Confronting the Mental Health Crisis in Prisons and Jails

The Psychological Impact of Incarceration

The state of mental health in incarcerated populations is a mirror of broader societal issues and how people with mental health challenges are treated in our communities. The connection between mental health and the criminal justice system is complex and cannot be fully resolved by the justice system alone.

An alarming number of people in the system grapple with preexisting mental health conditions as well as worsening mental health. A person’s incarceration has inherent stressors, including the series of events that led to the conviction.

The Link Between Incarceration and Mental Health

According to a report by the U.S. Department of Justice, 1 in 7 federal prisoners and 1 in 4 jail inmates experienced serious psychological distress (SPD) in the 30 days prior to a survey on the issue.

SPD is an extreme mental state in which a person is moderately or severely incapable of functioning in work, daily living, social, or learning settings. It is often linked to conditions including anxiety, depression, PTSD, and other mental health concerns.

A person with SPD may have the following symptoms:

• Difficulty sleeping or excessive sleep
• Persistent feelings of anger or persecution
• Overwhelming sadness
• Difficulty regulating emotions, which may include aggression
• Extreme fidgeting (nervous movement)

Often, an incarcerated person’s mental health concerns do not start in jail or prison. In fact, an overwhelming number of people with mental health issues end up in the prison system, and SPD often plays a role. Challenges related to SPD can interfere with social interactions and behavioral expectations.

An estimated 37% of inmates in state and federal prisons and 44% in local jails have a history of mental health conditions.

Gaps in Treatment and Continuity of Care

According to the Bureau of Justice Statistics, 63% of people incarcerated with mental health challenges are not receiving treatment while they are in prison or jail. However, access to treatment varies by facility, and the availability of mental health services is influenced by resources, staffing, and institutional policies.

Research suggests that access to psychiatric medications may be inconsistent, with approximately 50% of people who were prescribed psychiatric medication before incarceration reporting they did not receive their medications once behind bars. Interruptions in psychiatric care can pose challenges for individuals who were following treatment regimens before entering the system.

In fact, in 44 states, there are more people with mental health conditions in prison/jail than in the largest remaining state mental health hospital. This amounts to three times more people with mental health challenges being incarcerated than in psychiatric facilities, leading to discussions about the role of correctional facilities in mental health care and the availability of alternative treatment settings.

For example, a person who enters the system with mild or manageable mental health symptoms may experience worsening symptoms due to environmental stressors. If access to care remains limited during their sentence and after release, ongoing difficulties in managing mental health may increase the risk of reincarceration.

Types of Mental Health Challenges in Jails and Prisons

Among those in prison with a history of mental health disorders, a 2017 U.S. Department of Justice report found that:

• 24% have been diagnosed with major depressive disorder (MDD)
• 17% have been diagnosed with bipolar disorder
• 13% have been diagnosed with a personality disorder
• 12% have been diagnosed with post-traumatic stress disorder (PTSD)

The rate of these diagnoses is higher among jail inmates, with data suggesting that approximately one-third have been diagnosed with major depressive disorder and nearly one-quarter with bipolar disorder.

It’s important to note that estimates can vary widely, and discrepancies can come down to differences in record-keeping, how studies are conducted, and the level of access to psychiatric services, which may leave some people unaccounted for.

Gaps in data collection and treatment accessibility contribute to challenges in assessing the full scope of mental health needs among incarcerated individuals.

Impact of Incarceration on Mental Health and Reentry

The relationship between mental health and incarceration is multifaceted. Incarceration not only impacts individuals with preexisting mental health conditions, but it may also contribute to new or exacerbated psychiatric symptoms.

Factors that may affect mental health within prisons and jails include:

• Overcrowding
• Limited opportunities for social interaction or mental health support
• Challenges in accessing comprehensive physical and mental health care
• Limited access to balanced nutrition
• Restricted movement
• Concerns about safety
• Frustration with perceived or actual systemic issues

These factors can contribute to difficulties in rehabilitation and reintegration.

For some individuals, these challenges may increase the likelihood of recidivism, which generally refers to returning to criminal behavior after receiving a sanction or participating in a rehabilitation program for a previous crime.

How Mental Health Challenges Can Lead to Incarceration

Studies show a direct link between untreated mental health concerns and an increased likelihood of risky behaviors. People who struggle with untreated conditions, especially trauma, may turn to legal or illegal street drugs or alcohol to “self-medicate.”

As these individuals move deeper into this environment, they are often exposed to other crimes such as theft, vandalism, or violence. This can create a cycle of worsening mental health as well as an increased risk of behavior that can lead to incarceration.

A person who is experiencing an untreated mental health condition may also turn to risky activities as a way to cope. Such behaviors could include taking part in illegal activities to generate a dopamine rush.

