A recent report by the National Institute of Corrections showed 25 states, which kept records over the past 10 years, reported an increase in their populations needing mental health care (2001). This movement of the mental health population to the criminal justice system indicates not only the deinstitutionalization of the mental health system but a shift in the burden of care to corrections agencies, which have already been experiencing a host of other problems. This shift has created such overarching effects not only in the U.S., but internationally, to the extent that other countries have agreed that the topic of mental health in prisons should be given urgent priority and demands serious discussion (WHO, 1998).

The United States currently has more mentally ill men and women in jails and prisons than in all state hospitals combined. In addition, an increasing number of them have been placed in parole and/or probation populations. In 1998, there were nearly 284,000 prisoners diagnosed with a mental illness; this included 7% of federal prisoners, 16% of state prisoners, and 16% local jail inmates based on self-report data (Criminalization, 2000). Currently, there are roughly between 280,000 to 290,000 mentally ill people incarcerated in prisons and jails (Jailing, 2001; BJS 2001). This is more than half the number of mentally ill individuals in state mental hospitals during the 1950s, when total population reached its peak.

This paper addresses the many concerns raised in the research literature on mentally ill offenders and mental health care, including types of mental illnesses, types of mental health services, effective treatment, and criminality issues. We also list some current numbers pertaining to the status of mental health services and mental health populations in Maryland and other selected states, information about promising programs, and other related issues. Lastly, we discuss some implications of this research and list recommendations that correctional facilities may consider when planning, developing, providing, and maintaining proper and adequate mental health services for mentally ill inmates.

Mental Health v. Mental Illness

According to the Department of Mental Health and Human Services (DMHHS), mental health and mental illness are not polar opposites but rather points on a continuum (1999). In the middle of this continuum are "mental health problems" and at the far end lie mental illnesses such as schizophrenia, manic depression, and bipolar disorder. They define mental health as the successful performances of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with adversity (DMHHS, 2000). The World Health Organization (WHO) defines mental health as a positive sense of well-being, from which springs the emotional and spiritual resilience which is important for personal fulfillment and which enables individuals to survive pain, disappointment and sadness (WHO, 1998).

Mental illness refers collectively to all mental disorders, which are health conditions characterized by alterations in thinking, mood, or behavior associated with distress and/or impaired functioning. Furthermore, mental disorders alter mental life by affecting the function of neurocircuits, the elaborate pathways through which cells in the brain communicated with one another and with other parts of the body (Department of Health and Human Services, 2000). The precise causes of most of these disorders remain unknown; however, it is evident that genetic, psychological, social, and cultural forces shape them in many regards.

History of Correctional Mental Health Services

According to Ferrara and Ferrara (1991), the history of correctional mental health services can be divided into three stages: inmate model, court model, and rehabilitation model. The inmate model describes the period from 1900-1975 where inmates essentially provided mental health services for each other. This occurred largely in part because mental health clinics were understaffed and staff members were not properly trained, coupled with the fact that provision of sufficient mental health services was categorized as a low priority by the majority of correctional professionals.

The court model emerged in 1975 after intervention by the Federal court system that began during the 1960s, which introduced standards to protect people in state mental hospitals, and "dictated to state prison systems the nature and scope of required mental health services." In addition, several court cases, such as Estelle v. Gamble in 1976 and Ruiz v. Estelle in 1980, had a large impact on the evolution of the court model with respect to making the correctional community more accountable to inmates requiring mental health services. Some of these Federal mandates included requiring prisons to use trained and license professionals for treatment, setting guidelines for use and distribution of psychotropic medications, establishing components of proper treatment including screening and evaluation, creating a classification system, and delineating other constitutionally related issues (e.g., inmate consent).

The rehabilitation model (1990-present) consists of combination of elements from both previous models with more recent initiatives. These initiatives include the use of case management and crisis intervention services along with other innovative treatment approaches. In other words, this particular model focuses on teaching inmates who have mental health problems the necessary tools and skills needed to function normally in the community after release.

Another concept synonymous with the rehabilitation model found in the more recent literature is referred to as the "holistic approach" (Severson, 1992). This approach involves establishing treatment programs that address the behaviors, values, and attitudes of the offender, therefore, providing a comprehensive treatment framework that addresses the "entire" person. This approach is discussed more in depth later in this paper.

Types of Mentally Ill Inmates

According to Mobley (1986), there are four categories of mentally disturbed inmates: Type 1, Type 2, Type 3, and Type 4. A Type 1 inmate is unable to control his/her thought processes of emotions or is mentally retarded to the extent of being unable to adapt his/her behavior to the institution. Inmates classified as Type 1 are usually diagnosed as schizophrenic, major depressive, or manic. Many of these inmates, who are usually on some type of medication, can function within the general population while others cannot. A Type 2 inmate cannot adapt easily or effectively to incarceration and often complains of sleeplessness, nerves, fear of mistreatment by other inmates or officers, obsession with family matters, weakness, fatigue, and depression. Inmates classified as Type 2 are usually diagnosed with having anxiety disorders, specific fears of phobias, less serious depression disorders, stress, or psychologically related medical disorders. A Type 3 inmate has character disorders and may have one or several socially unacceptable or self-defeating patterns of coping with life roles and situations. Inmates classified as Type 3 are typically diagnosed with personality disorders such as antisocial, borderline, paranoid, chemical dependent, and sexual deviations. Furthermore, these disorders are not curable; however, inmates can be taught to control behaviors associated with their condition. A common characteristic of these disorders is they are likely to make others more uncomfortable than the individual with the actual disorder(s). A fourth classification, Type 4, which is mentioned throughout the literature on mentally ill inmates, is known as substance abuse disorders (Taylor, 2001). These disorders are curable and often involve problems with alcohol or drug abuse.

