There’s a grim joke among correctional officers across Pennsylvania: Prisons are no longer lock-ups for America’s worst offenders; they’re asylums for the mentally ill.
Based on an analysis of data from county and state prisons, PennLive estimates that nearly a third of Pennsylvania’s 87,756 inmates had a mental illness on an average day last year. Of those inmates, PennLive estimates, about a third of them had a “serious mental illness” – defined as the most chronic and debilitating of mental disorders, like schizophrenia and bipolar disorder.
Both those rates are significantly higher than the rate among Pennsylvanians outside of prison.
It begs the question: Why are so many of the state’s mentally ill being locked up?
Pennsylvania isn’t the only state to have significantly high numbers of mentally ill people behind bars. Multiple studies have found disproportionately high rates in correctional facilities across the country.
Keith Humphreys, a professor of psychiatry at Stanford University, said the trend goes back to the 1960s.
Through much of the early 20th century, Humphreys said, a large number of America’s seriously mentally ill were held in state psychiatric hospitals.
In the 1960s, however, due to growing concerns about abuses within these facilities and the ethics of confining people for the entirety of their lives, the country began a massive push to close state hospitals and move patients into the community. The hope was that they could live happier and more productive lives with the help of caseworkers and newly developed psychotropic drugs.
Between 1955 and today, America’s total state hospital population fell from 558,000 to 43,000 – a decrease of more than 90 percent.
Pennsylvania embraced that campaign, known as deinstitutionalization, as much as any other state. Since 1955, the Commonwealth has closed more than 10 state hospitals and cut its average daily patient population from 41,000 to 1,500 – a decrease of 96 percent.
While the plan to treat former patients in the community might have been well-intentioned, Humphreys said, there was a key problem: Many states didn’t invest enough money in case management and other community programs to meet the needs of former patients and those who would’ve been treated.
“So what happened is that people were kind of left to themselves,” Humphreys said. “And then some of them started ending up being homeless or winding up in the criminal justice system.”
Humphreys said deinstitutionalization had certainly vastly improved the quality of life for some people, particularly those with intellectual disabilities, but its failures were felt across the country to this day.
“And that’s why if you go to any American prison – and I’ve been in many of them – you find a very large number of people with mental illnesses or addictions or both,” he said.
A More Nuanced Explanation
While underinvestment might have been one the biggest reasons for the failure of deinstitutionalization in the United States, Humphreys added, there are several other factors at play, too.
Over the past 50 years, other wealthy nations closed many of their psychiatric hospitals but, as far as Humphreys is aware, they haven’t experienced the same degree of homeless and incarceration among their mentally ill populations as the United States.
One of the reasons, Humphreys said, is that the criminal justice system in the United States is typically more punitive than other wealthy countries. Humphrey said that mandatory minimum sentences and severe restrictions on parole and probation have led the U.S. to have the highest per capita prison population in the world, increasing the possibility that seriously mentally ill people are imprisoned.
In addition, Humphreys said, the United States’ unusually open access to firearms means that seriously mentally ill people are more likely to commit violent crimes that will lead to a prison sentence. By comparison, Europe has far more stringent gun regulations and significantly lower rates of violent crime.
But, Humphreys said, the nature of the nation’s health care system eclipses both of those reasons for the failure of de-institutionalization in the United States.
Unlike nearly all of its wealthy peers, the U.S. has an insurance-based health care system that doesn’t offer universal coverage to its citizens. While President Barack Obama’s 2009 health care overhaul had greatly improved coverage rates in recent years, the system’s underlying flaws remained.
Inherently, Humphreys said, an insurance-based system like ours will leave a disproportionately high numbers of mentally ill people without coverage.
“Because they have less wherewithal to figure out how to negotiate the system,” Humphreys said. “They’re less likely to have a job. They’re less likely to do whatever the expectations are of a society that says ‘you must do X, Y and Z’ in order to earn health insurance.”
By comparison, Humphreys said, mentally ill people are “in the club” from birth in Britain’s government-run health care system and face virtually no upfront costs for treatment or medication because the system is largely funded through taxes.