Studies show people with untreated mental health challenges are more likely to engage in other risky behaviors, including:

• Experiencing difficult or unstable relationships, which may lead to incidents of domestic conflict
• Becoming a “young” parent due to risky sexual behaviors
• Dropping out of school
• Struggling to hold a steady job

Mental Health of Incarcerated Youth

Young individuals in the juvenile justice system exhibit high rates of mental health disorders, with statistics suggesting that up to 70% of youths in detention may have diagnosable mental health challenges. This finding is consistent with other studies regarding incarcerated adults. Kids with mental health issues are more likely to follow a path that leads them into the juvenile system, which can eventually lead to the adult system.

The difference between incarcerated and non-incarcerated individuals is stark. Only 9% to 22% of youths in the general population have a diagnosable mental health condition compared to 70% of kids in the juvenile system who do.

Research shows that between 75% and 93% of kids entering the juvenile correction system each year have experienced some level of trauma, further emphasizing the profound impact of trauma on youth.

Putting a young person into the justice system without mental health support is setting up the individual for long-term struggles with mental health and a higher likelihood of recidivism. As few as 20% of kids in the system with a diagnosed mental disorder receive mental health care.

While youth is a prime time to help turn a person’s life around, overcrowded institutions often focus on punitive measures rather than addressing mental health needs.

One thing is clear: Addressing mental health needs at a young age is crucial for fostering rehabilitation and preventing a transition into the adult correctional system. Early intervention is critical and has implications for individuals, their families, communities, and society as a whole.

Challenges Within the Justice System

The justice system presents numerous and complex challenges to the mental health and well-being of incarcerated individuals. From inconsistent access to care to environments that can worsen symptoms, the obstacles within prisons and jails are significant and often overwhelming.

Understanding these challenges is essential to advancing reform that prioritizes rehabilitation and better mental health support.

Lack of Physical and Mental Health Care Resources

In U.S. prisons and jails, mental health treatment is inconsistent and often inadequate.

With tight budgets and a lack of support from governmental leadership, facility administrators often struggle to prioritize mental health care.

As a result, incarcerated people receive delayed diagnoses and limited access to ongoing care. Many facilities do not prioritize providing inmates with psychiatric medication because the cost is too great.

Professionals in these settings often try their best to provide care. However, they face insurmountable odds, outrageous workloads, and limited resources, further complicated by public perceptions of prisons as places for punishment rather than opportunities for rehabilitation. Shifting the focus to rehabilitation could potentially help reduce the prison population.

Gains Are Too Little and Too Late

The topic of mental health of incarcerated people has garnered increased advocacy in recent years. However, as soon as new programs arise, they become overwhelmed—needs outpace time and resources. A survey of corrections representatives from six states found that 80% of respondents believed their facility lacked sufficient mental health staff.

Exacerbating Factors

Prisons are crowded and lack privacy, and inmates remain on constant alert for possible threats. Incarcerated people often see, experience, or hear about violence daily. At the same time, because they have little control over their circumstances, they are not in a position to improve their situation.

Many who end up in the system have experienced violent trauma. In prison, they may face conditions that contribute to further trauma, with some serving sentences of five, 10, or 25 years with limited opportunities for relief. This situation has a direct impact on a person’s mental health, contributing to the well-documented correlation between incarceration and worsening mental well-being.

Separation Practices

It is estimated that over 122,000 incarcerated people are placed in restricted areas, separate from the facility’s general population, at any given time in the U.S., and people diagnosed with mental health challenges are much more likely to be placed in such settings.

Lack of mental stimulation, physical activity, and social interaction can lead to worsening mental health status, including but not limited to:

• Psychosis
• Obsessive thinking and behaviors
• Paranoia
• Suicide attempts or suicide

In fact, suicide rates in settings where individuals are separated from the general population are over five times that of the prison’s general population. People are social creatures—we need connection, regardless of the situation.

Worsening symptoms due to this separation can lead to longer stays in such conditions, further increasing the risk of suicide.

While practices of separating individuals from the general population are becoming less common, the impact of these practices remains a significant concern within the justice system. Efforts to reduce such practices are ongoing, signaling a shift toward more rehabilitative approaches that prioritize mental health and social support.

Suicide Risk

A small Illinois study found that 77% of those who attempted suicide in jail had severe and ongoing mental health problems compared to 15% in the general jail population.

In fact, suicide is one of the few mental health concerns treated as a major problem in institutions.

However, the impact extends beyond those who attempt or die by suicide, as others at the facility may be affected by the event. For vulnerable individuals, hearing about a suicide can increase the likelihood of experiencing suicidal thoughts themselves.

Disparity

Multiple disparities impact who ends up in the prison system.

Black, Latino, and Indigenous populations are overrepresented in the prison population. Members of these groups are also less likely to receive adequate mental health support in the system. Financial, economic, and educational barriers can worsen these discrepancies.