Types of Mental Health Services

Generally speaking, mental health services fall into four main categories (Severson, 1992). The first is referred to as "generic" treatment services, which provide services that are not necessarily specialized for any population or on any certain goals. These services include intake assessments, crisis intervention, suicide intervention, stress management, and situational conflict resolution services. The second is substance abuse treatment, which provides individual or group therapy in combination with other activities to treat those offenders with drug or alcohol abuse problems. The third is sex offender treatment programs, which use specific behavioral methods and some medications to treat sexual and some violent offenders. Finally, the fourth category is therapeutic communities that are often geared for substance abusers, but have been organized for the treatment of severe mental disorders (Severson, 1992). These programs use a more holistic approach by providing individual and group counseling services, behavior control, environmental adaptation, and preparation for successful reintegration into the community.

An evaluation by Taxman and Bouffard (1997) used structured observation and examined the therapeutic integrity of six selected residential therapeutic community programs. Their findings indicated that these programs did not properly implement the actual Therapeutic Community (TC) model in terms of goals/philosophies and program components. Many of the programs emphasized individual instead of community work, and were lacking in leadership, supervision, and direction. In addition, several programs had no clear established set of goals or organizing principles and if they did, they were usually "left on the shelf." In short, this technique of structured observation allowed the evaluators to get inside the "black box" of treatment. Although these programs were labeled as therapeutic communities, the types and degree of services offered did not adhere to the standards of the original TC model.

This evaluation is valuable because it documented exactly what services these various TC programs were offering and to what degree. Often times there are mental health programs available, but the real question becomes, is the staff doing what it is are supposed to be doing. In addition, this evaluation highlighted the fact that as we continue to learn and examine offenders and their mental health service needs, it is just as important that we identify mental health programs and their needs to make sure that adequate resources, including staff, funding, and training, are available for these programs to operate effectively.

Mentally Ill Inmates and Criminality

Several studies have been done to address the relationship between inmates with mental health disorders and crime. Much of the evidence suggests that those inmates with mental illness are more prone to commit crime, are at a greater likelihood for arrest, are more likely to commit violent crimes, and have the highest rates of recidivism of any offenders (NIJ, 1991, Sigurdson, 2000). Below is a list of some of the findings on inmates with mental illnesses and crime:

People with mental illness are 64% more likely to be arrested than those without a mental illness committing the same crime (Olson, 2001).

Forty-seven percent of the individuals with mental illnesses were arrested compared to 28% of those without mental illnesses committing the same offense (Criminalization, 2000).

According to the Bazelon Center for Mental Health Law, inmates with mental illnesses are more likely to be repeat offenders. Forty-nine percent of federal prisoners with mental illnesses have three or more prior probation/incarceration arrests, compared to 28% without mental illnesses. Forty-four percent of federal prisoners with mental illnesses had a current or prior violent offense, compared to 22% without mental illnesses (Criminalization, 2000).

Women prisoners are more likely to be mentally ill than male prisoners (1 in 4). (Jailing, 2000).

Many female mentally ill inmates are likely to report a history of physical or sexual abuse (Ditton, 1999).

White women inmates have a higher rate of mental illness than any other demographic group. The distribution found among female state prisoners was 29% white, 20% black, and 22% Hispanic (Jailing, 2000).

Mentally ill inmates (53%) are more likely to have committed violent crime than those without a mental illness (46%) (Ditton, 1999).

More than 75% of mentally ill inmates have been sentenced to prison, jail, or probation at least once prior to their current sentence. Half reported three or more prior sentences. (Jailing, 2000).

Issues Surrounding Care and Treatment of Mentally Ill Inmates

There are several issues that have plagued prisons and jails trying to provide proper care and treatment to offenders with mental health disorders. These problems include inadequate services, under-trained staff, lack of interagency collaboration, managing different populations (i.e. juveniles, racial minorities, elderly offenders), and funding. According to a recent article by Fitzgibbons and Gunter-Justice (2000), many jails, because of their size or locale, have little or no mental health assistance available either internally or within the community. They also noted that out of 3,300 jails and detention centers in the U.S., 83% have 249 beds or fewer and 1,579 jails house 49 inmates or less. Moreover, a report by BJS (2001) found that 125 facilities did not provide any mental health services to inmates. The lack of funding is always a problem with any type of social service issue and is a large factor in whether or not agencies can provide adequate services and for how long. One of the problems that usually occurs with mental health providers is that the number of caseloads for clinical staff continues to rise while the budget tends to remain frozen.

In addition to lack of funding, many staff members are under-trained and unaware of the most effective strategies and treatments available for different populations, such as adolescents. Boesky points out that in addition to common mental disorders found among youths (i.e. attention deficit disorder/hyperactivity disorder, posttraumatic stress disorder, bipolar disorder, major depression, mental retardation, and psychotic disorders), many experience co-occurring substance abuse disorders, which present further challenges in identification and management (2001). Other mental health issues concerning young offenders are their lack of social support, lack of control over their environment, isolation effects, and reluctance to express themselves due to a combination of negative feelings (i.e. loneliness, guilt, fear, and aggression) (WHO, 1998).

