Mental health disorders affect about 26.2% of Americans aged 18 and older.¹ Proper mental health “is a state of successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with challenges.”² Having a proper state of mental health leads to

1. Better physical health;
2. Improved productivity and financial stability;
3. Reduced strain/burden on the family;
4. Decreased risk of crime and victimization; and,

5. A longer “quality” of life.³

In the third installment of this four-part Health Capital Topics series, the state of mental illness was discussed generally, along with the availability of services, popular treatments, and government implementation of mental health resources with the Affordable Care Act (ACA). The National Sheriffs’ Association and the Treatment Advocacy Center have reported that there are more than three times as many mentally ill people housed within prisons and jails in the U.S. as are in hospitals (including psychiatric homes).⁴ Similarly, the study found that nearly 40% of the U.S. homeless population has a serious form of mental illness.⁵ This last installment will focus on these two special populations within the mental healthcare system: (1) prisoners; and, (2) the homeless.

As aptly noted by Alex Briscoe, Health Director for Alameda County in Northern California: “We’ve, frankly, criminalized the mentally ill, and used local jails as de facto mental health institutions.”⁶ As early as the 18^th century in Europe, in the first mental asylum facilities, patient care was not high on the list of priorities and patients were treated more as prisoners.⁷ Patients were chained to the walls of the hospital and mostly treated as outcasts.⁸ The first mental hospital in the U.S., Blackwell’s Island Lunatic Asylum, was built in New York at the beginning of the 19^th century.⁹ During the Great Depression, the economic crisis drastically cut state appropriations, and World War II created acute shortages of healthcare personnel; taking away psychiatrists who could potentially aid with mental health.¹⁰ Today, there are only a small number of the historic public and private psychiatric hospitals, and only 406 nonfederal psychiatric hospitals, in the U.S.¹¹

Psychiatric care and treatment are typically delivered through:

“a web of services including crisis services, short-term and general-hospital-based acute psychiatric care units, and outpatient services ranging from twenty-four-hour assisted living environments to clinics and clinicians’ offices offering a range of psychopharmacological and psychotherapeutic treatments.”¹²

However, jails and prisons have now become the housing ground for most of these patients, and are places where the most severe forms of psychosis are treated, with the inmates’ symptoms becoming more severe over time.¹³ Inmates are sometimes left untreated and or punished for acts that are exacerbated by their illness.¹⁴ In 2012, there were roughly 356,268 inmates with severe mental illnesses who were incarcerated in the U.S. In comparison, only 35,000 people with the same severity in illnesses were sent to a psychiatric hospital; the prisons are being used as an alternative for psychiatric hospitals.¹⁵ The federal government spends an estimated $111.7 billion a year on public mental health efforts, including:

1. $45.7 billion in Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) payments;
2. $60 billion in Medicare and Medicaid coverage;
3. $5.7 billion for mental health programs under the Departments of Defense and Veterans Affairs; and,
4. $386 million for mental health block grants to the states.¹⁶

However, federal spending used to incarcerate the mentally ill adds an extra $10 billion to this annual cost, which includes the additional cost of law enforcement, courts, and housing of the inmate while incarcerated.¹⁷ With the enactment of the ACA and the expansion of Medicaid in some states, previously uninsured “ex-offenders” may be able to afford medical care and receive the mental health treatment that they require.¹⁸

Within the federal and state prisons, however, there is a significant portion lacking treatment for their mental health conditions. Data obtained from a 2004 national sample showed at the time of incarceration, “18% of [federal and state prison] sample was taking medication for a mental health condition (prior to prison admission), but only 52% of that subset of the population in federal prisons and 42% in state prisons received [continued] medication during their sentence.”¹⁹ Prisons are not continuing the standard of care needed to contain the inmates’ symptoms. As a result of the lack of proper mental healthcare, the recidivism rate among convicts with serious mental illness is high; approximately 80%.²⁰ The Mental Health America (MHA) organization is calling for more treatment and services within correctional facilities to assist inmates with mental illnesses. The MHA supports implement of a new policy that will provide accessible mental health treatment for people in adult and juvenile correctional facilities; these services are deemed as “basic human rights” owed to every prisoner.²¹

Different forms of therapy and services have been used to treat patients with mental disorders. Some of these include: (1) a range of medications, called “pharmacotherapy”; (2) an array of services such as psychiatric hospitalization and peer services; (3) electroconvulsive therapy (ECT); and, (4) psychosocial treatments.²² The two most common forms of treatment used are psychosocial treatment and medication.²³ Psychosocial treatment is primarily used in prisoner reentry programs because of the collection of sub-treatments that are categorized within it, including:

1. Cognitive Behavioral Therapy (CBT), which aims to influence problematic and dysfunctional emotions, behaviors and cognitions through a goal-oriented, systematic procedure;
2. Psychotherapy, which typically allows the patient to come four or five times a week, lie on a couch, and attempt to say everything that comes to mind;
3. Behavior Therapy, which  uses techniques that follow the premise that maladaptive behaviors are learned, and therefore can similarly be unlearned; and,
4. Psychoanalytic treatment, which focuses on helping each patient become aware of underlying sources of his or her difficulties, not just intellectually, but emotionally by re-experiencing them with the analyst.²⁴

In most severe cases, ECT, or “electroshock therapy” is used. Treatment may be completed in an inpatient or outpatient setting in a course of six to 12 treatments administered two or three times a week.²⁵ An electric current is passed through the brain, intentionally triggering a brief seizure and causes a change in brain chemistry that can quickly reverse symptoms of certain mental illnesses.²⁶

Similar to prisoners, a large percentage of the homeless population also suffers from mental illness. In 2013, 40% of homeless population that were surveyed nationwide reported suffering from a mental health problem.²⁷ This could be a result of states cutting $5 billion from mental health services, along with 10% of psychiatric hospital beds, between 2009 and 2012; with 40% of people with severe mental illness receiving no treatment between 2013 and 2014.²⁸ Organizations like The National Coalition for the Homeless and The National Alliance to End Homelessness are fighting towards to bring more awareness to mental illnesses within the homeless population.²⁹ Both organizations endeavor to ensure the immediate needs of homeless individuals are met and their civil rights, i.e., healthcare justice, are protected.³⁰ USA Today, among others, has been exploring the human and financial costs that the U.S. pays for failing to treat Americans battling severe mental illness, however, the mentally ill homeless are the hardest group to track and the toughest to treat due to self-medication of alcohol and drugs.³¹ Without the ability to adequately monitor the homeless, the complete economic burden of mental health on the population cannot be fully understood; mental health won’t obtain the appropriate level of urgency among the citizens.

The economic costs resulting from the U.S.’s failure to treat mental illness is exceptionally high.³² The mentally ill are either institutionalized within the criminal system or left hidden among the homeless population. Patients are being re-institutionalized into the jail system or homeless shelters, while mental health programs are often the first to have their funding cut.³³ To track the impact of the homeless population on the nation’s economy is a trying task, due to the fact they are not stationed and monitored in one location.³⁴ Advocates are encouraging more access to primary treatments, such as pharmacotherapy and psychosocial treatments, which have been proven to work in combating mental illness.³⁵ CBT is the most popular and effective form of therapy used for offenders and has been mostly implemented in the reentry programs for those convicted.³⁶  To continue to incarcerate the mentally ill has not aided them, but has merely added to the economic burden, as the cost of an inmate with a mental illness is more than that of other inmates.³⁷