,656	10,392	10,767	2.2%	2.2%	2.3%
Alabama	276	302	419	1.1	1.2	1.8
Arkansas	100	108	101	0.8	0.9	0.9
Delaware	128	143	127	1.9	2.1	1.9
District of Columbiae	f	f	126	f	f	3.3
Florida	2,848	2,602	2,640	3.8	3.6	3.7
Georgia	1,123	1,150	938	2.4	2.5	2.1
Kentucky	f	105	124	f	1.1	1.3
Louisiana	503	514	500	2.5	2.6	2.6
Maryland	967	830	998	4.0	3.5	4.3
Mississippi	224	234	230	1.9	2.0	2.1
North Carolina	602	573	588	1.8	1.8	1.9
Oklahoma	146	130	145	0.9	0.9	1.0
South Carolina	544	559	560	2.4	2.6	2.7
Tennessee	218	231	215	1.5	1.7	1.6
Texas	2,528	2,388	2,492	1.9	1.8	1.8
Virginia	425	507	550	1.4	1.7	1.9
West Virginia	24	16	14	0.7	0.5	0.5

TABLE 6.7
State and federal inmates known to be HIV-positive, 2000–02 [CONTINUED]
SOURCE: Laura M. Maruschak, "Table 1. Inmates in Custody of State or Federal Prison Authorities and Known to Be Positive for the Human Immunodeficiency Virus, 2000–2002," in HIV in Prisons and Jails, 2002, Bureau of Justice Statistics, December 2004, http://www.ojp.usdoj.gov/bjs/pub/pdf/hivpj02.pdf (accessed March 31, 2005)

	Total known to be HIV positivea			HIV/AIDS cases as a percent of total custody populationb
Jurisdiction	2002	2001	2000	2002	2001	2000
West	1,908	1,964	2,291	0.7%	0.8%	0.9%
Alaska	16	16	f	0.5	0.5	f
Arizona	130	122	110	0.4	0.4	0.4
California	1,181	1,305	1,638	0.7	0.8	1.0
Colorado	182	173	146	1.1	1.2	1.0
Hawaii	22	13	19	0.6	0.3	0.5
Idaho	18	14	14	0.4	0.4	0.3
Montana	8	11	11	0.4	0.6	0.7
Nevada	113	127	151	1.2	1.4	1.6
New Mexico	30	27	28	0.5	0.5	0.5
Oregon	42	30	41	0.4	0.3	0.4
Utah	58	34	37	1.4	0.8	0.9
Washington	101	88	90	0.6	0.6	0.6
Wyoming	7	4	6	0.6	0.4	0.5
aCounts published in previous reports have been revised.
bPercentages are based on custody counts, except for New Mexico. New Mexico's percentages are based on its year end jurisdiction count.
cExcludes inmates in jurisdictions that did not report data.
dExcludes data from Maine, Kentucky, and Alaska for all 3 years due to incomplete reporting.
eAt year end 2001 responsibility for housing District of Columbia sentenced felons was transferred to the Federal Bureau of Prisons.
fNot reported.

TABLE 6.8
Percent of custody population known to be HIV positive, 1998–2002
SOURCE: Laura M. Maruschak, "Percent of Custody Population Known to Be HIV Positive," in HIV in Prisons and Jails, 2002, Bureau of Justice Statistics, December 2004, http://www.ojp.usdoj.gov/bjs/pub/pdf/hivpj02.pdf (accessed April 1, 2005)

Year	State	Federal
1998	2.3%	1.0%
1999	2.3	0.9
2000	2.2	1.0
2001	2.0	1.2
2002	2.0	1.1

A higher percentage of women were identified as mentally ill than men in 1998: 23.6% in state prisons and 12.5% in federal prisons. This contrasts with men, of whom 15.8% (state) and 7% (federal) were mentally ill. Some 22.6% of whites in state prisons and 11.8% in federal facilities were mentally ill. Among African-American prisoners, the prevalence was lower, 13.5% (state) and 5.6% (federal). Hispanics had the lowest rates: 11% in state and 4.1% in federal facilities. (See Table 6.13.)

Guidelines for Treating the Mentally Ill in Prison

The National Commission on Correctional Health Care (http://www.ncchc.org/) has issued guidelines that prisons should follow to provide adequate mental health treatment to inmates:

TABLE 6.9
Percent of the general population and prison population with confirmed AIDS, 1995–2002
SOURCE: Laura M. Maruschak, "Percent of Population with Confirmed AIDS," in HIV in Prisons and Jails, 2002, Bureau of Justice Statistics, December 2004, http://www.ojp.usdoj.gov/bjs/pub/pdf/hivpj02.pdf (accessed April 1, 2005)

Year	U.S. general population	State and federal prisoners
1995	0.08%	0.51%
1996	0.09	0.54
1997	0.10	0.55
1998	0.11	0.53
1999	0.12	0.60
2000	0.13	0.53
2001	0.14	0.52
2002	0.14	0.48
Note: The percent of the general population with confirmed AIDS in each year may be overestimated due to delays in death reports.