Another problem is lack of interagency coordination where gaps in communication between facilities and mental health providers create frustration, tension, and confusion about how they should complement each other's operation. Finally, corrections experts have uncovered that the outcome of mental health caseloads where there is a predominance of personality disorders, chronic mild, yet disruptive, mood disorders and substance abusers, is that the seriously mentally ill inmates often get less attention (Nelson, 1998). This finding is probably related to the inconsistency in the types of services provided for mentally ill inmates by correctional facilities across the country.

According to a study by the National Institute of Corrections, many differences exist among correctional facilities and the types of mental health services they provide (2001). This study included responses to a survey from 49 states, the Federal Bureau of Prisons (BOP), the Correctional Services of Canada (CSC), Guam, and Puerto Rico. Below is a list of some of the major findings.

• Sixteen DOCs said they made no operational distinction between inmates with mental illnesses and inmates with other mental health needs, compared to 33 agencies who indicated they did.
• Seven state DOCs, the BOP, and the CSC use the American Psychiatric Association's DSM-IV diagnostic classification system to assess mental illness among inmates. Most DOCs require an Axis I diagnosis of a clinical disorder for the inmate to be considered mentally ill; however, some consider those with an Axis II diagnosis and a low General Ability to Function (GAF).
• In eight state DOCs, inmates are considered mentally ill if their assessments result in a particular designation, such as "chronically mentally ill", "severely mentally ill", "seriously disturbed," or "seriously and persistently mentally ill." All others are excluded from receiving housing or program assignments.
• Lousiana and Virginia DOCs place inmates into one of five mental health levels of care while the Georgia and New Mexico DOCs identify six levels; both Arizona and Rhode Island DOC use mentally ill definitions that have been established by other state authorities instead of devising their own.
• All DOCs indicated they use a psychopharmacological approach to treating mentally ill inmates, but hours of counseling for non-acute cases varied.
• Most DOCs offer long-term or separate housing unit(s); eight state DOCs, including Maryland (Jessup), and the CSC have specialized facilities; six states and Guam send their mentally ill patients to facilities run by other agencies for housing mentally ill populations. Short-term housing of mentally ill offenders usually consists of placing them in an infirmary or in other units removed from the general population. Four DOCs, including Maine, North Dakota, Rhode Island, and South Dakota, offer separate housing only for crisis care.
• Some DOCs provide counseling and mental health treatment programs to address the needs of specific populations. For example, 19 state DOCs address the needs of juveniles; 18 state DOCs and the BOP address the needs of elderly inmates; and 10 states, the BOP, and Guam address the needs of ethnic and racial minorities.
• The report also revealed that DOCs differed on staff training issues. Thirty of the reporting DOCs provided custody/security staff preservice training on managing mentally ill inmates, but each varied on the amount of hours they use for such training. Also noted was that some agencies addressed the issues of inmates with serious mental health problems and those with other mental health needs separately while others addressed both issues in a combined training course. Less than half (22) of the DOCs provided inservice training, and they varied on the amount of hours used for training sessions as well.

Race, Culture, and Ethnicity

Another factor that cannot be ignored in the discussion of mental health is the intersection with race, culture, and ethnicity. According to the Surgeon General's report on mental health in America, it takes a heavy toll on minorities (i.e., Hispanic, African American, Asian, Americans Indians and Alaskan Natives, Asian Americans and Pacific Islanders) in the United States (Department of Health and Human Services, 1999). In this report, Surgeon General Satcher specified how each groups' historical background and demographic patterns, which include family structure, income, education, and health status, are essential factors to understanding the contemporary ethnic identity issues and mental health, and the need for mental health services. In addition, the "Outline for Cultural Formulation" in DSM-IV encourages the diagnosing clinician to: 1) Inquire about patients' cultural identity to determine their ethnic or cultural reference group; 2) Explore possible cultural explanations of the illness (i.e., idioms of distress); 3) Consider cultural factors related to the psychosocial environment and levels of functioning; 4) Critically examine cultural elements in the patient-clinician relationship; and 5) Render an overall cultural assessment for diagnoses and care. For example, some cultural groups conduct religious ceremonies that allow them to perceive visions or voices of mystic figures. This type of experience is considered normal in the culture but may be perceived as aberrant social functioning by the clinician. Another example is the culture-bound syndrome from Japan known as taijin kyofusho, which is an intense fear that one's body or bodily functions give offense to others. This is listed in the Japanese clinical modification of the WHO International Classification of Diseases. There is no accurate demographic picture of the mentally ill with respect to race; however, it is important that mental health professionals and correctional facilities become aware of these factors and the impact they play on offenders' lives.

Numbers of Inmates Receiving Mental Health Services in Selected States (taken from BJS, 2001)

The numbers of inmates receiving mental health services varies from state to state. The table below shows the numbers by selected states. Treatment includes receiving 24-hour care, therapy/counseling, or psychotropic medications

Current Status of Mentally Ill Offender Population and Services in Maryland

According to BJS (2001), approximately 5,400 out of 22,821 total inmates were receiving some type of mental health treatment in state correctional facilities in Maryland as of June 30, 2000. These treatments involved receiving 24-hour care, therapy/counseling, or psychotropic medications. According to Patuxent Institute, Maryland runs just under the national average (16.4%) of number of mentally ill offenders at 16.2%. Therefore, the number of mentally ill offenders in Maryland correctional facilities runs roughly 4,000 to 5,400 inmates. Data are not yet available on the types of mental disorders by demographics on these inmates but are currently being developed.

