Does deinstitutionalization cause criminalization? The penrose hypothesis.

WhenLionelPenrosepublishedhis study,“MentalDiseaseand Crime:Outlineof aComparativeStudyofEuropeanStatistics”1 75years ago,hehadnowayofknowing thathis researchwould still be the subject of interest, and even controversy, in major psychiatric journals 3 quarters of a century later.2 Penrose found an inverse relationship between prison and mental hospital populations.He theorized that if one of these forms of confinement is reduced, the other will increase. According to this theory, where prison populations are extensive,mental hospital populationswill be small, andviceversa. Writing before the advent of full-scale deinstitutionalization, Penrose could not have known that, in time, his hypothesis would be criticized by those who believe that there is no relationship between deinstitutionalization and criminalizationof personswith seriousmental illness andwould be cited by those who believe that there is. Mundt and colleagues, writing in this issue of JAMA Psychiatry,2 point out that both the Penrose study and a worldwide analysis performed in 2004,3 which found no support for the Penrose hypothesis, were based on crosssectional data. They indicate that longitudinal data are necessary to determine whether there is a direct association between decreasing numbers of hospital beds and increasing prison populations. Longitudinal data from the United States4 cast doubt on a direct association between decreasing numbers of beds and increasing prison populations. Further research pointed toward a potential role of the economy and suggested that both the numbers of psychiatric beds and the sizes of prison populations might be driven by broad economic factors.5 With all these factors in mind, as reported in this issue of JAMA Psychiatry, Mundt and colleagues2 performed a large, well-designed study in 6 South American countries. Using longitudinal data and taking into account economic growth, they still found a statistically significant association between the numbers of psychiatric beds and the sizes of prison populations. While the data did not prove that the decrease in numbers of psychiatric beds actually caused the increase in prison populations in South America, it did not disprove it either. Thus, this study is compatible with those who postulate, based on clinical evaluation of persons with serious mental illness who are incarcerated, that a driver of criminalization is deinstitutionalization. In my view, many of the persons with serious mental illness that one sees today in our jails and prisons could have just as easily been hospitalized had psychiatric beds been available. This is especially true for those who have committed minor crimes. If, in fact, jails and prisons can substitute for psychiatric hospitals, what is it that these various institutions can provide that many persons with serious mental illness need? A needed modality that all these institutions offer is structure. Structure is provided in the form of a safe, secure setting and of staff who can monitor and contain inappropriate and aggressive behavior, formulate an appropriate treatment plan, and monitor psychiatric medications. Although these needs can generally be met in community settings, for a significant minority of persons with serious mental illness, a highly structured setting is needed. Surely, for those persons with serious mental illness who have committed petty crimes, when a highly structured setting is needed, psychiatric inpatient treatment is preferable to incarceration in a jail or prison. Clearly, deinstitutionalization resulted in large numbers of persons with mental illness being moved from hospital to community settings. As the hospitals closed, many tens of thousands of persons were discharged into the community to face the stresses of the world. Moreover, a new generation of persons with serious mental illness, who had never been hospitalized, grew into adulthood. Many decompensated to the point where 24-hour structured care became necessary. However, the hospitals had been permanently closed, and large numbers of these persons had to be sent to other alternatives. Before deinstitutionalization, a large proportion of persons with serious mental illness would have lived their lives instatehospitals.Althoughtheconditions in thehospitalswere generally abysmal, these persons were not treated as criminals, nor did they live on the streets for long periods of time, as is true now for a sizeable minority of those who have been discharged. Community care has proven successful (provided that adequate community treatment resources are available) for the great majority of persons who formerly would have resided in state hospitals. However, funding shortages and giving priority to persons who are likely to be treatment adherent and nonviolent lessen the potential success of community treatment for persons who today are at risk of becoming criminalized. It is widely thought that many persons with serious mental illness who have been criminalized could be treated successfully in the community, if there were adequate and accessible community treatment facilities.6 Related article page 112 Opinion