• Inmates must be screened for mental health problems by a qualified health professional within two hours of admission.
• Inmates must be informed within twenty-four hours of arrival of the types of mental health services available and how to access them.
• Inmates must have a health appraisal within seven days of arrival that includes taking a history of any prior mental health problems, hospitalizations, psychotropic medications, suicide attempts, and alcohol and other drug abuse.

TABLE 6.10
HIV-positive prison inmates by gender, 1998–2002
SOURCE: Laura M. Maruschak, "HIV-Positive Prison Inmates by Gender, 1998–2002," in HIV in Prisons and Jails, 2002, Bureau of Justice Statistics, December 2004, http://www.ojp.usdoj.gov/bjs/pub/pdf/hivpj02.pdf (accessed April 1, 2005)

	State prison inmates
Year	Estimated number of HIV-positive inmates*	Percent HIV/AIDS in custody population
Male inmates
1998	22,045	2.2%
1999	22,175	2.2
2000	21,894	2.1
2001	20,415	1.9
2002	20,273	1.9
Female inmates
1998	2,552	3.8%
1999	2,402	3.5
2000	2,472	3.4
2001	2,212	3.1
2002	2,164	2.9
*To provide year-to-year comparisons, estimates were made for states not reporting a gender breakdown. For each state, estimates were made by applying the same percent breakdown by gender from the most recent year when data were provided.

• Inmates must receive a mental health evaluation within fourteen days of arrival that includes a complete mental health history and current mental status and screening for mental retardation and other developmental disabilities.
• Treatment plans must be created for inmates who are identified as having serious mental health needs and who are developmentally disabled.
• Inmates should be seen by a qualified professional within forty-eight hours of a request for nonemergency mental health services (seventy-two hours on a weekend).
• Prison procedures must address psychiatric emergencies and suicide attempts.
• Mental health treatment should occur in private (except for high security risks) and with respect for the offender's dignity and feelings.

Suicide in Prison

Broadly defined, mental illness is a leading cause of suicide in prison. According to Juvenile Suicide in Confinement: A National Survey (Washington, DC: National Center on Institutions and Alternatives, February 2004), there were 110 juvenile suicides in confinement between 1995 and 1999. These deaths occurred in training schools, detention centers, and residential treatment centers, among other correctional facilities. The study found that "a history of mental illness was found in 65.8% of the victims, with the vast majority (65.3%) suffering from depression at the time of their deaths."

Suicide among adult inmates in prison is also an unfortunately common occurrence. Prison Suicide: An Overview and Guide to Prevention (Washington, DC: National Institute of Corrections, June 1995) contains a report on a ten-year survey of prison suicides conducted by the National Center on Institutions and Alternatives (NCIA) from 1984 through 1993. This survey found that prisoners committed suicide at a much higher rate than does the general population. During the ten-year period, prison suicides occurred at a rate of twenty-one per 100,000 inmates per year, while suicides in jails occurred at the rate of 107 per 100,000 inmates. The rate of suicide in the general population during this period was 12.2 per 100,000. The study did find that prison suicide rates

TABLE 6.11
State and federal inmates known to be HIV-positive, by gender, yearend 2002

	Male HIV cases		Female HIV cases
Jurisdictiona	Number	Percent of population	Number	Percent of population
U.S. total
Estimatedb	21,704		2,280
Reported	20,728	1.9%	2,169	2.8%
Federal	1,431	1.1%	116	1.2%
State	19,297	1.9	2,053	3.0
Northeast	6,920	4.4%	700	8.1%
Connecticut	563	3.3	103	7.2
Maine	c	c	c	c
Massachusetts	249	2.7	41	5.9
New Hampshire	15	0.6	1	0.6
New Jersey	691	3.1	65	5.1
New York	4,590	7.2	410	13.6
Pennsylvania	738	2.0	62	3.5
Rhode Island	68	2.1	18	9.3
Vermont	6	0.5	0	0
Midwest	1,841	1.0%	151	1.2%
Illinois	520	1.3	50	2.0
Indiana	c	c	c	c
Iowa	29	0.4	4	0.6
Kansas	41	0.5	7	1.2
Michigan	544	1.1	47	2.1
Minnesota	37	0.6	0	0
Missouri	250	0.9	12	0.5
Nebraska	23	0.6	1	0.3
North Dakota	4	0.4	0	0
Ohio	388	1.0	29	1.0
South Dakota	5	0.2	1	0.4
Wisconsin	c	c	c	c
South	8,786	2.2%	1,044	3.5%
Alabama	252	1.1	24	1.5
Arkansas	89	0.8	11	1.4
Delaware	116	1.9	12	2.3
Florida	2,508	3.6	340	7.4
Georgia	1,023	2.3	100	3.2
Kentucky	c	c	c	c
Louisiana	472	2.5	31	3.0
Maryland	815	3.6	152	12.1
Mississippi	c	c	c	c
North Carolina	c	c	c	c
Oklahoma	138	1.0	8	0.5
South Carolina	502	2.4	42	2.6
Tennessee	194	1.5	24	2.1
Texas	2,261	1.8	267	2.7
Virginia	394	1.4	31	1.5
West Virginia	22	0.7	2	0.8

