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Prevalence of Serious Mental
Illness Among Jail Inmates
Henry J. Steadman, Ph.D.
Fred C. Osher, M.D.
Pamela Clark Robbins, B.A.
Brian Case, B.A.
Steven Samuels, Ph.D.

Objective: This study estimated current prevalence rates of serious
mental illness among adult male and female inmates in five jails during
two time periods (four jails in each period). Methods: During two data
collection phases (2002–2003 and 2005–2006), recently admitted inmates at two jails in Maryland and three jails in New York were selected to receive the Structured Clinical Interview for DSM-IV (SCID). Selection was based on systematic sampling of data from a brief screen for
symptoms of mental illness that was used at admission for all inmates.
The SCID was administered to a total of 822 inmates—358 during phase
I and 464 during phase II. To determine the current (past-month)
prevalence of serious mental illness (defined as major depressive disorder; depressive disorder not otherwise specified; bipolar disorder I, II,
and not otherwise specified; schizophrenia spectrum disorder; schizoaffective disorder; schizophreniform disorder; brief psychotic disorder;
delusional disorder; and psychotic disorder not otherwise specified), interview data were weighted against strata constructed from the screening samples for male and female inmates by jail and study phase. Results:
Across jails and study phases the rate of current serious mental illness
for male inmates was 14.5% (asymmetric 95% confidence interval
[CI]=11.0%–18.9%) and for female inmates it was 31.0% (asymmetric
CI=21.7%–42.1%). Conclusions: The estimates in this study have profound implications in terms of resource allocation for treatment in jails
and in community-based settings for individuals with mental illness who
are involved in the justice system. Psychiatric Services 60:761–765, 2009)

A

ccording to the Bureau of Justice Statistics, during the 12
months ending at midyear
2007, there were 13 million admissions to local jails in the United States
(1). At midyear 2007, local jails held
673,697 adult males and 100,047
adult females—figures that represent
increases of 24.0% and 42.1%, respectively, since midyear 2000. The
majority of these jail inmates were
pretrial detainees (1).

Prisoners have a constitutional
right to adequate health care, including mental health treatment (2–4),
and the growth of local correctional
populations has strained the limited
capacity of jails to respond to the
health needs of inmates (5). The situation is particularly challenging in the
case of inmates with serious mental
illnesses, who require specialized
treatment and services (6). There has
been consistent evidence that per-

Dr. Steadman, Ms. Robbins, Mr. Case, and Dr. Samuels are affiliated with Policy Research
Associates, Inc., 345 Delaware Ave., Delmar, NY 12054 (e-mail: hsteadman@prainc.com).
Dr. Osher is with the Council of State Governments Justice Center, Bethesda, Maryland.

PSYCHIATRIC SERVICES

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sons with mental illnesses are overrepresented in jails, and determining
the extent of these higher rates is a
first step to improved jail management and the development of alternatives to incarceration.
Prevalence estimates of mental illnesses in U.S. jails have varied widely
depending on methodology and setting. Using survey methodology, a
1999 report from the Bureau of Justice Statistics (BJS) estimated that
16.3% of jail inmates reported either
a “mental condition” or an overnight
stay in a mental hospital during their
lifetime (7). In 2006 BJS reported
that 64% of jail inmates had a recent
“mental health problem” (8). The
2006 findings were based on personal
interviews conducted in the 2002
Survey of Inmates in Local Jails, and
the rate of 64% included all inmates
who reported one or more symptoms
of any mental illness. Data on functional impairment and duration of illness were not collected, and inmates
were not excluded if their symptoms
were a result of general medical conditions, bereavement, or substance
use (8). Although the methods used
in this study are not consistent with
other efforts to establish the prevalence of mental illnesses in jails, the
findings are often, and mistakenly,
cited as evidence of an escalating
problem. More recently, Trestman
and colleagues (9) evaluated a cohort
of inmates who were not identified at
intake as having a mental illness and
found that over two-thirds met criteria for a lifetime psychiatric disorder,
including anxiety disorders and antisocial personality disorder.
761

