Health Disparities Among the Mentally

Ill in the Criminal Justice System

Priscilla Dorogoff - Jannat Esmail - Christi ParsonsAndrew Sinclair - Arthur Smith

Problem Statement• Problem: There are too many inmates who are

mentally ill and who are not getting appropriate treatmento Happens at all stages of the criminal justice systemo Result of a severe lack of resources or alternativeso One policy will not fix problem

Assemble Evidence• 2012: Estimated there are 10x more mentally

ill in prisons than psychiatric hospitals • Strains the criminal justice system as a whole

• Unique case-processing requirements and treatment needs• Recidivism rates 2.4x higher than other inmates. 3.3x higher for

bipolar inmates

Assemble EvidenceConditions

• Longer average sentenceso In California, average sentence for burglary for mentally ill is 30%

longer• Stress of prison life worsens illness

o Solitary confinement commonly used due to lack of optionso Higher rates of sexual assault victimization and suicide.

• Only 1 in 3 state prisoners have received mental health treatment since incarceration

Assemble EvidenceDeinstitutionalization

• One of the primary causes is the lack of psychiatric facilities

• From 2005-2010: Number of psychiatric beds reduced by 14%

• Minimum number of psychiatric beds: 50 per 100,000o 2011: 19.44 per 100,000

• In 44 states, one prison or jail in the state is holding more individuals with a serious mental illness than the largest remaining psychiatric hospital

Assemble EvidencePrevious Policy

• Mental Health Courts• 2000: America’s Law Enforcement and Mental

Health Project Act• California Proposition 36

o 1700 nonviolent offenders, mentally ill offenders releases• Washington v. Harper

o Underutilized

• When Ohio increased psychiatric bed capacity, recidivism dropped to 27%o National Average: 50%o Ohio still considered to have a bed shortage

Alternatives to Incarceration of the Mentally Ill

• Reform the way the Mentally Ill are sentenced o Use more Mental Health Courts

• Provide more treatment while incarcerated • Continue treatment after incarceration • Status Quo- Do not reform current policies and

continue the punitive incarceration of the Mentally Ill

Modification of Current Incarceration

Policies• Allow mentally ill patients to use Mental Health

Courtso Specialized Court that combines community supervision with inpatient

or outpatient professional mental health treatment. • Where appropriate, provide a non-prison sentence

for any defendant charged with a nonviolent crime/ non-serious offense.o Preponderance of the evidence shows the crime was committed due to

the mental illness o The cost of such treatment is significantly less than the cost of

incarceration.

Provide Meaningful Treatment in Prison

• Judge orders the provision of meaningful mental health services as part of the terms of incarceration sentence

• Will have more oversight • New Mental Health Prison Oversight Court would

be established to provide initial sentencing recommendations to trial court judges who request the court’s input.

• Oversight Court could change treatment plan during term

Continued Treatment After Incarceration

• Prior to release, evaluate all mentally ill prisoners and determine their level of competence

• Refer inmates needing help to mental health centers that can continue care.

Status Quo No Change•  According to the American Psychiatric

Association, on any given day, between 2.3 and 3.9 percent of inmates in state prisons are estimated to have schizophrenia or other psychotic disorder; between 13.1 and 18.6 percent have major depression; and between 2.1 and 4.3 percent suffer from bipolar disorder. (Aufderheide, 2014). Study of Mental

Health Court in Oakland, California between the years of 2010-2013 (Proxmire , 2013).

Select the Criteria• Criteria measures outcomes/ consequences • Mental standards for evaluating the results of action• Introduces values and philosophy into the analysis• Most important- whether or not the projected outcome

will solve the policy problem

Evaluative Criteria• Efficiency- maximizes satisfaction and individual

happiness. o is the most important in cost-effectiveness and

benefit-cost analysis

Evaluative Criteria• Equity- maximizes equality, fairness,

and social justice

Recidivism Rates for Mentally Ill Inmates

• A person's relapse into criminal behavior • Measured by criminal acts that resulted in

rearrests, reconvictions or return to prison within three years of the prisoner’s release

