03 May 2011

Deinstitutionalization Legacy Persists

According to Pete Earley, former Washington Post intelligence journalist and author of "Crazy: A Father's Search Through America's Mental Health Madness" (2006) the United States has made a little dramatic but little noticed change in the way it handles mental health issues from a medical model to a criminal justice orientation:

In 1955, about 560,000 Americans were being treated in state mental hospitals. Based on population growth since then, you would expect more than 930,000 people in such hospitals today. There are only 55,000. Nearly 300,000 are imprisoned. Another half-million are on probation.

The largest public mental-health facility in the U.S.? The Los Angeles County Jail, home to 3,000 mentally ill inmates.

A dramatic shift towards the deinstitutionalization of those with mental health conditions in the 1980s from being the developed nation with the highest institutionalization rate for mental health conditions in the world, to the lowest, afforded some more freedom, but rather than producing a reinvestment of funds previously used for a public sector mental health care into community based programs led to a massive disinvestment in public sector funded mental health care that ended up funnelling many people who had trouble functioning in the absence of that care or family support, into the criminal justice system. Now, it can be hard to find services for anyone but the most affluent, even for bureaucratically savvy middle class families.

The trend is ongoing, with Colorado having seen many of its psychiatric hospital beds taken out of service over the last few years in the face of their high cost, and declining funding support since these programs receive less federal support or budget process protections than programs that have been preserved and often lack of visible constituency.

Earley cites conditions like schizophrenia and bipolar disorder, rather than psychopathy, as driving the trend. Some criminologists, such as Bernard Harcourt, have identified the size of the total institutionalized population as an important driver of crime rates, despite the mystery that the demographics of mental health institutions are very different from those of prisons (particularly in the number of women institutionalized). Early's identification of the large number of people with mental health conditions who are on probation or in jails, rather than prisons also helps to shed light on this demographic mystery; many people who would formerly have been institutionalized in mental health institutions are now in the criminal justice system, but only through probation or jail rather than prison, while many other individuals convicted of crimes are now more likely to be incarcerated in prison than in the past as criminal sentences have grown stiffer.

The brief excerpt in the linked story doesn't shed light on the question of how the United States experience compares to our peers in the developed world. It isn't clear, for example, if Europe and Japan have deinstitutionalized (or never institutionalized) their individuals with mental health conditions to the same extent as the United States, and if so, what the consequences of doing so have been there. The mental health institutionalization rates are indeed higher in Europe compared to a rate of about 25 per 100,000 in the United States (down from a peak in the 1950s of over 600 per 100,000), although they are declining in Europe from past levels:

Among countries in the European Union, the highest rate regarding the number of beds in psychiatric hospitals per 100,000 inhabitants in 2000 was in the Netherlands, which had a rate of 188.5. Other highs were posted in Belgium (161.6), Switzerland (119.9), France (113), and Finland (102.9). The average for the 25 European Union countries in 2000 was 90.1, down from 115.5 in 1993.

Japan's mental health institutionalization rate of 282 per 100,000 is the highest in the world, something particularly notable because the overall prevalence of mental health conditions in Japan is below the developed world average.

It is also worth pointing out that even if the residential mental health institution population were similar now to what it was in 1955, that it would still only be a tiny percentage of the population that receives or needs mental health care. For example, 60% of the population experiences depression, anxiety disorders, alcohol dependence and/or marijuana dependence by age 32. About 11% of adults in Colorado have experienced significant psychological distress (other than substance abuse issues) within the last year. Schizophrenia has a prevalence rate of about 1% in the general population, in contrast, and is about 80% genetic, and the prevalence rate and genetic component of bipolar disorder are on the same order of magnitude, but is more common and less strongly genetic.

The link between mental health issues and criminal justice involvement tends to be a "mental health plus" relationship. In one recent study, for example:

Mental illness alone is not a meaningful predictor of future violent acts, but is very significant when accompanied by a history of violence and substance abuse.

There were 3,089 people deemed to have severe mental illness—schizophrenia, bipolar disorder and major depression—but no history of either violence or substance abuse. They reported very few violent acts, about 50, between interviews.

But when mental illness was combined with a history of violence and a history of substance abuse, as in about 1,600 people, the risk of future violence increased by a factor of 10.

As the same linked post notes, relying on Colorado Department of Corrections date, in Colorado, "Moderate to severe substance abuse is a problem for 82.0% of male and 82.4% of female inmates. Moderate to severe mental health problems exist for 27.8% of male and 34.2% of female inmates."

Mental health problems are also much more likely to lead to serious criminal justice system involvement for individuals who are high school dropouts or have high school diplomas or GEDs but no college degree of any kind.

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