More that sixty years ago, British scientist Lionel Penrose published a provocative study showing that the population size of prisons and that of psychiatric hospitals tended to be inversely related. Across 18 European countries, when fewer hospital beds were made available to care for mentally ill individuals, significantly more people were incarcerated in penal institutions. The "criminalization of the mentally ill" today is a contested hypothesis, and contemporary scholars view "Penrose's Law" as an oversimplification. (Most people who commit crimes are not mentally ill, and most with psychiatric disorders do not commit crimes.) Still, there is little doubt that inadequate care and treatment for persons with severe psychiatric disabilities can place them at higher risk of arrest and incarceration - with bad consequences not only for them, but ultimately for the whole community.
      A recent Duke University study of persons in North Carolina with severe mental illness found that 20 percent were arrested within one year following hospital discharge, largely for drug-related crimes or minor offenses such as trespassing, disturbing public order, and public intoxication. (Compare that to a lifetime arrest rate of less than 5 percent for the American public.) The U.S. Justice Department estimates that 16 percent of individuals currently incarcerated in our prisons and jails suffer from a severe psychiatric condition such as schizophrenia, bipolar disorder, or major depression. Among the indirect costs of mental illness to society, the 1999 Surgeon General's Report estimates $4 billion annually in lost productivity for incarcerated mentally ill Americans.
      In North Carolina, an estimated 23,000 adults with mental illness are under Department of Corrections supervision - about 5,000 incarcerated in state prisons and 18,000 on probation or parole. Additionally, over 7,000 North Carolinians were admitted last year to correctional treatment facilities for offenders with addiction disorders. A large proportion of the mentally ill in criminal justice settings also suffer from alcoholism or other drug abuse. An estimated 60 percent of mentally ill offenders were using illicit drugs or alcohol at the time they committed the offense for which they were arrested.
     Employing the criminal justice system to deal wholesale with the problematic behavior of people with untreated psychiatric disorders is not only unfortunate and misguided - it is also hugely expensive. Not counting capital expenditures, our state's Department of Corrections last year spent an estimated $117 million solely for the incarceration of persons with mental illness (excluding substance abuse).
      The disorders that afflict these thousands of North Carolinians currently in prison and jail are effectively treatable, with success rates of 60-85 percent. That's better than for heart disease. Given timely intervention with community-based mental health services - including medication, supportive therapy, or substance abuse treatment as appropriate - many of these persons might never have committed the offenses that landed them behind bars. Once they are incarcerated, things only get worse for most offenders with mental disorders.
      Unfortunately, psychiatric treatment is a scarce commodity in jail. U.S. Justice Department national surveys find that 60 percent of persons with severe mental illness in jail and 40 percent of those in state prisons receive no treatment. According to another government study, less than 1 percent of North Carolina's total state prison population receives specialized psychiatric inpatient care; only 7.5 percent receive psychological counseling; and only 8.9 percent receive psychotropic medication.
      Besides lack of treatment, the prison environment is no place for someone who is suffering from a serious, disabling psychiatric illness such as schizophrenia. A 1993 study of offenders' adaptation to life in prison found that inmates with schizophrenia fared significantly worse than their fellow prisoners on every correctional outcome measure that could be studied - number of lock-ups, length of stay in lock-up, ability to work while in prison, and ability to obtain release. When they are released, many mentally ill offenders find themselves poor, unsheltered, and alone. They may turn again to substance abuse, drift into dangerous environments where violence and crime are commonplace, and may be victimized themselves. Arrest begets future arrest. Half of mentally ill persons in prison for violent crimes are repeat offenders.
      It is past time for a serious public investment to improve community mental health services in North Carolina. Allowing our mental health system to erode is unfair to members of our community who, through no fault of their own, suffer from severe and persistent psychiatric disabilities. Such neglect also demonstrates short-sighted stewardship of public resources. In the long run, the cost of doing nothing is measured in wasted lives, more prison admissions, and even decreased public safety. Other states have shown by example that it is possible to simultaneously reduce hospital admissions and arrests of persons with mental illness, by investing in state-of-the art therapies and infrastructure for community-based mental health services. Effective legal and clinical tools exist to address the special circumstances of mentally ill offenders: jail diversion programs for those who commit minor offenses; mental health courts devoted exclusively to offenders with psychiatric disorders; assertive case management for persons with dual diagnoses; involuntary outpatient commitment for persons who are unable or unwilling to comply voluntarily with treatment and who may become dangerous without it. But none of these policy solutions will work, in the long run, without a public mental health system that is adequately funded to deliver effective treatment in the community to those who really need it.