Mental patients in prisons: punishment versus treatment?

One issue that has attracted the attention of our profession for decades is the struggle against political abuse of psychiatry, i.e. preserving political opponents or people otherwise breaking the law from being kept in mental hospitals under the pretext of mental illness. Investigations and efforts to monitor and prevent such violation included visits to mental hospitals and attempts to ensure that no person is being kept there for reasons other than his or her suffering from a mental disorder. The scope of such initiatives has been widely covered in the literature. The Hawaii and Madrid Declarations, which set guidelines and regulations to prevent abuse of our profession, have been a valuable product of this concern.

The other side of the coin, i.e. the incarceration of mental patients or their neglect in prisons, should not receive lesser attention and concern. Despite efforts over the last 30 years to promote diversion from jail for individuals with serious mental illness who have engaged in criminal behavior, few jail diversion programs have been adequately implemented. A sobering Guardian article on March 3, 2003 reports 300,000 mentally ill people to be held in US prisons. The US Bureau of Justice reports that an estimated 16% of the two million prisoners in the US are mentally ill, "often because there is nowhere else for them to go. So serious is the problem that one jail in Los Angeles has become in effect the biggest mental institution in the country". The situation has been exacerbated by the closure of many mental institutions: between 1982 and 2001, the numbers of public hospital beds available for the mentally ill decreased by 69% in the US. According to Oscar Morgan, a senior consultant at the National Mental Health Association (NMHA) and a former mental commissioner for the state of Maryland, this was a major issue for the prison service and "it is acknowledged now that many people in the prison system could, with proper treatment, be elsewhere".

The high numbers reported from the US are probably because of the transparency of the subject and its coverage in the media. The same phenomenon is to be expected in many other countries: a recent report form India revealed equally high figures of mental patients in prisons. In several countries mental patients are in prisons because they did not have the chance to be examined before being convicted of a crime. In many countries which adopted the deinstitutionalization policy, the community care system is not reliable and is lacking in both financial and trained human resources to be able to provide the necessary service for mental patients, which contributes to the increased number of mental patients in prisons. It is also noteworthy that many Ministries of Finance did not channel the budgets of closed mental hospitals into other forms of mental health care services.

One disorder that stands out in this respect is substance abuse, which has been reported to have a high association with violence. Illicit drug abuse requires access to the black market; from there the road of substance abusers frequently leads into prison rather than into substance abuse rehabilitation centers (1). Other symptoms/disorders showing various degrees of association with criminal behavior include delusions, organic brain disorder, major affective disorder and antisocial personality disorder. Investigations of representative samples of US prison inmates (2-5) and Canadian penitentiary inmates (6) have revealed higher prevalence rates of mental disorders, particularly of the major mental disorders such as schizophrenia and major affective disorders, within these facilities than in the general population. Most of the major mental disorders were present before the current period of incarceration (7).

Offenders in prison experienced more social maladjustment than offenders in drug addiction treatment, they were less preoccupied by their drug consumption and less motivated to change (8). If anything, this should call for a treatment environment that responds more to rehabilitative needs than to punitive ones. Implications of jail diversion services for mental health professionals include learning how to collaborate with law enforcement personnel, integrating mental health and substance abuse services into the criminal justice system despite segregated funding streams, and ensuring that clients who are intensively monitored are also provided with adequate treatment.

Some WPA member societies have expressed their concern regarding the incarceration of mental patients in prisons and especially in the US. The President of WPA brought these concerns to the attention of the WPA/APA leadership meeting in San Francisco in May 2003. Furthermore the President referred the issue to the WPA Review Committee, which promised a full report as how to best address this problem.

The presence of mental patients in prisons does not only deprive them of their right to proper treatment and care, but also leads to possible maltreatment and stigmatization. It is an ethical obligation to stop both. The UN resolution 1991 on the human rights of mental patients requires that they should be treated in adequate facilities, preserving their dignity. The Madrid Declaration states that mental patients should be treated by the least restrictive methods. Incarcerating mental patients is a violation of both.

As long as the budget of mental health is treated as the Cinderella of health services, mental patients will continue to be deprived of their right to be managed in mental health premises rather than in prisons and other incarcerating places.