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The most rigorous data on the
prevalence of mental disorders
among both male and female jail inmates were collected by Teplin,
Abram, and McClelland (10–14) in
the 1980s and 1990s in Cook County
(Chicago), Illinois. The data were collected for the purpose of measuring
severe mental disorders, which are
not comparable to broader estimates
of serious mental illness. These researchers used the National Institute
of Mental Health Diagnostic Interview Schedule with stratified random
samples of inmates awaiting trial in
the Cook County Department of Corrections and estimated rates of current (two-week) severe mental disorders to be 6.4% for male inmates (12)
and 12.2% for female inmates (11).
The study reported here sought to
estimate current prevalence rates of
serious mental illness at two jails in
Maryland and three jails in New York
during two time periods. These inmates would constitute the group that
meets constitutional requirements for
jail mental health services and for
whom aggressive discharge planning
would be a priority (15). Data from a
screen for mental illness were collected for all inmates who were booked
into the jails during the data collection
phases, and a portion of those screened
were selected through systematic sampling for administration of the Structured Clinical Interview for DSM-IV
(SCID). Prevalence rates were estimated through a weighting procedure
whereby the data were organized into
strata by gender, phase, and jail. The
original purpose of gathering the data
used in this study was to validate and
refine a mental health screen for correctional officers to administer to jail
inmates at intake (16,17).

Methods
From large samples of recently admitted jail inmates who were screened
with the Brief Jail Mental Health
Screen (BJMHS), subgroups were selected and the SCID was administered
to them. Results for the subsamples
were weighted back to the larger
screened samples in order to estimate
current prevalence rates of serious
mental illness. Because the original
purpose of data collection was to validate the BJMHS, systematic sampling
762

methods were used to select individuals for the SCID subsamples in order
to obtain an adequate sample of inmates who screened positive and a sufficient number of female inmates to
enable a separate gender analysis.
Data collection
The BJMHS was developed as a jail intake screen to determine whether an
inmate should be referred for further
mental health evaluation. The BJMHS
was validated during two phases of
data collection. During phase I (May
2002 through January 2003) the original eight-item screen was validated at
two county jails in Maryland (Montgomery County and Prince George’s
County) and two county jails in New
York (Albany County and Rensselaer
County). For phase II (November
2005 through June 2006) a revised 12item version of the screen was tested
at the same jails in Maryland and at the
Rensselaer County jail, but the Monroe County jail in New York was substituted as the fourth site. During both
phases, the screen was administered to
inmates during intake, except for
Monroe County in phase II, where
screens were administered within 24
hours of intake after the initial court
appearance (17).
SCID
The SCID is a semistructured clinical
interview designed to assess the presence of selected DSM-IV axis I diagnoses (18). The instrument is administered by a trained clinical interviewer
or mental health professional and uses
a modular format with skip patterns
within diagnostic sections. When criteria for a given diagnosis are met, the
diagnosis is scored in terms of its lifetime prevalence and its presence in
the past month. For the phase I and
phase II data collections, a subset of
modules were administered.
For this study, serious mental illness
was defined as the presence of one or
more of the following diagnoses in the
past month: major depressive disorder; depressive disorder not otherwise
specified; bipolar disorder I, II, and
not otherwise specified; schizophrenia
spectrum disorder; schizoaffective disorder; schizophreniform disorder;
brief psychotic disorder; delusional
disorder; and psychotic disorder not
PSYCHIATRIC SERVICES

otherwise specified. There were no
measures of functional impairment.
As soon as inmates were classified
into those who screened positive and
those who screened negative, clinical
research interviewers who were blind
to the inmates’ sampling group status
approached the inmates on their list of
potential participants. Participation in
both phases was voluntary. Informed
consent forms approved by the institutional review board of Policy Research
Associates, Inc., were required and obtained for all SCID subsample participants. Participants were informed that
the decision to participate would not
affect their stay in the jail, and a brief
quiz was administered to assess competency to consent. All SCID interviews occurred within 72 hours of an
inmate’s admission to the jail but typically not within the first eight hours.
In both phases the overall refusal
rate of inmates approached for the
SCID interview was 31% (16,17). In
phase I women were more likely than
men (p<.05) to refuse when approached for an interview, and in
phase II the refusal rate was particularly high in the Prince George’s
County jail—126 of 228 inmates
(55%) who were approached refused
to participate. The refusal rate was
likely due to the fact that compensation was not offered to SCID sample
participants at this jail and to the constraints imposed by the jail on scheduling and conducting interviews.
However, because the results of all
analyses are presented by gender and
by jail and because no significant differences were found between those
who refused and those who consented
in Prince George’s County, there are
no biases on these two factors.
Interviewer training
Nine clinical research interviewers
were trained for phase I, and 16 were
trained for phase II. Many of the
phase I interviewers also participated
in phase II. During each phase, interviewers participated in a two-day onsite training in administration of the
SCID by a certified SCID instructor.
Interviewers practiced with acquaintances and volunteer psychiatric patients. Interrater reliability (α=.964)
was ensured by having each interviewer complete two reliability tapes,

