Prison Mental Health in the United States of America and India: A Dual Perspective

Rachel Natasha Varadarajulu; Ananya Mahapatra

doi:10.4103/wsp.wsp_19_23

AWARD PAPER/ORATION

Year : 2023 | Volume : 5 | Issue : 1 | Page : 42-46

Prison Mental Health in the United States of America and India: A Dual Perspective

Rachel Natasha Varadarajulu¹, Ananya Mahapatra²
¹ Albert Einstein College of Medicine, New York, NY, USA
² Department of Psychiatry, Dr. Baba Saheb Ambedkar Hospital and Medical College, New Delhi, India

Date of Submission	21-Mar-2023
Date of Acceptance	22-Mar-2023
Date of Web Publication	26-Apr-2023

Correspondence Address:
Dr. Ananya Mahapatra
Department of Psychiatry, Dr. Baba Saheb Ambedkar Hospital and Medical College, New Delhi
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/wsp.wsp_19_23

Abstract

Approximately 40% of the incarcerated population in the world are reported to suffer from a mental health condition. People in correctional settings are subjected to multiple psychosocial adversities which negatively affect their mental health. Moreover, people with mental illness are at higher risk for abuse and exploitation within the criminal justice system. The prison populations of the United States (US) and India are among the highest, among both high-income and low-middle-income countries, respectively. In this article, we aim to describe the existing prison mental health services in the US and India and discuss their challenges.

Keywords: Correctional settings, mental health, prison, psychosocial stressors

How to cite this article:
Varadarajulu RN, Mahapatra A. Prison Mental Health in the United States of America and India: A Dual Perspective. World Soc Psychiatry 2023;5:42-6

How to cite this URL:
Varadarajulu RN, Mahapatra A. Prison Mental Health in the United States of America and India: A Dual Perspective. World Soc Psychiatry [serial online] 2023 [cited 2023 Jun 3];5:42-6. Available from: https://www.worldsocpsychiatry.org/text.asp?2023/5/1/42/374619

Introduction

There are over 11 million people incarcerated globally. Psychotic illnesses are 2–16 times higher and major depression is 2–6 times higher in them compared to the general population. Suicide is one of the major cause of death in prison and suicide rates are 3 times higher in male and 9 times higher in female prisoners when compared to the general population.^[1] Around 70% of the world's prison population are incarcerated in low-and-middle-income (LMIC) countries.^[2] At the same time, the United States (US) penal population of 1.6 million adults is one of the largest in the world, exceeded only by China.^[3] Incarceration results in psychosocial stress related to the loss of personal liberty, and resource-constrained correctional settings are further affected by a host of adverse social factors such as overcrowding, understaffing, poor sanitation, lack of access to safe drinking water and health services, and limited opportunities for educational and vocational rehabilitation.^[4] In this article, we aim to describe the prison mental health systems of a high-income country (US), and a LMIC (India), both of which have a significant incarcerated population. We aim to discuss their existing mental health services, their challenges, and future directions to overcome them.

Prison Population in the United States

The US Department of Justice has recorded that rate of imprisonment has more than quadrupled during the past four decades.^[4] The US rate of incarceration, with nearly 1 out of every 100 adults in prison or jail, is 5–10 times higher than the rates in Western Europe.^[5] Roughly, half of all incarcerated individuals are from smaller cities and rural communities. The number of women held in local jails and prisons has also grown over the past several decades.

Incarcerated individuals are particularly vulnerable, due to frequent history of trauma, unmet physical and mental health needs, and adverse childhood events. Furthermore, people of color, particularly black people, are incarcerated at higher rates than white people and racial disparities cause disproportionate economic, health, and social harm to communities of color.^[6]

Correlation between De-Institutionalization and Mass Incarceration

Lionel Penrose formulated the theory of transinstitutionalism in 1939 (also termed “Penrose's Law”), which postulates that a reduction in the state mental hospital population would result in an increase in the state prison population.^[7] The number of individuals admitted to long-term psychiatric facilities decreased significantly after the Community Mental Health Act was passed in 1963, which resulted in the deinstitutionalization of many state hospitals. Parsons et al. used the term “institutional recycling” to describe the pattern of mass confinement of individuals.^[8]

Prevalence of Mental Illness within Correctional Settings in the United States

Individuals with mental illness and substance use disorders are significantly overrepresented in American jails and prisons. The rate of mental disorders in the incarcerated population in 3–12 times higher than that of the general community, and the rate of severe mental illness in prisons is estimated to fall between 16% and 24%, compared to that of the general community, which falls between 3.9% and 5.0%.^[9] An investigation of 28 studies, done by Prins on the prevalence of mental illnesses in prisons identified estimates in the following ranges: major depression (9%–29%), bipolar disorder (5.5%–16.1%), panic disorder (5.5%), and schizophrenia (2%–6.5%).^[10]

Suicides in prisons and jails occur disproportionately more often among prisoners with mental illness. A study of 132 suicide attempters in the King County, Washington, jail system reported that 77% of them had a “chronic psychiatric problem,”^[11] and a study of 154 completed suicides in the California prison system reported that “73% had a history of mental health treatment.”^[12]

Mental Health Services in United States Prisons

Most people in the US with mental illness, including substance use disorders, do not receive treatment, and for many individuals, contact with the criminal justice system may represent the first occasion for any treatment services.^[13] Prisons are often the only places in the US where health care is guaranteed by law. Thus, correctional facilities in the US are widely held to be the largest provider of mental health services in the nation.

