Growth of Mental Health Services in State Adult Correctional Facilities, 1988 to 2000

Growth of Mental Health Services in State Adult Correctional Facilities, 1988 to 2000

Ronald W. Manderscheid, Ph.D., Aliya Gravesande, B.A.
and Ingrid D. Goldstrom, M.Sc.

Psychiatric Services August 2004

Abstract

OBJECTIVE: This study examined trends in the availability and use of mental health services in state adult correctional facilities.

METHODS: Results from the 1988 Inventory of Mental Health Services in State Adult Correctional Facilities of the Center for Mental Health Services were compared with those from the 2000 Census of State and Federal Adult Correctional Facilities survey of the Bureau of Justice Statistics. The two surveys were chosen because they occurred more than a decade apart, had a reasonable amount of data, and could be made comparable.

RESULTS: This analysis used data from 757 state adult correctional facilities that were sampled in 1988. The number of such facilities increased to 1,097 in 2000, a 44.9 percent increase. A dramatic increase was also seen in the prison population, from 505,712 in 1988 to 1,084,625 in 2000, a 114.5 percent increase. Mental health services were offered in significantly more facilities in 2000 than in 1988. However, the relative percentage of facilities that offered mental health services decreased overall. Simultaneously, the percentage of inmates who used these services increased overall.

CONCLUSIONS: The growth in prison facilities and the growth in prisoner populations are outstripping the more meager growth in mental health services. These results suggest that mental health services are becoming less available to the prison population, and service populations are becoming more concentrated in the facilities that do offer such services.

Introduction

The Center for Mental Health Services conducts national surveys on mental health services in the United States. In 1988 the center surveyed the availability of mental health services in state adult correctional facilities and focused on the availability of services, location of services, staffing of services, volume of services, and demographic and clinical characteristics of service users (1). The 1988 study was sparked by reports about rapidly increasing prison populations and facilities. At the time of the study, the Center for Mental Health Services reported that between 6 and 14 percent of the correctional population had a major psychiatric disorder and that the lifetime prevalence rate of major psychiatric disorders among prisoners and detainees was 82 percent. One of the center's concerns was that the proportion of persons with mental illness who were incarcerated had increased significantly as a result of insufficient community-based mental health services.

The 1988 survey was the first to investigate the national availability of mental health services for prisoners within the state correctional system. The data were as accurate a representation of mental health services in correctional facilities as possible. However, these data are now more than 15 years old. They no longer present an accurate portrait of the mental health services that are currently available in state adult correctional facilities. Yet the survey is an excellent historical reference that can be compared with more recent studies to identify changes in services over time.

Since the deinstitutionalization of persons with mental illness began, an increasing number of these individuals have been imprisoned, with no indication of a decline in this trend (2). At the end of 1988 more than 100,000 patients resided in state and county mental hospitals. By the end of 2000 fewer than 56,000 patients resided in these hospitals, a reduction of almost one-half (3). These hospitals were also admitting only half as many patients in 2000 as they were in 1988, which may have played a role in the increasing number of persons with mental illness who appeared in the criminal justice system. In addition, throughout the 1990s, prison populations and prison construction increased (4). This escalation would also lead to an increase in the number of inmates in need of mental health services, because a disproportionate number of inmates are likely to be mentally ill compared with the general population.

Identifying trends in the availability and use of mental health services that are provided by state adult correctional facilities in the United States has proven to be difficult because of variability between surveys. Recent data on mental health services in state adult correctional facilities were relatively easy to find. However, each data source varied in its definition of the terms "correctional facilities" and "mental health services," which made comparisons difficult. To address differences between existing surveys and to make comparison as accurate as possible, uniformity between surveys needed to be established. The methods that were used to make the two surveys that we examined comparable are described below.

Our study examined trends in the availability and use of mental health services in state adult correctional facilities. We hypothesized that the increase in the availability and use of mental health services in state adult correctional facilities would be at least proportionate to the growth of these facilities and of their prisoner populations.

Methods

The two surveys that we examined were chosen because they occurred more than a decade apart, had a reasonable amount of data, and could be made comparable. Thus results from the 1988 Center for Mental Health Services survey "Inventory of Mental Health Services in State Adult Correctional Facilities" were compared with those from the 2000 Bureau of Justice Statistics survey, Census of State and Federal Adult Correctional Facilities (1,4).

The 1988 Center for Mental Health Services survey covered state adult correctional facilities in the United States and its territories operating during the month of September (1). The sample for the survey was derived from the American Correctional Association's 1988 Directory of Juvenile and Adult Correctional Departments, Institutions, Agencies, and Paroling Authorities (1). Facilities were excluded from the survey if they were identified as youthful offender facilities, prison farms, road camps, and federal prisons. A total of 799 facilities were asked to participate, and 781 responded, giving a response rate of 98 percent. For comparison purposes we excluded facilities that were in U.S. territories, leaving 757 sample facilities for our analyses.

