There are ten times as many mentally ill prisoners as there are patients of mental hospitals in the United States today. 

Over a century and a half ago, reform advocates like Dorothea Dix campaigned for prison reform, urging lawmakers to house the mentally ill in hospitals rather than in prisons. 

"The confinement of the criminal and of the insane in the same building is subversive of that good order and discipline which should be observed in every well-regulated prison," wrote Dix in 1843 in a report to the Massachusetts legislature. 

The efforts undertaken by Dix and other like-minded reformers were successful: from around 1870 to 1970, most of the United States’ mentally ill population was housed in hospitals rather than in prisons. According to a report released by the Treatment Advocacy Center (TAC) in 2014, “All of this began to change with the emptying of the state mental hospitals beginning in the 1960s. Widely referred to as deinstitutionalization, this was probably the most well-meaning but poorly planned medical-social policy of twentieth-century America.” 

How did we get here? 

It seems almost incomprehensible that so many people with serious mental illnesses reside in prisons instead of receiving treatment, considering reformers made great strides in improving this situation over a century and a half ago. Granted, mental hospitals in the late 19th and early 20th century were often badly run and critically flawed, but rather than pushing for reform of these hospitals, many politicians lobbied for them to close their doors, switching instead to a community-based system for treating the mentally ill. 

TAC’s website attributes this mid-20th century shift to the development of the first successful antipsychotic medication in 1955 and the adoption of Medicare and Medicaid in the 1960s. The Community Mental Health Act, signed into law by President John F. Kennedy in 1963, also played a pivotal role in transitioning care of the mentally ill from hospitals to "community mental health centers." 

A study titled conducted by the Three Strikes Project at Stanford Law School had this to say of deinstitutionalization:

"Although deinstitutionalization was originally understood as a humane way to offer more suitable services to the mentally ill in community-based settings, some politicians seized upon it as a way to save money by shutting down institutions without providing any meaningful treatment alternatives. This callousness has created a one-way road to prison for massive numbers of impaired individuals and the inhumane warehousing of thousands of mentally ill people."

The Stanford Law School study, which focused primarily on California, reported that the mentally ill population of California prisons has nearly doubled since 1999. According to the study, around 45 percent of California’s prison population is mentally ill, a number that’s mirrored in American society at large.

Harold Pollack of The Washington Post argues that deinstitutionalization is often overly simplified and unfairly maligned.  

“On the whole, deinstitutionalization improved the lives of millions of Americans living with intellectual and developmental disabilities (I/DD) — albeit with many exceptions. These policies allowed people to live with proper support, on a human scale, within their own communities,” Pollack wrote. 

While deinstitutionalization may indeed have changed the lives of those with less serious mental illness for the better, its impact on the American prison system is difficult to ignore. Many of the individuals with serious mental illness who find themselves facing prison time would better benefit from treatment than incarceration. Yet the scarcity of mental hospitals and the tendency of judges to sentence the mentally ill more harshly means that the mentally ill who come into contact with the criminal justice system often pay a very steep price for the failings of the mental health care system in the United States.

"From police departments and prisons to courthouses and jails, the care of those who are mentally ill weighs heaviest on law enforcement authorities, many of whom readily acknowledge that they lack both resources and expertise to deal with the crushing responsibility," a USA Today report from July 2014 said. 

What are the consequences of incarcerating the mentally ill?

The consequences of prisons overflowing with the mentally ill are many and varied. According to the Stanford study and the TAC's report, they include increased suicides in prisons, longer sentences, higher rates of recidivism, more instances of solitary confinement, larger costs to taxpayers, and greater likelihood of prisoners being abused. 

Mentally ill prisoners also often face longer sentences. According to the TAC’s report, the average stay for mentally ill individuals in Riker’s Island prison in New York is 173 days longer than the average stay of non-mentally ill individuals. It’s less likely that those with serious mental illnesses will be able to post bail or get reduced sentences due to good behavior than it is for inmates not suffering from mental illnesses. 

Mental illnesses often worsen in prison, especially with lack of suitable treatment, solitary confinement, and abuse at the hands of other prisoners. According to the TAC’s report, “mentally ill prisoners who refuse to take medication are especially likely to end up in solitary confinement, both because they are so disruptive and sometimes for their own protection.”

And with a lack of suitable treatment upon release from prison, recidivism rates among mentally ill prisoners in the United States stand at almost 50 percent. Thus, taxpayers also pay more for mentally ill prisoners due to longer and more frequent incarceration, in addition to the cost of medicine for these inmates. 

What can be done?

The TAC’s report includes the following recommendations for public officials: “Reform mental illness treatment laws and practices, reform jail and prison treatment laws, implement and promote jail diversion programs (i.e. mental health courts), use court-ordered outpatient treatment, encourage cost studies, establish careful intake screening, institute mandatory release planning and provide appropriate mental illness treatment.” 

NAMI, the National Alliance on Mental Illness, echoes many of these same sentiments on their website, noting the organization’s support for retaining the “insanity defense,” and establishing mental health courts. 

The justice and dignity that should be the purview of all Americans is often overlooked when it comes to our incredibly overcrowded prisons - out of sight, out of mind.

"Perhaps the most alarming aspect of the present situation," write the authors of the TAC report, "is that such numbers (of prisoners with mental illnesses) no longer elicit much professional or public reaction."