Why are Recidivism Rates so High for Mentally Ill

Inmates?• When patients are moved out of large state mental

hospitals into community-based outpatient settings, treatment centers could not handle the large arrival of patients

• Many are homeless and suffer from substance abuse

Weighting Conflicting Evaluative Criteria

• The analyst imposes a solution• Our interest is underrepresented in government

and politics• The analyst understands this underrepresentation• Permitted to right the balance

Alternatives

Reform the way

mentally ill individuals

are screened

and treated in prisonProvide

meaningful

treatment in prison

Continue meaningful treatment

after prison

Criteria

Efficiency

Equity/Fairness &

Justice

Recidivism Rates

Alt 1: Reform How Mentally Ill are Screened and Treated

Efficiency

• Cost of screening and treatment is

less than incarceration

Equity

• Adequate screening will help the offender function better and be prepared to return back to the community. Less chance of suicide and violence.

Recidivism Rates

• Mentally ill inmates that are isolated from the general prison population will likely want to better themselves and not return to prison

Alt 2: Provide Meaningful Treatment in Prison

Efficiency

Early intervention leads to cost savings in both the prison system and health system.

Equity/Fairness & Justice

In prison treatment will provide inmates with a fair chance to recover. Treatment will also maximize an offender’s ability to “fit in” once released.

Recidivism Rates95% of prisoners return to the community. Providing mental health services in prisons will lead to a reduction in crime rates.

Alt 3: Continue Meaningful Treatment after Prison

• Providing these services will likely keep offenders from re-entering prison

• Mental health programs are less expensive than the cost of incarceration.

Efficiency

• The mentally ill confront challenges as they reintegrate into the community.

• Providing them with equitable support will help them reintegrate better.

Equity • Mentally ill inmates who received after prison treatment for up to a year were twice as likely to refrain from entering prison as those who did not receive treatment. Recidivism

Rates

Efficiency Equity/Justice

Recidivism Rates

Reform Mentally Ill Sentencing

Efficient Equitable Reduced incarcerati

onProvide Meaningful Treatment in Prison(Best Alt.)

Most Efficient

Provided the most Equity to

mentally ill

Showed a high

reduction in

recidivism rates

Continue Meaningful Treatment in Prison

Somewhat efficient

Equitable Reduced incarcerati

on

Criteria

Alte

rnat

ives

Treatment in Prison

Outcomes

71% reduction in number of days spent homeless

50% reduction of days spent in

jail 40% reduction in number of days spend in a mental

health facility

Tradeoffs

Determining who to treat

Managing inmate

behavior

Controlling the prison

environment and its affects

on mental health

Difficulty for inmate to adjust to

prison life

The Decision Maker • The Federal Bureau of Prisons (BOP)

• The Congress in regards to Medicaid

• Between 2004-2013 the BOP spent majority of funds on miscellaneous professional services, office furniture, social rehabilitation & fences and gates.

• Total annual budget of $6.820 billion.

The Congress• Increasing recidivism rates are associated with a

lack of access for the mentally ill.

• Medicaid expansion under the ACA needs to be implemented by all states.

• For individuals currently incarcerated Medicaid will finance inpatient services if provided by a licensed medical facility in the community.

The Result• Increased resources for those incarcerated.

• Rehabilitation for the mentally ill.

• The BOP must work together with Congress to push the decision makers

Our Story • The problem: A lack of resources and services are

resulting in offenders with mental illnesses receiving no treatment.

• Alternatives: Mental Health Courts, the mentally ill should receive different sentencing, and provide more treatment while incarcerated and after.

• Criteria: Efficiency (screening and treatment will save money), Equity (treatment in prison will provide inmates with a “fair” chance), reduction in recidivism rates.

Our Story • Projections: Less chance of being homeless,

reduction in days spent in prison, and a reduction in days spent in a mental health facility.

• Trade offs: managing inmate behavior, adjustment issues, trying to control the operation of prisons, and determining who is considered mentally ill.

• The 350,000 incarcerated mentally ill inmates need treatment and thus the policy changes need to begin.