The 1988 survey gathered specific data for each category of mental health service: availability of services, location of services, staffing of services, volume of services, and demographic and clinical characteristics of service users. Data were collected at the facility level and then aggregated. State and national findings were reported.

The comparison survey was conducted in June 2000 by the Bureau of Justice Statistics (4). The survey's universe of facilities was developed from the Department of Justice's Census of State and Federal Adult Correctional Facilities, 1995 (5). However, the report was updated with the 2000 Census of State and Federal Adult Correctional Facilities to identify new facilities and to eliminate facilities that had closed (6). The survey included adult correctional facilities, prisons and penitentiaries, boot camps, prison farms, reception centers, diagnostic centers, classification centers, road camps, forestry and conservation camps, youthful offender facilities, vocational training facilities, prison hospitals, drug and alcohol treatment facilities, and state-operated local detention facilities.

The 2000 survey asked 1,584 state facilities to participate; 1,519 responded, giving a response rate of 95.9 percent. Data were reported by type of facility, security level of the facility, maximum, medium, and minimum, and other characteristics of the facility. Data were not collected for U.S. territories....

Two differences existed between the surveys. The 1988 survey collected data on the number of facilities that offered medication services and specifically inquired about facilities that monitored psychotropic medication. The 2000 survey reported on facilities that distributed psychotropic medication, a slightly different type of service. Finally, the 1988 survey reported on facilities that provided psychiatric testing and assessments, whereas the 2000 survey reported on those that provided psychiatric assessments.

Results

Findings from 1988

... of the 757 facilities that we examined, 76.2 percent reported that they provided 24-hour mental health care, 89.3 percent provided counseling or therapy, and 82.3 percent monitored medication. Also, 84.8 percent of the facilities provided testing and assessment.

.. .7 percent of the 505,712 inmates in the 1988 survey used 24-hour mental health care, 9.6 percent received counseling or therapy, and 5 percent had their medication monitored. Finally, 4.2 percent received testing or assessment.

Findings from 2000

...of the 1,097 confinement facilities that responded, 77.9 percent screened inmates at intake. Also, 63.2 percent of the facilities provided 24-hour mental health care, 78.8 percent conducted psychiatric assessments, 84.4 percent provided counseling or therapy, and 83 percent distributed medications. Of the 1,097 confinement facilities that reported, only 4.6 percent stated that they did not provide any mental health services to inmates. By security level, results indicated that 99 percent of maximum- and medium-security facilities provided some type of mental health treatment; 86.6 percent of minimum-security facilities did so as well. ...16,986 inmates (1.6 percent) used 24-hour mental health care, 122,376 (11.3 percent) received counseling or therapy, and 95,114 (8.8 percent) had medication distributed to them.

Comparative analysis

Tables 1 and 2 show the percentage increases in the availability and use of mental health services from 1988 to 2000. For our analyses, 757 state adult correctional facilities were surveyed in 1988. That number increased to 1,097 in 2000, a 44.9 percent increase. With the increase in the number of correctional facilities, a dramatic increase in the prison population was also seen, from 505,712 in 1988 to 1,084,625 in 2000, a 114.5 percent increase.

Mental health services were offered in significantly more facilities in 2000 than in 1988. However, the relative percentage of facilities that offered mental health services decreased overall. Simultaneously, the number and the percentage of inmates who used these services increased overall.

The service with the smallest percentage increase was 24-hour mental health care, which was provided by about 76.2 percent of facilities in 1988 and 63.2 percent in 2000 yet showed a 20.1 percent increase in the number of facilities offering this service. This increase was less than the 44.9 percent increase in the number of all prison facilities. Between 1988 and 2000 the percentage of inmates who used 24-hour mental health care rose from almost 1 percent to nearly 2 percent, which represented a 408 percent increase in the number of inmates who used this service (Table 2).

The 1988 survey also reported that about 85 percent of facilities performed psychiatric testing and assessments, whereas the 2000 survey reported that about 79 percent performed psychiatric assessments, yet there was a 34.6 percent increase in the number of facilities offering this service. Data were not available from the 2000 survey on the number of prisoners who received psychiatric assessments, so a comparison between the two surveys in this category could not be done.

Facilities that provided counseling or therapy increased from 676 in 1988 to 926 in 2000, a 37 percent increase, although the relative percentage of facilities declined slightly. The number of inmates who used counseling or therapy services also increased between 1988 and 2000_from 48,329 in 1988 to 122,376 in 2000, a 153.2 percent increase in the number of inmates who used these services.