Because a disproportionate number of people in these groups have spent time in the system, their communities are impacted. Without proper support upon release, a cycle of mental health issues and incarcerations is likely to continue.

Recidivism

Having a criminal record of any kind stacks the cards against you. If a person entered the system years ago during a mental health episode, having the episode on their record could likely impact future sentencing for unrelated and often minor offenses. The fact that the individual has since managed their mental health may not always be considered in the judicial process.

With that said, recidivism is not inevitable. Research shows that improving access to outpatient mental health treatment for people leaving prison reduces the chances they will commit a serious crime that lands them back in prison.

While some states and communities are better than others at offering release services, many communities have resources available. Such programs help people access mental health care and reintegrate into society. These programs can assist with housing, employment, and ongoing mental health treatment.

The Current Mental Health Evaluation Process

Within the U.S. federal prison system, every inmate undergoes a mental health screening. This process is primarily intended to identify urgent mental health needs that, if left untreated, could pose a risk to self, other members of the prison population, or staff.

The intake process is often in the form of a questionnaire, for which there may be follow-up if red flags emerge.

Depending on the outcome, the patient may:

• Be placed in a separate unit from the general population (in extreme situations)
• Be enrolled in therapy
• Receive medication

However, while intake is a standard procedure, limited resources and a lack of mental health infrastructure can often result in inadequate care. Inmates whose cases are deemed non-urgent or not serious may not receive treatment.

It’s important to mention that these are federal prison standards. Procedures and level of care can vary by state. Funding, laws, and oversight procedures can all impact the actual procedures and care a person receives upon entering the system.

For example, in the state of Massachusetts, every inmate undergoes an initial assessment for urgent mental health concerns.

If they do not have an urgent issue, the state requires that they undergo a mental health evaluation within 14 days of arrival by a licensed and qualified mental health professional. This professional can then refer the inmate to various levels of treatment.

Under Massachusetts law, inmates can also self-refer by making a written or verbal request for a mental health evaluation.

Prison Release Mental Health Discharge Planning

Effective discharge planning is essential for the mental health of incarcerated people. According to the American Psychiatric Association (APA), prison discharge plans should include:

• Arranging follow-up appointments for inmates with serious mental health conditions
• Transferring medical records to referred providers
• Arranging to have prescriptions renewed or reevaluated

However, despite such recommendations, federal standards for discharge planning do not exist, and mental health discharge planning varies by state.

The American Medical Association (AMA) compares prison discharge with hospital discharge, for which the Centers for Medicare and Medicaid Services offer clear guidelines.

In contrast, prison discharge practices across the U.S. are inconsistent and often underfunded. Plans range from nonexistent (no medications or medical records are coordinated) to partial (with support from community-based organizations) to relatively robust (medications, medical appointments, and the release of medical records are arranged).

The effectiveness of discharge planning can significantly affect how individuals reintegrate into their communities following incarceration. The more comprehensive discharge planning is, the better recently incarcerated people can adjust to their communities outside of prison.

Enhancing Mental Health Care in Correctional Facilities

Improving mental health care in correctional facilities requires a multifaceted approach. Organizations like the National Commission on Correctional Health Care (NCCHC) and the American Correctional Association (ACA) establish standards to guide care, while broader system and reentry reforms address the ongoing needs of incarcerated individuals, particularly juveniles.

NCCHC and ACA’s Role in Mental Health Care Standards

The National Commission on Correctional Health Care (NCCHC) and the American Correctional Association (ACA) are instrumental in enhancing mental health care within correctional facilities, each setting critical standards and offering resources to ensure the effective treatment and support of inmates with mental health conditions.

The NCCHC develops and promotes standards for health care services in jails, prisons, and juvenile facilities, including mental health care. Its accreditation process helps correctional facilities follow best practices, ensuring staff receive training to appropriately respond to individuals experiencing mental health crises.

Research shows that NCCHC accreditation ensures better adherence to health care standards, decreases mortality, and lowers the rate of repeat offenses.

Similarly, the ACA establishes operational standards for correctional facilities, including guidelines for mental health services. Its accreditation process evaluates compliance in areas such as safety, care, and rehabilitation.

The ACA also advocates for policy changes that prioritize mental health care and provide training for corrections staff, reinforcing a system that supports individuals from initial screening through long-term treatment.

It is important to note that both the NCCHC and ACA accreditation processes are voluntary. As a result, standards of care may vary across different correctional facilities.

Addressing Systemic Challenges in Mental Health Care

While accreditation sets important benchmarks, broader reforms are needed to improve mental health care within the justice system. Experts have called for policy changes such as:

• Updating mental health treatment laws at the state and potentially federal level
• Implementing alternate court systems for certain individuals based on mental health
• Expanding outpatient programs to serve as a preventative measure
• Requiring mental health screening at intake

In addition to these steps, it’s vital for prison systems to address staffing shortages, prioritize hiring mental health professionals, and train non-clinical staff with a baseline understanding of working with people who have mental health challenges.