That means that people who need mental health services are more likely to get them and are less likely to have a psychiatric crisis that leads them to living on the streets or getting in trouble with police.
But not everyone believes that there is a disproportionate number of mentally ill people in Pennsylvania’s correctional system.
Lynn Keltz, executive director of Pennsylvania Mental Health Consumers’ Association, a group that represents people with mental illnesses, is deeply skeptical.
Keltz, an ardent supporter of the closure of state hospitals, said that even if PennLive’s figures on mental illness in the correctional system in 2014 are correct, she believes there’s no historical research to prove that they’ve grown over time.
“I don’t think anybody ever did a study 50 years ago, 25 years ago, to determine how many people in prison-type environments had mental-health needs,” she said. “So I think it’s a little difficult to say now that your numbers are increasing.”
Without that evidence, Keltz maintains, it’s impossible to say that the closure of state hospitals has led to an increase of seriously mentally ill inmates into the correctional system in Pennsylvania.
Dennis Marion, deputy secretary for the state Office of Mental Health and Substance Abuse Service, is also skeptical that the closures of Pennsylvania’s state hospitals have led to higher rates of incarceration among the state’s mentally ill.
Marion pointed to a study published by Allegheny County this year that looked at the impact of the closure of Mayview State Hospital, near Pittsburgh, in 2008.
“If you look at that, very few of the seriously mentally ill folks who came out of that hospital found their way in the justice system,” he said.
But academics, corrections officials, and mental health care professionals interviewed by PennLive dispute those arguments.
A National Problem
Humphreys, the professor of psychiatry from Stanford University, said it was difficult to not see a connection between the closure of state hospitals across the U.S. and the high proportions of mentally ill people in its correctional system today.
While he said he agreed with Keltz’s argument that there was relatively little historic research on the changing rate of prevalence of mental illness in the correctional system, intuitively, he said, the proportion of the American population that was formerly treated in state hospitals had to go somewhere.
“Almost all of those places have closed or downsized, so we have to explain where all their residents went,” he said. “Unless we assume they all got better, they had to go somewhere else and it was usually prison.”
There is some evidence in Pennsylvania to support Humphreys’ assertion. While historical data is limited, Department of Corrections data in the state prison system shows a gradual increase in the prevalence of mental illness and serious mental illness since record keeping began in 1999.
John Wetzel, secretary of the Department of Corrections, said that those increases are partly due to better diagnosis of mental health issues within the state prison system, but also due to an influx of mentally ill inmates.
“So it’s a combination of things,” he said. “We’re getting more mentally ill offenders and we’re getting better at diagnosing and recognizing things that, 10 years ago, we may have thought was behavioral.”
For their part, more than a dozen county prison officials and prison mental health workers interviewed by PennLive also believed that the proportion of mentally ill inmates had increased over the past few decades in Pennsylvania, driven largely by the closure of state hospitals.
Ed Sweeney, director of corrections for Lehigh County, said he saw a direct impact from the closure of Allentown State Hospital in 2010 on his prison.
“Without question,” he said. “There has been a significant increase in the number of mentally ill inmates being incarcerated.”
Sweeney, like many of those interviewed by PennLive, said he didn’t believe that Pennsylvania needed to go back to the 1950s when roughly 40,000 Pennsylvanians were held in state hospitals. He believed the majority of seriously mentally ill people could lead normal lives in the community with the right help and medication.
But he said, Pennsylvania now had the worst of both worlds: It doesn’t have enough state hospital beds for those mentally ill people who genuinely need long-term treatment and it doesn’t have a community mental health care system that could meet the needs of those who don’t need inpatient care.
“And they just can’t take it,” Sweeney said.
“There’s not adequate services to take care of these people.”
Daniel Simmons-Ritchie, a writer for PennLive, is a 2014-2015 John Jay/Langeloth Justice and Health Reporting Fellow. This is an abridged version of part 1 of a series published by the Harrisburg Patriot-News/Penn Live, as part of his fellowship project. The series, which began this week, examines the treatment of the mentally ill. For the full version and other stories in the series, please click HERE. He welcomes comments from readers.