Other data on Maryland state correctional facilities showed that 12 facilities offered intake screening; 14 conducted psychiatric assessments; 13 provided 24-hour mental health care; 18 provided counseling therapy; 18 distributed psychotropic medications; and 22 helped released inmates obtain services.

According to the Maryland Division of Corrections, the Patuxent Institute houses the majority of the incarcerated mentally ill offenders in the State. The mental health services they provide are part of a cooperative effort that involves mental health professionals employed both by the State and by medical/mental health contractors who are located at each Division of Correction institution throughout the state and at the Division of Pretrial Detention and Services in Baltimore. The identification of individuals with mental health needs begins at time of intake into a State correctional facility and continues throughout the incarceration period.

The Division of Pretrial Detention and Services offers inpatient services for detainees who answer "yes" on any of the automatic booking screen health/mental health questions (Patuxent, 2001). Outpatient services are offered to those offenders who have mental health needs other than in a crisis situation.

The Division of Corrections has mental health staff available at each of the state institutions to provide planning for individuals who are incarcerated and/or getting released, monitoring, and assistance in crisis situations. It also provides referrals for offenders who exhibit severe symptoms of a particular mental disorder to the Correctional Mental Health Center-Jessup, which is the inpatient mental health unit for the Division of Corrections (Patuxent, 2001). The Jessup facility has three components: 1) acute unit, 2) step-down unit, and 3) transitional unit. The goal of the acute unit is to stabilize the individual through medication and therapy so that the offender may return to the maintaining institution. The step down component is for mentally ill inmates who do not require the types of service provided by the mental health unit and who cannot function in the general population. The goal is to focus on emotional and behavioral functioning. The transitional unit, created in 1999, involves working one-on-one with mentally ill inmates who are within 6 to 8 months of release and preparing them for reintegration into society. This component also incorporates case management, collaboration with the Department of Mental Health and Hygiene, the Division of Parole and Probation, and several private industries.

Effective Treatment

It is estimated that between 20 and 30 percent of individuals in jails or prisons have diagnosable mental illnesses. Moreover, between 60 to 80 percent of offenders have significant drug and alcohol abuse problems. These estimates lead us to the main questions of this section. How do we properly identify and treat mentally ill offenders? Additionally, what does the literature tell us about effective treatment and what works?

Work concerning these questions has been considered by several corrections experts. In particular, Eulon Taylor has outlined some important protocols for jails and prisons in order to properly identify and treat mentally ill offenders (2001).

Jails

Should focus on three level of care including acute, subacute, and chronic, each with distinct goals.

1. Acute Level
   • At time of arrest offender should be screened for acute intoxication and acute psychiatric problems.
   • Jails should be prepared to examine offender during booking (minimum assessment includes a set of vital signs such as blood pressure, pulse, temperature, substance abuse screening, suicidal ideation, etc.).
   • When possible, mentally ill offenders should be transferred to a treatment facility (this requires cooperation of jail administration, mental health services admin, and the prosecutor's office); program officials also should establish the types of offenses that will be eligible for referral to a treatment program.
   • Those identified within the first 48 hours should be referred to community programming after release.
2. Subacute Level
   • Those incarcerated from 48 hours to one month should be given a comprehensive diagnostic work-up with emphasis on making a proper diagnosis to prevent false labeling of that individual.
   • Maintain relevant and accurate records about an offender's treatment.
   • Offenders should be closely monitored for relapse especially during first stages of treatment.
   • Continuity of care should be emphasized if offender is incarcerated more than one month.
3. Chronic Level
   • For those inmates incarcerated from two months to several years, a program must be set up to address chronic needs, including psychiatric appointment to monitor medication and the need for medication, psychoeducational groups, and plans for referrals to hospital-type settings.

Prisons

• They should have an intake process where all inmates are screened.
• Screening must have a high-false positive rate.
• Their underlying philosophy should be to treat diagnosed problems as needed with the minimum amount of medications necessary to treat the illness.
• They should also focus on developing problems, supportive care, and emergency referrals for inpatient care.

• If the medication works do not change, officials must recognize that other problems encountered could be due to stress of incarceration.
• Prescribe medication in high dosage; avoid using multiple medications.
• Try supportive therapy first, then try adjusting the medication.
• When possible, withdraw medications; use less expensive medication if there is no clear-cut advantage is found with the new medication.
• Use an objective scale (i.e. psychiatric scale) at each clinic visit.
• Determine reason for noncompliance with medications.
• Do not administer medicine to someone who does not need it, regardless of lawsuit threats.
• Be aware of malingering, or feigning illness to avoid work.

Besides these protocols, the literature on mental health and effective treatment eludes to more specific approaches that have been developed and practiced in recent years. For example, holistic treatment and telemedicine are two widely discussed approaches that have experienced widespread support from mental health professionals.

Holistic treatment

As mentioned previously, many innovative approaches to mental health are being explored. In particular, much of this exploration has been focused on creating holistic mental health programs. Severson (1992) has written extensively about such programs, identifying ten concise components necessary to create a holistic approach to improve the mental health of inmates. These components are the following: communication, medical services, training, employee education, classification, work/academic/vocational programming and job education/training, visitation, employee counseling, and administrative duties. In addition, the major underlying goals of these components are (1) to have all corrections personnel highly involved from the mental health professionals to the security guard to the administrators, and (2) to assume a stake of responsibility or ownership in order for effective implementation of this holistic approach to occur.