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number in the person’s SCID sample
stratum. If a certain number—represented by “a”—of those who also were
administered the SCID are classified
as having serious mental illness, then
the estimated prevalence in the stratum is p=a/n and the estimated number of population members with serious mental illness in the stratum is
A=(N/n)a=Np. These stratum numbers were added to form the numerators and were divided by the known
population totals to get estimated
prevalence rates. Confidence intervals
for specific rates for jail, phase, and
gender were based on the assumption
that within strata individuals were selected for the SCID by systematic
sampling. This was at best an approximation. The pooled gender-specific
rates compute confidence intervals by
treating jails as sampled clusters. The
intervals were computed on the logit
scale and transformed to the probability scale (19) and were asymmetric.

which were scored. Interviewers were
also observed while conducting interviews in the jails.
Data analysis
All data management and analyses
were conducted in SPSS (version 12)
or Stata (release 10). Weighted prevalence estimates and confidence intervals were computed with the survey
procedures in Stata (release 10).
Weighting
Persons who were screened by the
BJMHS (a “population”) were
grouped into strata defined by study
phase, jail, gender, and BJMHS result
(positive or negative). Those who also
were administered the SCID (the
“sample”) were classified into the
same strata. Each person in the SCID
subsample received a selection weight
W=(N/n), where N was the number of
population members in the person’s
population stratum and n was the

Screening samples
Phase I. Screening data were collected
from 11,438 male and female jail inmates admitted to one of four county
jails from May 2002 through January
2003. Valid data were obtained for
11,168 inmates. The percentage with
positive scores on the eight-item
BJMHS ranged from an overall high of
14% (N=399) in Prince George’s
County to an overall low of 9%
(N=287) in Albany County.
Phase II. Between November 2005
and June 2006 a total of 10,562 inmates admitted to one of the four
county jails were screened with the
12-item BJMHS. Valid data were obtained for 10,240 inmates. The percentage of screened inmates classified as positive on the basis of scoring
for the eight-item BJMHS ranged
from 24% (N=296) in Monroe County to 9% (N=880) in Montgomery
County. The high positive rate in
Monroe County is due to the large

Table 1

Inmates at four jails who screened positive or negative on the Brief Mental Health Jail Screen (BJMHS) and rates of
serious mental illness among those selected for assessment with the Structured Clinical Interview for DSM-IV (SCID),
by gender and study phase
BJMHS

SCID-diagnosed serious mental illness

Positive

Negative
Selected for SCID

Gender, phase,
and county jail
Male inmates
Phase I
Montgomery
Prince George’s
Rensselaer
Albany
Phase II
Montgomery
Prince George’s
Rensselaer
Monroe
All
Female inmates
Phase I
Montgomery
Prince George’s
Rensselaer
Albany
Phase II
Montgomery
Prince George’s
Rensselaer
Monroe
All

