Cleaveland: New book 'Insane' gives voice to mentally ill in prison

From the Chattanooga Times Free Press
By Clif Cleaveland, MD

Treatment of the mentally ill in the criminal-justice system is appalling in many American jurisdictions. In jails and prisons in some cities and states, the level of care qualifies as cruel and unusual punishment, which is prohibited by the 8th Amendment to the U.S. Constitution. The plight of this population seldom attracts attention.

In a powerful, heart-wrenching narrative, "Insane: America's Criminal Treatment of Mental Illness," author Alisa Roth investigates the status of mentally impaired persons held in U.S. jails and prisons. Her narrative is a summons to action to correct a system that inflicts needless suffering on people in custody.

In 1971, 330,000 Americans were incarcerated, 130,000 of whom were in county jails. The total rose to 2.2 million in 2013, of whom 215,000 were in federal prisons, 1.27 million in state prisons and 731,000 in county jails.

Estimates of mental illness among prisoners vary widely. In large metropolitan areas, jails are the major providers of psychiatric care. Author Roth cites the Los Angeles County Jail, which has an average daily census of 16,000, of whom 25 percent require mental health care. Los Angeles, like many other large cities, maintains special units for those prisoners who are too ill to remain in the general population.

Nationally, more than half of males and three-quarters of women in state prisons suffer from some form of mental illness, which includes bipolar disorder, schizophrenia and major depression. Many of these prisoners also have substance-abuse problems.

Federal courts have ruled that prisoners have a constitutional right to medical care, including psychiatric care. Guarantee of this right is spotty.

Mentally ill persons often experience problems making bail, lengthening their stays in jails, sometimes for months. Their detention may be further extended by delays in obtaining psychiatric evaluations to determine fitness for standing trial.

The quality of care for prisoners with mental illness varies widely from state to state. Some states have privatized their penal systems, emphasizing low costs over all other considerations. Overcrowding is a frequent problem. Too often, mentally ill prisoners are placed in solitary confinement. In one horrendous example, solitary consisted of a small cell with a Bible, another religious text, removal for a shower on alternate days and a half-hour to walk in a confined space once a week. Another prisoner spent 23 years in solitary confinement in an Illinois correctional facility. Imagine the effect of such treatment upon average, healthy people.

Some prisons are severely understaffed, both with security personnel and counseling staff. Noncompetitive pay, poor working conditions and remote location of many prisons make jobs unattractive. There may not be adequate, trained staff to screen incoming prisoners for mental disorders. Psychiatric care may consist of a weekly inquiry by a psychologist, who asks through a slot in a cell door if a prisoner is feeling OK. Short of staff, many prisons depended upon medications to keep prisoners quiet. Administration of medication may not be dependable. Prisoners are described who amputated fingers and, in one instance, blinded an eye.

Would better community-based psychiatric care prevent persons with mental illness from involvement in crime in the first place?

Do we need a single standard of health care, especially psychiatric care, for all prisons? Hospitals must meet rigorous standards and undergo periodic inspections to meet the accreditation standards of the Joint Commission. Why not add prisons to the list?

When politicians push for reduced taxes and fewer regulations, do they have a realistic assessment of how their proposals will affect the health of prisoners? Do they care? How many have visited a prison to assess its treatment of inmates, especially those with mental illness?

Moved by the wretched state of women in a Massachusetts jail in which she conducted Sunday School, Dorothea Dix launched a 19th-century crusade to reform both jails and asylums. She worked tirelessly during the latter four decades of her life to push state legislatures to pass legislation to protect the rights and to ensure humane treatment for mentally ill subjects. She influenced the founding of 32 new asylums to provide a therapeutic environment for these individuals.

Alisa Roth provides a similar summons to action for the 21st century. Read her book and consider how we the abled can ensure proper care for mentally ill inmates.

Clif Cleaveland, M.D., is a retired internist and former president of the American College of Physicians. Email him at