Some other key points that will improve mental health services involve self-assessments by correctional personnel and time. Many corrections professionals, especially those in mental health, need to reexamine why they are working in corrections. Is it just to have a job, to contribute some knowledge to the field, or to help an inmate? They need to be able to define their purpose and understand their primary role(s) and responsibilities. Also, more attention needs to be paid not on "how much time is spent on the holistic approach but rather how the time spent."

Telemedicine

This form of treatment is experiencing a rapid growth in various facilities across the United States, including hospitals, mental health clinics, detention facilities. Two separate projects funded by the National Institute of Justice were conducted to examine the application of telemedicine, one in a rural jail setting and another in an urban jail setting (Fitzgibbons & Gunter-Justice, 2000). The first project, done in Kansas Lyon County Jail, resulted in the success of having 32 consultations conducted within the first eight weeks of installation, and a significant improvement in the overall management of inmates needing mental health services. The second set of projects conducted at detention facilities in Beaufort, S.C. and Lexington, KY also had successes. Mental health evaluations were conducted more effectively and efficiently; hours of manpower were saved which translated into cost savings; the drain on local mental health resources was reduced; and relationships with other professionals in the field never before thought possible were established.

Other Mental Health Issues

Besides focusing on what correctional agencies can do to improve their mental health services, similar attention must be directed toward offenders taking responsibility to promote and maintain their own mental well-being and toward staff to promote a positive atmosphere. Some ways offenders can promote and maintain their own mental health are by keeping in contact with family and friends, realizing that they are not alone, being a friend to others, getting involved in different activities to prevent mental boredom, keeping active by getting involved in sports or exercising, and not being afraid to ask for help (WHO, 1998). These recommendations show how important it is to provide a complete and holistic framework in order to fully rehabilitate offenders with mental illnesses. It is somewhat helpful to think of this rehabilitative process in terms of a daily life of an average individual. On a daily basis, the average individual participates in some type of mental or physical activity, converses with an immediate relative or a friend to discuss their problems or seek help, and usually works at a job where a positive environment exists or at least he/she feels comfortable. The same routine must be applied or simulated within the rehabilitative treatment process on inmates with mental illnesses, but probably even to a greater degree than a person without mental illness.

Staff must also be trained to recognize mental health problems, but, more importantly, on how to create a positive atmosphere within the prison community. Kupers noted that many prisons today are warehousing and mistreating large numbers of mentally ill people and that current prison policies are also traumatizing formerly normal prisoners and making them angry, violent, and vulnerable to severe emotional problems (1999). One way to alleviate this problem is by training prison staff to promote mental well-being and teaching them the necessary knowledge to understand symptoms and signs of mental illness. By recognizing these signs, staff can encourage inmates to seek help or at least steer them in the right direction (WHO, 1998).

Another reason prison staff should work collectively to create a positive environment is because this could help prevent suicide attempts common among inmates with mental disorders who often experience mistreatment and harsh prison conditions. According to Sigurdson, approximately 10 to 15% of individuals with mental disorders such as schizophrenia, manic-depressive illness or major depression in the United States die by suicide (2000). A study by Holley, Arboleda-Florez, and Love found that persons with multiple previous attempts had a higher prevalence of mental illness compared with single attempters (1995). Also, they found that lifetime history of a suicide attempt was found to predict mental illness with 70.6% accuracy.

What's Happening in Other States

California (Rivera, 2000)

In November of 2000, the state began a pilot project that took place in Los Angeles, Sacramento, and Stanislaus counties. The program called AB34 draws participants from county jails, hospitals emergency rooms, shelters, parks, and other areas where homeless people congregate. The aim of the program is provide mental health care and services to homeless individuals, who are usually left out of the total mental health provider equation. According to Rivera, there are nearly 50,000 people living on the streets in California who suffer from severe mental illness. Mental health experts believe, however, that with proper assistance and medication(s) many of them could lead relatively stable lives. Based on early data of 1,200 men and 900 women in L.A. who voluntarily enrolled in the program, officials estimate the number of those hospitalized dropped 64%; the number of days spent in jail declined 73% and the number of days spent homeless fell by 58%. This $10 million experiment gained so much support across the political spectrum, among law enforcement, mental health experts, and patients' advocates, that Governor Gray Davis increased the funding to $62.5 million in the 2001 budget to expand the program to additional counties.

Florida (Suriano, 2002)

Recent news shows that Florida jails are crowded with nearly 10,000 mentally ill offenders, not including the 22,000 that are homeless. A group called Partners in Crisis, which consists of judges, mental-health professionals, law enforcement personnel and other advocates, feel that this situation presents a dangerous and expensive burden on law enforcement. Furthermore, the group believes that more money should be given to programs such as the Florida Assertive Community Treatment (FACT), which are already in place in some communities. This program essentially takes a whole team of trained mental health professionals to the client's home and provides the same level of intense care offered in hospital settings. The cost of keeping an individual in an institution is estimated at $107,000 versus only $10,000 for providing these types of intense services in the community.

Georgia (Shanche, 2002)

The mentally ill prison population in Georgia has more than quadrupled from 1,251 in 1991 to 5,737 in 2001. Annual spending grew nearly tenfold from 2.6 million in fiscal 1990 to $24.1 million in 2001. The total bill comes to about $125 million a year to house, guard, and treat almost 6,000 mentally ill inmates. Based on these figures and the increased numbers of mentally ill patients in Georgia, mental health authorities say that Georgia is clearly below the average and the chances that they can deliver good mental health services at this level of investment is "marginal" at best.