PSYCHIATRIC SERVICES

Total
N

N

%

Total
N

BJMHS
Selected for SCID

Positive

N

N

%

N

%

%

Negative

275
323
87
201

18
14
15
27

7
4
17
13

3,092
2,268
987
2,484

31
35
30
41

1
2
3
2

7
6
7
18

39
43
47
67

5
3
5
7

16
9
17
17

271
689
65
103
2,014

16
10
6
17
123

6
1
9
17
6

3,345
2,886
543
723
16,328

42
44
27
44
294

1
2
5
6
2

7
5
3
6
59

44
50
50
35
48

2
2
2
6
32

5
5
7
14
11

113
76
35
86

14
4
9
24

12
5
26
28

326
256
156
403

24
12
26
34

7
5
17
8

7
2
8
11

50
50
89
46

5
4
10
15

21
33
39
44

100
191
50
193
844

21
15
13
37
137

21
8
26
19
16

442
375
71
193
2,222

75
30
18
49
268

17
8
25
25
12

10
6
6
16
66

48
40
46
43
48

11
5
4
5
59

15
17
22
10
22

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Table 2

Weighted prevalence rates of serious
mental illness among inmates at four
jails, by gender and study phasea
Gender, phase,
and county jail
Male inmates
Phase I
Montgomery
Prince George’s
Rensselaer
Albany
Total
Phase II
Montgomery
Prince George’s
Rensselaer
Monroe
Total
Both phases
(pooled data)
Female inmates
Phase I
Montgomery
Prince George’s
Rensselaer
Albany
Total
Phase II
Montgomery
Prince George’s
Rensselaer
Monroe
Total
Both phases
(pooled data)
a

%

95% CI

18.0
12.8
19.1
20.8
17.5

8.8–33.4
6.1–25.2
9.4–35.0
10.3–37.5
12.5–24.0

7.7
13.3
12.0
16.3
11.1

3.5–16.0
6.3–26.0
5.6–23.7
7.9–30.9
6.1–19.5

14.5

11.0–18.9

28.3
37.1
47.7
44.4
38.3

14.7–47.5
20.5–57.5
28.5–67.6
25.9–64.6
25.4–53.1

20.7
24.5
32.1
26.7
24.4

10.3–37.4
12.5–42.6
17.1–52.0
13.8–45.5
19.4–30.1

31.0

21.7–42.1

Rates are based on the number of inmates
given a diagnosis of a serious mental illness on
assessment with the Structured Clinical Interview for DSM-IV The percentages are weighted to reflect the total population at each jail.
Confidence intervals are asymmetric.

proportion of female inmates and the
consistently higher number of positive scores for women.
SCID samples
The SCID was administered to a total
of 822 inmates—358 during phase I
and 464 during phase II. In both phases, women and inmates who screened
positive were approached in larger
numbers for an interview. Across the
four jails, a total of 147 (41%) women
were interviewed in phase I, and 258
(56%) women were interviewed in
phase II. Of the inmates in the SCID
subsample, 125 (35%) at phase I and
135 (29%) at phase II had screened
positive on the basis of the eight-item
BJMHS. Among both men and
women, consistently higher rates of se764

rious mental illness were observed for
those who screened positive, which
was expected given the predictive accuracy of the BJMHS (16,17).

Results
Prevalence of mental illness
Table 1 shows the results of screening
at the four jails by phase and by gender as well as the SCID results for the
subsamples.
Table 2 presents the weighted
prevalence and asymmetric 95%
confidence intervals (CIs) of current
serious mental illness in the jails by
gender and phase. The weighted estimates adjust for oversampling in
the SCID subsample of women and
of inmates who screened positive
and provide accurate estimates of
the prevalence of serious mental illness. Data from all four jails were
used for analysis in each phase. The
same analysis using just the three
jails that participated in both phases
yielded results that were not significantly different.
Male inmates. Prevalence of serious
mental illness among male inmates in
phase I ranged from 12.8% in Prince
George’s County to 20.8% in Albany
County, with an overall rate of 17.5%.
In phase II prevalence of serious mental illness for men ranged from 7.7% in
Montgomery County to 16.3% in
Monroe County, with an overall rate of
11.1%. Analysis of pooled data from
the two phases yielded an estimated
14.5% prevalence rate of serious mental illness among male jail inmates.
The addition of posttraumatic stress
disorder (PTSD) as a serious mental
illness increased the estimate to 17.1%
(asymmetric CI=3.2%–21.8%).
Female inmates. Estimated rates of
serious mental illness among female
inmates in phase I ranged from 28.3%
in Montgomery County to 47.7% in
Rensselaer County, with an overall
rate of 38.3%. Phase II results for
women were slightly lower, with
prevalence rates ranging from 20.7%
in Montgomery County to 32.1% in
Rensselaer County and an overall rate
of 24.4%. Analysis of pooled data from
the two phases yielded a prevalence
rate of 31% among female jail inmates.
As with the male inmates, the addition
of PTSD as a serious mental illness
raised the prevalence rate among fePSYCHIATRIC SERVICES

male inmates only modestly to 34.3%
(asymmetric CI=24.4%–45.7%).