TABLE 6.11
State and federal inmates known to be HIV-positive, by gender, yearend 2002 [CONTINUED]
SOURCE: Laura M. Maruschak, "Table 2. Inmates in Custody of State and Federal Prison Authorities Known to Be Positive for the Human Immunodeficiency Virus, by Gender, Yearend 2002," in HIV in Prisons and Jails, 2002, Bureau of Justice Statistics, December 2004, http://www.ojp.usdoj.gov/bjs/pub/pdf/hivpj02.pdf (accessed April 1, 2005)

	Male HIV cases		Female HIV cases
Jurisdictiona	Number	Percent of population	Number	Percent of population
West	1,750	0.7%	158	0.9%
Alaska	14	0.5	2	0.8
Arizona	117	0.4	13	0.5
California	1,107	0.7	74	0.8
Colorado	156	1.1	26	1.7
Hawaii	21	0.6	1	0.2
Idaho	17	0.5	1	0.2
Montana	7	0.4	1	0.5
Nevada	98	1.1	15	4.2
New Mexico	27	0.5	3	0.6
Oregon	42	0.4	0	0
Utah	48	1.2	10	3.4
Washington	91	0.6	10	0.8
Wyoming	5	0.5	2	2.2
aAt yearend 2001 responsibility for housing District of Columbia sentenced felons was transferred to the Federal Bureau of Prisons.
bIncludes estimate of the number of inmates with HIV/AIDS by gender for Maine, Wisconsin, Kentucky, Mississippi, and North Carolina. Estimates were based on the most recent data available by gender.
cNot reported.

declined from 1985 through 1993. In 1995 state prisons reported 160 inmate suicides; the number in 2002 was 166. In federal prisons, the number for 2001 was eighteen suicides; in 2002 it was seventeen.

Methods of preventing suicide in prison have been advanced by several organizations. The American Correctional Association (ACA) has developed suicide prevention standards that are now used in many prisons across the country:

• A written policy and procedures to ensure that all special management inmates are directly observed at least every thirty minutes.
• More frequent observation for inmates who are violent or have a mental illness than for inmates who are not violent and do not have mental illness.
• Continual observation for actively suicidal inmates.
• A written suicide prevention and intervention program approved by a qualified medical or mental health professional.
• Training for all correctional staff in the suicide prevention and intervention program.
• Intake screening, identification, and supervision of inmates who may be prone to suicide.

TABLE 6.12
Jail inmates ever tested for HIV and results, by selected characteristics, 2002
SOURCE: Laura M. Maruschak, "Table 9. Jail Inmates Ever Tested for the Human Immunodeficiency Virus and Results, by Selected Characteristics, 2002," in HIV in Prisons and Jails, 2002, Bureau of Justice Statistics, December 2004, http://www.ojp.usdoj.gov/bjs/pub/pdf/hivpj02.pdf (accessed April 1, 2005)

	Tested inmates who reported results
Characteristic	Number	Percent HIV positive
All inmates	374,711	1.3%
Gender
Male	324,370	1.2%
Female	50,340	2.3
Race/Hispanic origin
White	136,069	0.8%
Male	113,671	0.6
Female	22,398	1.6
Black	163,219	1.2
Male	144,330	1.0
Female	18,889	3.0
Hispanic	55,938	2.9
Male	49,819	2.9
Female	6,120	2.9
Age
24 or younger	101,362	0.2%
25–34	126,607	1.1
35–44	103,566	2.1
45 or older	43,176	2.7
Marital status
Married	56,397	1.0%
Widowed/divorced	67,281	1.9
Separated	26,747	1.7
Never married	223,706	1.2
Education
Less than high school	143,272	1.6%
GED	90,300	1.3
High school or more	140,341	1.1
Note: Data are from the 2002 Survey of Inmates in Local Jails.