While all states require jails and prisons to have some form of mental health services available, the type of program offered varies from facility to facility. Despite legislature, American correctional systems have been criticized for failing to provide even minimally appropriate mental health services for prison inmates, one of the reasons for which is a rapid growth of incarceration rates.

In 44 of the 50 states and the District of Columbia, a prison or jail in that state holds more individuals with serious mental illness than the largest remaining state psychiatric hospital.^[14] While there is access to treatment for individuals with mental illness in correctional settings, they face many other challenges. They are more likely to have behavioral issues resulting in disciplinary action (such as being placed in segregated housing). Mentally ill prisoners are also more likely to remain in prison and jail for longer, since they are less likely to obtain bail and are more likely to break the rules, thus failing to get a reduction in their sentence for good behavior.

Another issue that arises in prisons is if a mentally ill inmate is found to be incompetent to stand trial. Often, these inmates languish in jail for a much longer period, awaiting a hospital bed, which often may exceed their sentence.^[15]

Future Directions

The ultimate solution to addressing the needs of mentally ill individuals is to have robust public health policies to ensure community treatment and integration. With the development of programs such as alternatives-to-incarceration courts, drug courts, and problem-solving courts, many individuals are now being court mandated to mental health treatment instead of being incarcerated for their offenses. This might help mitigate high-risk individuals from reoffending.

At the correctional level, more robust screening upon intake should be implemented to help identify individuals who would benefit from treatment early on. Housing mentally ill inmates with other individuals with mental illness might encourage them to seek treatment, and also prevent them from becoming targets of abuse and bullying.

Finally, reforms in community mental health treatment laws and practices might encourage mentally ill individuals to seek help before their arrest. Educating primary care providers, law enforcement officers, and teachers would also be an appropriate step to spread awareness of the signs of mental illness.

Prison Population in India

According to the latest National Crime Report Bureau's (NCRB) Prisons Statistics report, the total number of prisons in India has increased from 1306 in 2020 to 1319 in 2021.^[16] Around 554,034 inmates are lodged in various jails in the country as on December 31, 2021, of which around 70% are undertrials. In India, the nationwide occupancy of prisons exceeds 130%. The occupancy rate is close to 180% in some states such as Uttarakhand, Uttar Pradesh, and Delhi, which in turn undermines the ability of the prison system to meet the basic needs of prisoners and endangers their human rights. This makes the prison setting in India a risk factor for adverse mental health consequences and further increases the vulnerability of the inmates who are already suffering from mental illness.

Mental Illness in Prison Population in India

The NCRB report 2021 reports a total of 9,180 inmates as suffering from mental illness, accounting for 1.7% of the total inmates.^[16] However, the prevalence studies conducted among the prison population yield much higher figures. There is a dearth of large-scale epidemiological studies, and only five studies have been conducted in the past two decades which involved screening for mental illness by a psychiatrist using standard measures (Mini-International Neuropsychiatric Interview-Plus, Structured Clinical Interview for DSM, etc).^[17] The earliest and landmark study called the Bangalore Prison Mental Health study conducted over a sample of 5024 inmates reported the prevalence of mental illness to be 79.6%.^[18] Subsequent studies have reported the prevalence of current mental illness among inmates ranging from 23.8% to 68.6%.^[19] The most common disorders reported were substance use disorder, mood disorder, adjustment disorder, antisocial personality disorder, and psychosis. The majority of the inmates suffering from mental illness were found to be males. However, a cross-sectional study conducted in 50 female offenders in a state-run prison in an urban area, reported the prevalence of psychopathology in 82%, the most common diagnosis being substance-related disorder followed by major depressive disorder, adjustment disorder, personality disorder, and generalized anxiety disorder.^[20] The glaring discrepancy between administrative and clinical research data highlights the need for high-quality nationwide epidemiological studies among the prison population for mental illness. There is also a need to improve the mechanism of data collection within the prison system, not only of health-related statistics but also of the social determinants to align and integrate mental health and social welfare policies effectively.