Many believe the best alternative is community mental health treatment, which is also believed to be more cost effective. Community Service Board Director Derril Gay says the average cost of treating and adult mental health client in DeKalb is $3,076 compared to the $21,000 it costs on average to keep a mentally ill person in prison for a year. Other experts add this type of treatment contains several hidden benefits as well.

In any event, these initiatives will require more investment in community mental health system. Unfortunately because of recent incidents and the brief economic slowdown, many departments have actually been ordering budget cuts. This is troublesome to many including lawmakers and health authorities because the population of persons with mental illness has been increasing yet the money to provide the necessary services has either decreased or remained stagnate for the most part.

Hawaii (Altonn, 2001)

State health and public safety officials are exploring the possibility of developing a treatment program at an Oahu prison for dangerous mentally ill criminals sent to the State Hospitals in Kaneohe. Some of the concerns include whether a consent decree with federal oversight of the State hospital would follow patients in a prison treatment program, if they have enough room in the prison being that is already overcrowded, and, whether the facilities are appropriate for treatment, physically, because they were really built as correctional facilities. There have been several cases where acquitted criminals who are mentally ill patients have escaped or taken an unauthorized leave from the State Hospital, another reason people are supporting the prison treatment program.

Maine (Remal, 2001; Associated Press, 2001)

Carol Carothers, executive director of the National Alliance for the Mentally Ill of Maine proposed a large, controversial, and expensive bill for a new treatment program. Rep. Edwar J. Povich, House chairman of the Legislature's Criminal Justice Committee, which oversees the state's prison and jails, said he would sponsor legislation derived from her study with a few alterations (Remal, 2000). This bill was sparked by two recent violent incidents that happened at the Maine Supermax prison and by a recent study by the U.S. Department of Justice. The study found that Maine inmates are more likely to be mentally ill than prisoners in most other states. In both Maine county jails and state prisons, nearly a quarter of prisoners are mentally ill and receiving some level of mental health services (Associated, 2001). Furthermore, 220 people per 100,000 are incarcerated in Maine, compared with 682 per 100,000 nationally. This number is relatively high given the small number of people jailed in the state.

Montana (Bellinghausen, 2000)

The criminal justice system has been struggling with several issues pertaining to mental illness and planned a meeting to hear suggestions from mental health advocates professionals and law enforcement officers. These issues involved transportation, availability of services and Medicaid benefits, and training. They discovered that "solving any one of these problems means addressing all of them" because they are indeed interrelated. Two recommendations that received support from subcommittee members were1) to reclassify offenders in pre-release programs so that they can qualify for Medicaid and continue medications, and 2) increase the income limit for seriously mentally ill offenders to qualify for that state's non-Medicaid mental health care programs.

Tennessee (Snyder, 2000)

According to Snyder, nearly one in five inmates in Tennessee jails is mentally ill. The problem, however, is that the state is experiencing a lack of mental health services, particularly in rural counties. A recent report by the Criminal Justice Task Force found a lack of appropriate housing, social service support, and transportation for low income and homeless individuals with mental illnesses and substance abuse problems. In short, the Task Force recommended that mentally ill inmates be given access to mental health services equal to that of the general population, and that diversion services be established to prevent "unnecessary incarceration."

Texas (Timms, 2001)

According to the Dallas Morning News, the Texas prison system has been under federal supervision for several years pending state officials to present a plan that ensures seriously mental ill inmates whose conditions could be worsened by solitary confinement are housed in hospital or other facilities. Some of these measures include: 1) inmates being screened before they are placed in administrative segregation and are regularly visited by medical staff and mental health experts, and 2) no offender with a serious mental illness being placed in segregation until a mental health clinician evaluates the offender and designates housing to be consistent with their treatment plan. In addition, the Texas Dept. of Criminal Justice has increased training for correctional officers and mental health staff to better recognize psychotic patients. So far, two reviews of the inmates in solitary confinement have resulted in 79 transfers from confinement to inpatient hospital for further evaluation and treatment.

Promising Programs

Many mental health programs that are available throughout the criminal justice system have faced trying to effectively manage their limited resources. Some programs have failed while others have showed great promise in assisting mentally ill offenders with needed services and reintegrating them back into their communities. One such program is the Maryland Community Justice Treatment Program (MCCJTP), which deals with mentally ill offenders confined in local jails, prepares treatment and aftercare plans for them, and provides community follow-up after their release (NIJ, 1999, Ortiz, 2000). This program also provides services for mentally ill probationers and parolees, and mentally ill offenders who are homeless and/or have co-occurring substance use disorders. Furthermore, each jurisdiction involved has a local advisory board that oversees the coordinated program assessments, monitors service delivery, and reviews program options. Some of its successes include a reduction in inmates' disruptive behaviors, better trained correctional officers who can effectively identify and refer mentally ill inmates for screening, an increased support system across criminal justice professionals, and several clients that have been able to contribute back to their communities.

Another excellent mental health program operates through Oregon's Department of Corrections. This program adheres to two main philosophies: prioritizing treatment services to those with severe and persistent mental health problems and acting quickly once individuals in need of services are identified (Ortiz, 2000). Much of the programs emphasis is on case management and transitional programs to bring mental health community resources into the prisons prior to release.

