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1. There are a large number of individuals suffering from serious and persistent mental illness in jails and prisons, including a significant number with dual diagnosis (co-occurring mental illness and substance use disorder). Estimates of the prevalence of serious mental illness in this population range from 7 to 20 percent, meaning that there are between 140,000 and 400,000 individuals suffering from serious mental illness, with or without substance use disorder, behind bars. These figures do not include the significant number who suffer from other potentially disabling Axis I disorders such as serious anxiety disorders, including PTSD; non-psychotic mood disorders; impulse control disorders, often related to neurological deficits; cognitive impairment disorders; and affective dysregulation disorders; or the large number having substance use disorder as the only diagnosis.

While scientific advances have made treatment of serious mental illness increasingly effective, society has failed to make access to mental health services a reality for a large segment of the population. Lack of access to effective community treatment means that many individuals remain untreated, and become incarcerated either as a direct result of symptomatic behavior or because psychiatric hospitalization is not available. In addition, the vastly increased use of incarceration as society’s primary response to drug abuse means that there has been a dramatic increase in individuals with a dual diagnosis of mental illness and substance use disorder behind bars.

2. Conditions in jails and prisons exacerbate mental illness. Confinement, overcrowding, and idleness due to lack of rehabilitation programs all increase the likelihood of decompensation. Because of vulnerability to other inmates, or inability to comply with regulations, mentally ill inmates are frequently housed in protective or punitive segregation, where the isolation and enforced idleness lead to further deterioration in their condition. Mentally ill inmates are disproportionately sent to "supermaximum security units", where isolation and sensory deprivation make decompensation the rule. It is not surprising that the rate of suicide in prisons is twice that in the general population. In jails the rate is 9 times higher.

3. At the same time that the number of incarcerated mentally ill and dually diagnosed individuals has increased dramatically, along with the average length of sentences, opportunities for treatment and rehabilitation have decreased. Correctional mental health services are, in general, entirely inadequate. Correctional psychiatrists do the best job they can under the circumstances, but because of lack of funding they are responsible for too many seriously disturbed inmates to be able to provide adequate treatment, and psychiatric treatment and rehabilitation programs are sorely lacking in correctional settings. Exceptional model programs exist, but they are not available to the large majority of mentally ill inmates who are in urgent need of services. Society is incarcerating more mentally ill and dually diagnosed individuals for longer times, with fewer opportunities for treatment and rehabilitation. 

4. There is little or no continuity of care between correctional and community mental health and substance abuse services. As a rule there is no communication with community providers at the time of incarceration, and individuals whose condition may have deteriorated in prison are released directly to the community with no transition planning. This is true even for inmates who have been housed in supermaximum security units until the day of their release. Upon release their decompensated mental state, combined with unavailability of housing, jobs and community mental health and dual diagnosis treatment, puts these individuals at risk for homelessness, psychiatric hospitalization, and re-incarceration.

To address the serious problems of the mentally ill behind bars, we must:

1. Address the lack of access to community mental health and dual diagnosis services, in order to improve early diagnosis and treatment of individuals suffering from serious mental illnesses and dual diagnosis who are at risk for committing crimes if left untreated.

2. Create alternatives to incarceration for as many non-violent mentally ill offenders as  possible, including the large number of dually diagnosed offenders. Alternatives to incarceration should include quality mental health, dual diagnosis and substance use treatment programs, with adequate access for all who require these services. Special priority should be given to youthful offenders, who should be diverted into non- correctional settings where their mental health and substance use problems and their educational and vocational needs can be addressed. Commitment and sentencing laws should be explored with a view to providing options for conditional release at appropriate stages of a term of incarceration.

Diversion to alternative programs would allow mentally ill offenders to receive appropriate treatment in therapeutic settings; decrease overcrowding in correctional settings; lessen recidivism; and be cost-effective compared to incarceration in jails and prisons.

3.  Improve jail and prison conditions that have negative effects on the mental health of inmates. This includes:

• reducing overcrowding;

• providing educational and rehabilitation programs, to decrease idleness, frustration and violence in the general population;

• supporting programs of spiritual practice, conflict resolution, and other non-clinical approaches which promote personal growth and development;

• requiring mental health assessments of inmates before being transferred to punitive or protective segregation, or to supermaximum control units, with reassessment at regular intervals while in such units, and removal from segregation of all inmates showing exacerbation of serious mental illness;

• reversing the trend toward housing an increasing proportion of the prison population in supermaximum security units.

4. Improve availability and quality of correctional mental health and dual diagnosis programs. This will require:

• joint treatment planning with community providers to allow continuity of care on entering a correctional facility;

• adequate psychopharmacology, psychotherapy, dual diagnosis and psychiatric rehabilitation services for all inmates in need;

• rigorous and comprehensive suicide prevention programs;

• comprehensive health and mental health care for inmates with HIV/AIDS.

5. Establish vigorous programs designed to reintegrate inmates suffering from serious mental illness and dual diagnosis into the community following release, including:

• links to community providers to allow transitional treatment planning and follow-up;

• Ano-reject" policy by community providers for individuals with a history of incarceration;

• case management services prior to and following release, with programmatic links between pre- and post-release providers to assure continuity of care for each individual;

• available and affordable housing, including supportive housing programs which do not discriminate against individuals with forensic histories who are homeless.

6.  Create oversight bodies to prevent human rights abuses; to guarantee adequate health, mental health and dual diagnosis services for all inmates; and to ensure that correctional services meet appropriate standards for mental health and dual diagnosis services to inmates.

7. Advocate for these changes by:

• educating state legislatures and the public concerning the enhancement of public safety and the savings in public funds that would result from these recommendations;

• creating alliances with governmental (SAMSHA, NIC, NIJ), professional (APA, AACAP, American Psychological Association, NASW, ASAP), advocacy (NAMI, Amnesty International) and correctional organizations to advocate for these recommendations and to take other actions to improve the condition of mentally ill and dually diagnosed individuals in correctional settings;

• developing task forces including community and correctional psychiatrists, policy-makers from corrections, social welfare and education, and representatives of all other stakeholders, to address the problems of mentally ill and dually diagnosed inmates. 

• using the lobbying power of organized psychiatry and our allies both nationally and in the states to combat the trend toward harsher sentences, racial disparities in sentencing and the criminalization of substance use problems and homelessness.