Deinstitutionalisation in Australia has seen the number of public and private psychiatric hospital beds fall from 30 000 in the early 1960s to 8000 today. The population of Australia doubled during this time. There is no doubt that many people with serious mental illness are not being managed well in the community.1 Some mental health researchers,2-4 as well as the popular press, argue that there has been a recent related transmigration of people from psychiatric beds to remand centres (which house prisoners who have been charged with an offence but not yet convicted) and prisons. Australian remand centres often contain more seriously mentally ill people than general hospital mental health inpatient units. However, it is unclear whether the apparent rise in prevalence of mental illness among prisoners reflects a genuine increase or an improvement in detection rates. Statistical modelling of the effect of deinstitutionalisation on the number of prisoners with mental health problems is fraught with methodological challenges and the absence of longitudinal data.5 This debate has tended to overshadow other major areas of concern about mental illness among prisoners.6 As Herrman et al pointed out 15 years ago, whatever the cause, services for people with mental illness in Australian prisons are inadequate and in need of urgent reform.6

On 30 June 2005, there were 25 353 people in prisons in Australia. This represents an overall imprisonment rate of 163 per 100 000 adults, although there was considerable variation between states. The average age was 34.5 years (with 20.2% aged under 25 years); 6.8% were women; 22.2% were Indigenous people (the Indigenous imprisonment rate was 2021 per 100 000); and 60.4% had been in prison previously. In Queensland, the Department of Corrective Services estimates that the custodial population will increase by 90% over the next 10 years.

Australian and New Zealand studies have shown that many people involved in the criminal justice system have had psychiatric contact before entering the system. Prevalence rates for all psychiatric morbidities in the prison population are markedly higher than rates in community samples.6-14 This is particularly evident for substance misuse, with up to 80% of remandees and prisoners dependent on alcohol, cannabis or amphetamines before entering prison.6,7,12,14

However, few published studies allow direct comparison with rates of psychiatric morbidity in community populations. Butler et al9 compared the 12-month prevalence rate for prisoners in their survey to the results of the National Survey of Mental Health and Well-Being, a community-based survey. Prevalences of psychiatric disorders in prisoners were more than double those among people living in the community (Box). Studies in remandees have found prevalences of psychotic illness, such as schizophrenia, ranging from 5.1% to 9.6%.10,13 By comparison, in the general community, the 1-month prevalence is 0.5% for psychosis and 0.3% for schizophrenia.15 Other Australian and New Zealand studies of prisoners have found prevalence rates of between 25% and 50% for non-psychotic disorders such as major depression, anxiety disorders and post-traumatic stress disorder.6,8-10,12

Ex-prisoners also have an increased relative risk of mortality. Death from all causes in some groups was found to be 17 times higher than in the general population in the 2 weeks following release.16 The main causes of excess death are associated with drug and alcohol misuse. These deaths have been cited as an indicator of the poor mental health of prisoners. The experience of release may present an additional challenge to prisoners’ mental health and wellbeing, particularly in the absence of ongoing support.

Despite these high morbidity and mortality rates, treatment services for prisoners and ex-prisoners are very limited and often ineffectual. This makes little sense, even from a criminal justice perspective, as comprehensive services can delay or prevent recidivism in mentally ill offenders.17

In February 2006, the Council of Australian Governments (COAG) announced a major reform of mental health services in Australia.18 In April 2006, the Prime Minister announced the Australian Government would commit $1.8 billion over 5 years to this reform. In July 2006, COAG released a National Action Plan on Mental Health, to be supported by a total federal, state and territory government commitment of almost $4 billion over 5 years.19 While only some of the funding announced at COAG by the states and territories is new funding, there is a clear commitment by governments to improve the state of mental health services in Australia.

As COAG reforms bind all government agencies, they bring with them the opportunity to improve services in all the relevant government departments in order to provide the range of health, housing and community services needed by people with mental illness. This must include improved and expanded prison mental health services, court diversion programs, and well resourced inpatient and community forensic services that link mental health, judicial and correctional services and provide specialist pre-release assessment, consultation and liaison for clinical managers. Diversion from the criminal justice system of mentally ill people who have committed minor offences is one of the few opportunities for community-based prevention. Access to stable housing and to appropriate vocational rehabilitation services is essential for functional recovery. All of these programs will need specially trained and supported mental health and custodial personnel, including psychologists, psychiatrists and specialist case managers. Adequate training of other personnel involved, such as court and police staff, is also necessary. Thus, crucial to the success of the COAG package will be necessary workforce reforms.

Forensic and prison mental health services are target areas for the COAG National Action Plan. However, drafting and funding an action plan is one thing; turning good intentions and money into better services is another, much harder task. To know whether services are improving, we will need public reporting of specific performance indicators, which are currently being developed. In time, the data may be able to tell us whether the historical deficiencies in care for people disadvantaged by both mental illness and involvement in the criminal justice system are at last being addressed.