I have always regarded the French saying “plus ça change, plus c’est la même chose” (the more things change, the more they are the same) to be a quote for the ages. Nowhere is this truism more evident than in the fluctuations in incarceration of individuals with serious mental illness (SMI) in the United States and persecution of real and faux patients in certain regimes around the world.

A truly jarring 2010 report by E. Fuller Torrey et al¹ revealed the shocking deterioration and regression of the United States mental health system. In 2010, the percentage of persons with SMI in jails and prisons ballooned to the same as it was 170 years ago! The deplorable mistreatment of the mentally ill in 1840, due to pervasive ignorance, prompted legendary reformer Dorothea Dix to launch her historic campaign for a more humane (asylum-based) treatment of persons afflicted with severe mental disorders. How troubling it is that the iconic Dorothea Dix Hospital in Raleigh, NC was shuttered earlier this year! Built on >2,300 acres and eventually growing to 282 buildings (in 1974), housing approximately 3,000 patients cared for by >6,000 employees on 3 around-the-clock shifts, this institution was a revered symbol of the transition from unjust criminalization to humane medical treatment of the SMI population. All other states eventually established similar medical institutions to house, protect, and care for the severely mentally ill, even though no effective treatments were available until the serendipitous discovery that an anesthetic adjunctive agent, a phenothiazine called chlorpromazine, could miraculously suppress delusions, hallucinations, and bizarre behavior.

Throughout the 20^th century, while patients with SMI in the United States were hospitalized instead of incarcerated, several despotic regimes abused the mentally ill or misused psychiatric institutions as proxies for prisons. The malevolent and criminal Nazi regime determined that mentally ill or mentally challenged individuals were “unworthy to live” and turned many psychiatric institutions into “killing centers” to “euthanize” persons with SMI with lethal injections, and later with carbon monoxide. Some psychiatrists and clergy raised objections but they were ignored or suppressed.

The totalitarian Soviet Union was notorious for abusing psychiatry by “diagnosing” political dissenters as “schizophrenic” and incarcerating them for life in psychiatric hospitals, which eventually were transformed into political prisons for those protesting the dictatorship of the Soviet regime. Other communist countries adopted a similar approach to silence dissenters and some reportedly still are doing this today. Regrettably, a regressive event took place in America, a paragon of freedom and social justice in the world. In 1983, 6.4% of prison inmates had SMI. This proportion almost tripled to 16% in 2010 and continues to grow steadily. This tragic deterioration is embodied in the following statistics from Torrey et al¹: today there are 300% more patients with SMI in jails and prisons than in hospitals around the United States. Some states have truly scandalous figures: in Arizona and Nevada, there are 10 times more patients with SMI in prisons and jails than in hospitals!

There also is an alarming, even dangerous, shortage of psychiatric beds in the United States. Psychiatrists and other mental health professionals are painfully aware of how many inpatient units have closed in cities and towns across the country: In 1955, there was 1 psychiatric bed for every 300 citizens. In 2010, the ratio had fallen drastically to 1 bed for every 3,000 Americans. To make things worse, in most states most remaining beds are filled by court-ordered patients and are, in fact, not available for new patients.

Sadly, as was the case in 1840, the United States now incarcerates the majority of its seriously mentally ill citizens. So much has changed in the United States over the past 2 centuries, yet for patients with SMI, things are practically the same as in a medically primitive era of our past. How can we allow this virulent plague of widespread incarceration and criminalization that has afflicted the sickest and most vulnerable psychiatric patients, who are being denied the compassion and medical management that they deserve? When will we unite and strongly demand and lobby for a more just treatment of persons with psychiatric disorders and scream that they are medical conditions, not criminal cases? Why do we, mental health professionals, remain silent and go on with our daily work, implicitly accepting the awful status quo? Isn’t incarcerating, instead of hospitalizing, the truly mentally ill just as immoral and deplorable as forcibly hospitalizing mentally healthy political dissenters in the Soviet Union? Why was there universal condemnation of human rights violations by the Soviet dictatorship but a deafening silence about widespread incarceration of medically disabled persons in the land of the free? Why aren’t we adopting policies to expedite and facilitate psychiatric treatment, ensure adherence, and promote remission in those who suffer their first psychotic or manic episode? Why are we building more jails and prisons instead of therapeutic communities?

Although things have changed a lot in the United States since 1840, if a modern day Dorothea Dix does not emerge, then in many ways they will remain the same. And that’s a real shame.

Psychiatry and the politics of incarceration