The type of service that grew the most was medication monitoring or distribution. The 1988 survey reported that 82.3 percent of facilities monitored medication. The 2000 survey reported that 83 percent distributed medication, yet there was a 46.1 percent increase in the number of facilities offering this service, which was about the same rate as the growth of all prison facilities. The percentage of inmates who received medication services also increased from 5 percent in 1988 to 8.8 percent in 2000; this represented a 278.2 percent increase in the number of inmates who used these services.

Discussion

Between 1988 and 2000 there was a 44.9 percent increase in the number of adult state correctional facilities. At the same time there was a 114.5 percent increase in the number of adult state prisoners. The rate of growth in incarceration was more than twice the rate of facility construction.

Although the percentage increase in facilities that offered mental health services was generally below the overall rate of facility growth, we found very large increases in use of each service in question. One potential explanation for this disparity is that caseload increased in the facilities that offered services. Clearly, the growth in prison facilities and the growth in prisoner populations are outstripping the more meager growth in mental health services. These findings suggest that mental health services are becoming less available to the prison population, and service populations are becoming more concentrated in the facilities that do offer such services.

This interpretation is supported by the fact that other findings from the 2000 survey suggested that minimum- and low-security confinement facilities are less likely to offer any mental health services and that persons with mental illnesses are more likely to be confined elsewhere in the state system (4).

Another explanation for the relative decrease in mental health services could be lack of funding for mental health staff and services. Funding for mental health services has been dwindling since the 1980s and remains a significant factor in the transinstitutionalization of persons with mental illness (7). Clearly, a majority of resources for correctional facilities are not directed toward treatment, but rather security. Therefore, a lack of funding for mental health services may also be a limiting factor (8).

Conclusions

Overall, mental health services in state adult correctional facilities have expanded somewhat, and use has increased dramatically. However, overall availability has decreased. Our findings have important implications for mental health policy: What should be the relative balance between service expansion and diversion? Should services be introduced at lower levels of confinement? How should we transform the specialty care sector to better serve this population? Considerably more policy discussion and research are urgently needed to illuminate these pressing questions.

Dr. Manderscheid and Ms. Goldstrom are affiliated with the division of state and community systems development of the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 5600 Fishers Lane, Room 15-C-04, Rockville, Maryland 20857 (e-mail, rmanders@samhsa.gov). Ms. Gravesande is a graduate student with the department of psychology at Towson University in Towson, Maryland.

References

Goldstrom ID, Rudolph L, Manderscheid R: Inventory of mental health services in state adult correctional facilities, in Mental Health United States, 1992. Edited by Manderscheid R, Sonnenschein M. Department of Health and Human Services pub no SMA-92_142. Washington, DC, US Government Printing Office, 1992

Psychiatric Services in Jails and Prisons. Washington, DC, American Psychiatric Association, 1989

Atay JE, Manderscheid R, Male AA, et al: Additions and Resident Patients at End of Year, State and County Mental Hospitals, by Age and Diagnosis, by State, United States, 2000. Rockville, Md, Center for Mental Health Services, 2002

Beck AJ, Maruschak LM: Mental Health Treatment in State Prisons, 2000. Washington, DC, US Department of Justice, Bureau of Justice Statistics, 2001

Census of State and Federal Adult Correctional Facilities, 1995. Washington, DC, United States Department of Justice, Bureau of Justice Statistics, 1995

Census of State and Federal Adult Correctional Facilities, 2000. Washington, DC, United States Department of Justice, Bureau of Justice Statistics, 2000

Thomas AR: Ronald Reagan and the commitment of the mentally ill: capital, interest groups, and the eclipse of social policy. Electronic Journal of Sociology 3(4), 1998. Available at www.sociology.org/content/vol003.004/thomas.html

Steadman HJ, Cocozza JJ: Mental Illness in America's Prisons. New York, Museum of Modern Art, 1993

This 'Mental Health E-News' posting is a service of the New York Ass'n of Psychiatric Rehabilitation Services, a statewide coalition of people who use and/or provide community mental health services dedicated to improving services and social conditions for people with psychiatric disabilities by promoting their recovery, rehabilitation and rights. To join our list, please click on the E-News Subscription button.

Last Updated on 02/20/05 webmaster@namiscc.org

Opinions expressed in this web site do not necessarily reflect the views of NAMI Santa Cruz County, NAMI California or any affiliated organizations. We attempt to present a balanced perspective on issues by presenting multiple viewpoints.

FAIR USE NOTICE: This may contain copyrighted (©) material the use of which has not always been specifically authorized by the copyright owner. Such material is made available to advance understanding of ecological, political, human rights, economic, democracy, scientific, moral, ethical, and social justice issues, etc. It is believed that this constitutes a 'fair use' of any such copyrighted material as provided for in section 107 of the US Copyright Law. For more information go to: http://www.law.cornell.edu/uscode/17/107.shtml If you wish to use copyrighted material for purposes of your own that go beyond 'fair use', you must obtain permission from the copyright owner.