Mentally ill more likely to be in prison than a hospital

The move in the Legislature came as Riverview faced the prospect of losing $20 million in federal funds after an unannounced inspection of the 92-bed facility by federal officials. In an 88-page inspection report, the officials pointed out a number of deficiencies that put the funding at risk, from a failure to ensure staff and patient safety to a dentist’s failure to wear eye protection during exams.

The legislation was an attempt to ease Riverview’s overcrowding. The state’s transfer of some patients from the psychiatric hospital to the state prison would fit a trend in recent decades in which prisons and jails have seen a surge in the number of people with mental illness.

A move away from hospitals

The United States in the 1950s started a major move away from the use of psychiatric hospitals to treat the mentally ill. Deinstitutionalization, as the change was known, came as a new antipsychotic medication, Thorazine, was introduced, potentially allowing mentally ill adults to manage their conditions outside institutional walls.

In 1965, the start of Medicaid, the public health insurance program for the poor and disabled, accelerated the shift away from institutional treatment for the mentally ill. Deinstitutionalization also gained momentum as public opinion turned against psychiatric hospital treatments such as electroshock therapy.

In 1959, nearly 559,000 patients with mental illness were committed to state-run psychiatric hospitals. Forty years later, according to the National Institute of Corrections, that number had dropped to about 70,000.

In 1955, there was one hospital psychiatric bed for every 300 Americans. Fifty years later, that ratio dropped to one bed for every 3,000, according to a 2010 study by the National Sheriffs Association and the Treatment Advocacy Center.

“There was an effort to get folks out into the community,” said Jenna Mehnert, executive director of Maine’s chapter of the National Alliance on Mental Illness. “The challenge is, you have to do the work to make sure what that plan [for providing services in the community] looks like and really be smart about the services you put in place, and you have to fund it.”

But states largely failed to put in place the quality of community-based services — such as housing and specialized treatment — that mentally ill patients leaving psychiatric institutions required.

“Services in the community are harder to manage because they’re not happening right under your nose,” Mehnert said. “They’re the right thing to do. They’re just the harder thing to do.”

As institutions released their patients, the percentage of inmates with mental illness at local jails, state prisons and federal correctional facilities grew rapidly. In 1983, a study estimated about 6.4 percent of the U.S. prison and jail population had a serious mental illness. Today, according to the sheriffs association study, the number is about 16 percent.

The Bureau of Justice Statistics estimated in 2006 that 1.3 million mentally ill adults were incarcerated in U.S. prisons and jails.

The growth in the mentally ill prison population isn’t directly connected to the closure and downsizing of state psychiatric hospitals, said Helen Bailey, general counsel for the Disability Rights Center.

“Would the fact that we no longer put people into institutions lead to more mentally ill people in prison?” she said. “If we’re failing people and not providing services that they otherwise need, then that would happen.”

It’s also a matter of definition, she said. “The whole notion of what is mental illness has changed.”

Maine’s shrinking psychiatric hospitals

While a national move away from psychiatric institutions began in earnest in the 1950s, Maine’s two state-run psychiatric hospitals in Bangor and Augusta didn’t start shrinking until the 1970s.

The Bangor Mental Health Institute’s patient count peaked in 1970 at 1,200. The population dropped to 470 in 1974, and the hospital housed 300 patients through much of the 1980s. The hospital was renamed the Dorothea Dix Psychiatric Center in 2005, and today it’s a 51-bed facility.

The Augusta Mental Health Institute treated an average of about 1,700 patients in the 1950s. In the 1960s, the hospital started moving some of its patients to foster and boarding homes, but the order to deinstitutionalize didn’t come until the next decade.

In the 1970s, AMHI’s population dropped to about 300 patients from 1,500 in five years. AMHI’s population continued to shrink, and the hospital closed in 2004, replaced by the new, 92-bed Riverview Psychiatric Center on the AMHI campus.

Mental health treatment in Maine

As the Bangor and Augusta psychiatric hospitals contracted, Maine relied heavily on boarding homes for housing the patients who left the hospitals, said Bailey.

“We developed a system, and then I think we’ve neglected the system,” she said.

There have been a number of efforts over the years to provide services for people with mental illness, according to Bailey, but those services often fell victim to state budget cuts. Plus, the treatments often have involved frequent changes for the people receiving them, she said, with patients being moved to different settings to receive different levels of care.

“If you want to stabilize mental illness, you have to stabilize housing and stabilize relationships,” Bailey said. “We do things that are absolutely destructive. We change things.”

And without appropriate services, she said, “Guess what door they’re going to re-enter through. They’re going to re-enter through the emergency department.”

Or through the criminal justice system, which often is someone’s only outlet for receiving required treatment.

It remains a challenge in Maine today to find specialized mental health services in many parts of the state. According to Mehnert, it’s nearly impossible to find specialized services north of Augusta.

That means it becomes more challenging to diagnose mental health conditions early in life, when people can be taught to manage those conditions and live with them without being hospitalized, Mehnert said.

“It really is a workforce issue layered on top of a service issue,” she said.

Mehnert recommends a concerted effort to attract mental health professionals to work in Maine through a student loan forgiveness program. The professionals need to be paid well, and they need frequent, hands-on training in best practices, she said. And the state needs to contract with treatment providers who are using evidence-based treatments recognized by the U.S. Substance Abuse Services and Mental Health Administration.

“The challenge is, how do we look comprehensively at a continuum of quality services that start in the community, that start with early identification for kids,” she said, “and not invest all our money in the deeper end and institutionalize mental illness.”

Matthew Stone is BDN opinion page editor.