In Texas, there exists a legislatively mandated Continuity of Care Program that has shown some promising work. This program identifies mentally ill offenders in need of services six months prior to their release, and community continuity counselors go into the prisons and conduct all the release plans (Ortiz, 2000). The information regarding the offender is then sent to the mental health center in the community where the offender is expected to return and the appropriate supervising authorities are informed of any special conditions.

Conclusions

Considering the history and present status of mental health services and the criminal justice system, it is important that we recognize that prisons were never designed to be primary providers of mental health care. Furthermore, the deinstitutionalization of state mental health hospital caused a shift in responsibilities to the correctional community, which was completely unprepared for such a movement. Another reason we are in what some correctional experts have called "the current crisis in mental health care" is because as state hospitals were emptied, the money necessary to care for patients with severe mental illnesses did not generally follow them into their communities. Essentially, prisons, and jails especially, are becoming the "new state hospitals" but are functioning without the financial resources to do so (Walsh, 2001). Finally, many mentally ill offenders in prisons advance to a more costly high-security level because of irrational or threatening behaviors, and these costs usually exceed the cost of appropriate mental health care in the community. These factors, among others, have created a number of serious implications for correctional facilities in creating and maintaining supportive, sensible, and effective mental health programs in jails and prisons.

Despite the many issues that surround the increasing numbers of mentally ill offenders, the correctional community and mental health professionals have responded with several initiatives. In the past decade they have devised better management solutions of the limited resources available and the developed some promising projects, treatment frameworks, and promising programs, such as jail diversion programs. Reginald Wilkinson, Ohio (DRC) Director, put it best when he said that it is important to have a good correctional mental health treatment program because it is the "right thing to do." Furthermore, he articulated that spending early on mental health treatment programs means spending less later, better protection for community, and safer, easier-to-manage prisons.

According to University of New Mexico psychologist Roger Paine, "There is really no way to produce an accurate picture of mental illness in prisons." Requesting numbers on mentally ill inmates from prisons or jails results in fictitious numbers because most do not have adequate measures to determine who has a mental illness or not (Associated Press, 2001). Regardless of this problem, it is imperative that the appropriate resources are allocated to correctional facilities to provide the essential types of mental health services required for mentally ill inmates. There must also be proper documentation and evaluations of promising programs and projects already mentioned and forthcoming, with emphasis on informational systems. This will allow researchers to examine the integrity of these programs and to develop better mental health models with regard to diagnostics, staff training, treatment issues, aftercare, and other mental health issues.

Recommendations

Below is a list of recommendations from Sigurdson (2000), unless otherwise specified.

1. End stigmatization and discrimination that surround mental illness and make clear distinctions between treated and untreated mental illnesses.
2. Prevent harmful delays in the treatment of individuals with severe mental illnesses--make treatment more accessible.
3. Develop laws that enforce treatment for mentally ill individuals before a far more restrictive commitment-to prison-is the only option.
4. Require mental health centers to provide comprehensive care and supervision, including the use of clinics, hospitals, day treatment, residential programs and assertive case management (Wilkinson, 2000).
5. Increase usage of outpatient commitment programs, which are often underused.
6. Continue formal coordination between police, courts, and mental health officials to maximize use of limited resources of most community mental health systems.
7. Ensure that treatment and care for mentally ill offenders are conducted by properly trained and licensed staff.
8. Incorporate more and increase telemedicine services, which will allow contact with more specialists in the field of mental health and increase accessibility to appropriate treatment and care (Fitzgibbons & Gunter-Justice, 2000).
9. Increase pre- and in-service training for correctional staff and specialized mental health training for specific staff members (e.g., Ohio DOC requires new staff to complete a five-week pre-service training program, three weeks at the Corrections Training Academy, and two weeks on the job training. In addition, annual in-service training is required and a three-day program designed to increase knowledge about mental illness is required for non-mental health staff (Wilkinson, 2000).
10. Divert more correctional funds to mental health programs so planning revolves less around cost saving issues and more attention can be focused on ensuring that inmates receive appropriate treatment and upgrading resources.
11. Require correctional administrators to reevaluate their personnel and mental health staff to facilitate a better understanding of their role(s), purpose, and goals, and to ensure the staff understands their responsibilities as well.
12. Continue development of innovative programs, such as jail diversion programs that provide legal sanctions and appropriate health care to mentally ill offenders.
13. Continue educating mental health professionals about the importance of understanding the differences among race, ethnicity, and culture when diagnosing, treating, and caring for mentally ill offenders.
14. Consider adopting advance health care directives, also know as living wills, to secure treatment for offenders before they become mentally incompetent (Failing, 2001).
15. Continue to inform the public on mental health issues through newsletters, media, etc.

References

Associated Press. (2001). One-fifth of mentally ill state prisoners left untreated. Retrieved October 16, 2001 on the World Wide Web: http://msnbc.com/news/601138.asp?cp1=1

Associated Press. (2001). Maine prisoners have higher rate of mental illness. Retrieved September, 18, 2001 on the World Wide Web: http://bangornews.com/cgi-bin/article.cfm?storynumber=41317.

Associated Press. (2001). Mentally ill inmates need aid, report says. Retrieved February 1, 2001 on the World Wide Web: http:// bangornews.com/cgi-bin/article.cfm?storynumber=28276.