Such reforms aim to create a more humane and effective system that not only addresses immediate mental health needs but also contributes to long-term recovery and rehabilitation.

Reentry Reforms

The transition from incarceration to community life presents significant challenges for individuals with mental health conditions. Effective reentry programs are vital for reducing recidivism and supporting successful reintegration.

Initiatives like the Court Services Offender Supervision Agency (CSOSA) in Washington, D.C., exemplify the positive impact of early reentry planning and coordination of necessary services. This program offers mental health services to people immediately upon release, regardless of whether they’ve been previously diagnosed.

The Second Chance Act, approved by Congress in 2008, authorized federal grants for programs and systems that improve the reentry process.

The act supports state, local, and tribal governments as well as non-profit organizations to improve outcomes for formerly incarcerated individuals.

Reentry services include:

• Trauma-informed programming and support
• Mentoring and peer support
• Behavioral health/substance use disorder treatment
• Physical health care
• Safe and affordable housing
• Coordinating literacy and education services
• Employment

Enhanced communication between correctional facilities and community service providers is critical. It ensures that individuals returning to their communities receive timely and appropriate care. When correctional facilities establish partnerships with mental health agencies and community organizations, returning individuals are more likely to access essential services.

By providing a structured support system, reentry programs mitigate the risks associated with transition. They foster stability and well-being for formerly incarcerated individuals.

Juvenile Care

Youths in the juvenile justice system face unique mental health challenges and require tailored approaches to care and treatment. The mental health challenges that can lead a young person deeper into the justice system can be addressed with evidence-based interventions, such as the following:

• Cognitive behavioral therapy (CBT) involves changing thinking and behavioral patterns. Treatment usually includes problem-solving skills and relaxation techniques.
• Functional family therapy (FFT) is an intensive, short-term treatment that explores how a youth’s behavior has been shaped by the family environment. Treatment aims to assess risk and protective factors within and outside the family and modify strained family relationships.
• Multisystemic therapy (MST) assesses how a youth’s mental health condition and environment influence involvement in the juvenile justice system. Treatment includes improving problem-solving skills, developing positive coping skills, and reducing negative behaviors.

Each of these treatments has shown promise in addressing the mental health needs of justice-involved youths, reducing recidivism rates, and promoting positive outcomes.

Diversion initiatives and specialized juvenile mental health courts can prevent the unnecessary criminalization of youths with mental health conditions.

Such programs ensure that a young person’s mental health status is consistently being taken into account. They provide alternatives to detention because they emphasize treatment and rehabilitation over punishment.

Ensuring access to appropriate mental health services, both during and post-detention, is crucial for addressing the complex needs of this vulnerable population.

Prioritizing Mental Health Care in the Justice System

Addressing the mental health needs of incarcerated individuals is critical to breaking the cycle of untreated mental health conditions that lead to incarceration, worsen during imprisonment, and create barriers to accessing care both during incarceration and after release.

With higher rates of psychological distress and mental health disorders among incarcerated individuals compared to the general population, the need for comprehensive mental health care is undeniable.

Shifting focus to rehabilitation, coupled with effective discharge planning and early intervention, especially for youth, can help break this cycle, supporting individuals in leading healthier, more stable lives after incarceration.

Prioritizing mental health care within the justice system is essential to fostering long-term recovery and reducing recidivism.

Mental Health Resources for Formerly Incarcerated Individuals and Their Families

Stepping Up Initiative
This initiative aims to prevent those with mental health challenges from entering the justice system in the first place. They work directly with counties nationwide to ensure individuals have access to the resources and training they need to increase collaboration in the justice system.

Criminal Justice System Intercept 4 – SAMHSA
The Substance Abuse and Mental Health Services Administration website helps individuals find local mental health resources. This program specifically focuses on assisting people to transition back into the community.

Reentry After a Period of Incarceration – NAMI
The National Alliance on Mental Illness provides valuable resources for inmates and families planning a successful release. It includes information, websites, and phone numbers for local organizations that can help with immediate needs, such as food, housing, social reintegration, health care, and ongoing mental health care.

Mass.gov Reentry Planning Resources
This program provides contact information for Massachusetts residents leaving incarceration who need help with food, housing, mental health care, employment, and community resources. If you’re not in Massachusetts, a similar webpage is available for your state.

Prison Policy Initiative
This nonprofit organization researches and exposes the harm of mass incarceration and advocates for prioritizing mental health support in the justice system.

Prison Mindfulness Institute
This program trains prisoners, prison staff, and prison volunteers in the power of mindfulness to transform how to understand and relate to the world for the better.

Contributors

Ashley M. O’Brien, MSN, RN, Amanda Seirup, PsyD