Mental Health Services, Policy and Legal Provisions in India

The National Mental Health Policy 2014, recognized for the first time, that persons in custodial settings including prisoners constitute one of the sections of the society vulnerable to suffer from mental disorders.^[21] Among the strategies for the prevention of mental illness and suicide, the policy also recommends that police and judicial officers should be sensitized on mental health and its interface with legal issues. It advocates the need to “institutionalize a culture of respect for rights of persons with mental illness and a culture of openness and integration,” which must extend beyond general communities to include correctional settings.

As a step forward, the Mental Health Care Act (MHCA) 2017, under section 31 (2) further provides for mandatory training of all medical officers in prisons to provide basic and emergency mental healthcare.^[22] Moreover, section 103 (6) of the Act, mandates each state's government to set up mental health establishments in the medical wing of at least one prison in the state. Most importantly, the MHCA 2017, extends to prisoners the right of persons with mental illness to access quality treatment, and mandates prison authorities to ensure the fulfilment of this right. However, much remains to be achieved in terms of the implementation of these legal provisions as well as the ethos of inclusivity and nondiscrimination envisioned in the National Mental Health Policy. At present, majority of the state prisons do not have sanctioned positions for psychiatrist or psychologist to cater to the mental health needs of the inmates. It is reported that there is only one psychologist or psychiatrist for every 16,503 people in prison^[23] and as many as 24 of the 36 states and union territories in India do not even have a post of psychiatrist and psychologist sanctioned in prisons.^[15]

Future Directions

The existing divide between mental health legislation in India and service delivery within the criminal justice system highlights the need to reconceptualize mental health care from a human rights and social justice perspective. Training and orientation of judicial officers need to incorporate a nuanced understanding of the spectrum of mental disorders that extends beyond a restricted viewpoint based on gauging capacity and competence to stand trial. Within the prison system, guidelines for screening and early identification of mental illness as well as risk assessment for suicide need to be formulated. A multipronged approach needs to be strategized that include scaling up of mental health services within prisons, recruitment of mental health professionals specifically for the prison populations, training of jail staff as well as peer-led identification and support group. During the COVID-19 pandemic, under the aegis of the Ministry of Home Affairs, the National Institute of Mental Health and Allied Sciences (NIMHANS) issued a set of guidelines on the management of mental health issues in prison inmates as well as staff.^[24] One of the innovative strategies to deal with the resource constraints include the “Gatekeeper Model” for the identification of mental illness.^[25] In this model, selected inmates are trained to identify fellow prisoners at risk of suicide, so that they can be refer for treatment or supportive services in a timely manner. NIMHANS has also formulated a peer-led social intervention called the “Buddy System” wherein, selected inmates called “buddies” are trained to deliver basic psychosocial support intervention to inmates suffering from psychological distress.^[26] However, there is a need to scale-up such interventions across the nation, to gauge their effectiveness in reducing the mental health burden within the prison system.

Discussion

Both the US and India have a significant incarcerated population. In both countries, they represent a grossly underserved population with a high number of individuals suffering from mental illness. Incarceration itself can be a traumatic event, necessitating adequate mental health screening and treatment services. Moreover, persons with mental illness are more likely to be victims of persecution, bullying, and exploitation within the criminal justice system.

In India, there exists a discrepancy in the estimates of the total number of mentally ill prisoners. Further research would be helpful to accurately determine of the prevalence of mental illness within the criminal justice system, which in turn can guide policy in determining appropriate mental health to the incarcerated populations. Most medical colleges and postgraduate training programs in India do not have any specialized training opportunities related to prison mental health. Increasing exposure with the introduction of clinical rotations and lecture series might encourage future mental health professionals to work in these settings.

There are several systemic challenges within the criminal justice system in the US, which include institutionalized racism, a high number of incarcerated individuals, and inadequate access to care. Oftentimes, people with mental illness do not get adequate treatment until they are incarcerated. This is problematic because there is an overrepresentation of mentally ill individuals within prisons. Increasing community mental health services, diversion programs, and court-mandated mental health and substance use programs might help prevent mentally ill individuals from encounters with the criminal justice system. Educating primary care physicians, teachers, and police officers might also help them recognize signs and symptoms of mental illness and help bridge these individuals to treatment early on.

Conclusion

Low-middle-income countries and high-income countries both face challenges when it comes to caring for incarcerated populations with mental illness. The common themes include inadequate access to care in the community, resulting in overrepresentation of people with mental illness in the prison system, and inadequate mental health resources within the prison systems.

Combating these issues can start at many different levels. At the community level, increased awareness about mental health treatment can help bridge mentally ill individuals to treatment. At the outpatient and hospital level, an increased awareness about the criminal justice system among treatment providers would help them identify risk factors and ways to reduce recidivism. At the prison level, access to mental health care, housing units for individuals with mental illness, psychotherapy, and engagement in prosocial activities can help mitigate future recidivism. In a nutshell, policies to address rehabilitation in the form of mental health treatment, vocational training, and insight building might greatly benefit patients in correctional settings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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