Discussion
The final, weighted prevalence rates
of current serious mental illness for recently booked jail inmates were 14.5%
for men and 31.0% for women across
the jails and study phases. When these
estimates are applied to the 13 million
annual jail admissions in 2007, assuming that the proportion of female admissions was 12.9%, there were about
two million (2,161,705) annual bookings of persons with serious mental illnesses into jails. If a primary SCID diagnosis of PTSD was included as a serious mental illness, the weighted estimates increased to 17.1% for men and
34.3% for women.
The estimated prevalence rates
among female inmates found in this
study were double those for male inmates. This gender difference is particularly important given the rising
number and proportion of female inmates in U.S. jails (1). The estimated
prevalence among female inmates is
higher whether or not current PTSD is
included as a serious mental illness.
These prevalence estimates provide evidence for what jail staff already know to be true: the volume of
inmates entering jails with serious
mental illnesses is substantial. One
possible explanation for the high estimates is limited access to community
behavioral health services (20). We
believe that rates for male and female inmates could be applied to a
particular jail to yield a reasonable
estimate for planning purposes. Using these estimates, jail administrators can likely anticipate that the
prevalence of serious mental illness
will be between 11.0% and 18.9%
among men and between 21.7% and
42.1% among women, with a 14.5%
average among men and a 31.0% average among women.
Several limitations of this study are
noteworthy. Because no measure of
functional impairment was used, it is
unclear whether these individuals met
federal and state definitions of serious
or severe mental illness (21). In addition, the definition of serious mental
illness did not include some axis I disorders that can be very severe, such as
anxiety disorder. Similarly, some axis II

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disorders, such as borderline personality disorder, can also be severe, and
none were included. On the other
hand, only a small proportion of the
overall SCID subsample who were
deemed to have a serious mental illness received a primary diagnosis of
depressive disorder not otherwise
specified (four inmates, or 1.9%)
Although some variation was noted
across the jails and study phases, the
estimates were consistent. The reason
for the variation is unclear because the
same screening and diagnostic interview, and in many cases the same interviewers, were employed during
both phases. We examined other factors, such as differences or changes in
racial composition, as possible reasons
for the differences among jails or phases, but none were found.

Conclusions
There is broad consensus that jails are
not the optimal settings to provide
acute psychiatric treatment. In line
with the recommendations of the
Criminal Justice/Mental Health Consensus Project report (22) and the
President’s New Freedom Commission on Mental Health (23), many
communities have instituted mechanisms to divert individuals with serious
mental illnesses from the front door of
the jail to community-based services
or have established linkages to services
by way of transition planning at the
back door. Since a 1992 survey estimated that only 52 jail diversion programs operated in the United States
(24), there has been a rapid expansion
of specialized law enforcement–based
responses (25), problem-solving mental health courts (26), and specialized
probation models (27) aimed at reducing the prevalence of individuals with
mental illnesses in jail settings. Such
expansion has been supported by an
array of state and federal grant programs, including the Criminal Justice,
Mental Health and Substance Abuse
Reinvestment Act in Florida; the
Mental Health Courts Program and
the Justice and Mental Health Collaboration Program of the Bureau of Justice Assistance; and the Targeted Capacity Expansion for Jail Diversion
Programs and the Jail Diversion and
Trauma Recovery–Priority to Veterans
initiatives of the Substance Abuse and
PSYCHIATRIC SERVICES

Mental Health Services Administration. Nonetheless, the substantial
presence of individuals with serious
mental illnesses in our country’s jails,
as estimated in this study, calls for a
clearer explication of the contributing
factors and discussion of appropriate
responses.
Acknowledgments and disclosures
This research was partly supported by a contract
from the Council of State Governments. The
original data were collected under grants 2001IJ-CX-0030 and 2005-IJ-CX-0004 from the Office of Justice Programs, National Institute of
Justice, U.S. Department of Justice. The points
of view in this article are those of the authors and
do not necessarily represent the official positions
or policies of the U.S. Department of Justice.
The authors report no competing interests.

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