Alton H. (2001). Prisons examine treating mentally ill. Retrieved June 27, 2001 on the World Wide Web: http://www.starbulletin .com/2001/06/26/news/story5.html

Bellinghausen, P. (2000). Justice system struggles with mental illness. Retrieved January 11, 2000 on the World Wide Web: http://www. billingsgazette.com/region

Boesky, L. (2001). Mental health training in juvenile justice. Corrections Today, 98-101.

Bureau of Justice Statistics. (2001). Mental health treatment in state prisons, 2000. U.S. Department of Justice.

Criminalization fact sheet IV. (2000). Mental Illness Among Inmates in Criminal Justice Facilities. Judge David. L. Bazelon Center for Menatal Health Law. Retrieved October 16, 2001 on the World Wide Web: http://www.bazelon.org/criminal14.html.

Department of Health and Human Services. (1999). Mental health: Culture, race, and ethnicity. A supplement to mental health: A report of the surgeon general. U.S. Public Health Service.

Ditton, P. (1999). Mental health and treatment of inmates and probations. National Institute of Justice. U.S. Department of Justice.

Failing, L. (2001). Medical treatment and mentally incompetent inmates. Corrections Today, 106-109.

Ferrara, M., & Ferrara, S. (1991). The evolution of prison mental health services. Corrections Today, 53: 198-203.

Fitzgibbons, M., & Gunter-Justice, T. (2000). Telemedicine and mental health in jails: A new tool for an old problem. Corrections Today, 62 (6): 104-107.

Holley, H., Arboleda-Florez, J., & Love, E. (1995). Lifetime prevalences of prior suicide attempts in a remanded population and relationship to current medical mental illness. International Journal of Offender Therapy and Comparative Criminology, 39: 190-209.

Jailing the mentally ill. (2000). Retrieved on October 16, 2001 on the World Wide Web: http://www.american radioworks.ord/features/mentally_ill/poll/stats.html.

Kupers, T. (1999). Prison madness: The mental health crisis behind bars and what we must do about it. San Francisco: Jossey-Bass Publishers.

Liska, A., Markowitz, F., Whaley, R., & Bellair, P. (1999). Modeling the relationship between the criminal justice and mental health systems. American Journal of Sociology, 104 (6): 1744-75.

Mental health promotion and well being in young offenders institutions for all who work in prisons. Health in Prisons Project. World Health Organization.

Mobley, M. (1986). Mental health services: Inmates in need. Corrections Today, 48: 12- 14.

National Institute of Corrections. (2001). Provision of mental health care in prisons. U.S. Department of Justice.

National Institute of Justice. (1991). Mental disorder and violent crime: A 20-year cohort study; Final report. U.S. Department of Justice.

National Institute of Justice. (1999). Coordinating community services for mentally ill offenders: Maryland's Community Criminal Justice Treatment Program. U.S. Department of Justice.

Nelson, B. (1998). Changing paradigms in correctional mental health care: Georgia DOC meets the challenges of the new managed care. Corrections Today, 60 (2): 126.

Olson, J. (2001). Incarceration, homelessness, and health. National Health Care for the Homeless Council Policy Statement.

Ortiz, M. (2000). Managing special populations. Corrections Today, 62 (7): 64-68.

Patuxent Institution. Retrieved December 6, 2001 on the World Wide Web: http://www.dpscs.state.md.us/pat/index.htm

Remal, G. (2001). Report: Mentally ill prisoners ill served. Retrieved January 31, 2001 on the World Wide Web: http://www.centralmaine.com/news/stories/010131mental_j.shtml

Rivera, C. (2000). Helping hands for mentally ill. Retrieved June 9, 2000 on the World Wide Web: http://www.latimes.com/news/politics/calpol/

Schanche, D. (2002). Prisons: A costly answer to mental health care. Retrieved June 28, 2002 on the World Wide Web: http://www.macon.com/mld/telegraph/2555684.htm.

Severson, M. (1992). Redefining the boundaries of mental health services: A holistic approach of inmate mental health. Federal Probation, 56: 57-63.

Sigurdson, C. (2000). The mad, the bad and the abandoned: The mentally ill in prisons and jails. Corrections Today, 62: 70-78.

Snyder, B. (2000). Mental illness high in state jails. Retrieved June 28, 2000 on the World Wide Web: http://www.tennessean.com/sii/00/06/28/jail28.shtml

Suriano, R. (2002). Mentally ill crowd jails, group says. Retrieved June 30, 2002 on the World Wide Web: http://www.orlandosentinel.com/

Taxman, F., & Bouffard, J. (1999). Assessing Therapeutic Integrity in Modified-Therapeutic Communities for Drug-Involved Offenders. National Institute of Justice.

Taylor, E. R. (2001). Using algorithms and protocols in diagnosing and treating offenders with mental health disorders. Corrections Today: 80-83.

Timms, Ed. (2001). State says it has begun treatment of seriously mentally ill inmates. Retrieved on December 18, 2001 on the World Wide Web: http://www.dallasnews.com/texas_southwest/

Walsh, B. (2001). Counties'crisis: Jails become the 'new state hospitals'. Retrieved November 5, 2001 on the World Wide Web: http://www.portland.com/news/local/011104jails.shtml

Wilkinson, R. (2000). Mental health care for Ohio state prisoners: The view from the director's office. Correctional Mental Health Report.

World Health Organization. (1998). Health in prisons project: Third meeting (Helsinki). Regional Office of Europe, Department of Health, and UK National Health Service.