Evidence-Based Reviews

Psychiatry behind bars: Practicing in jails and prisons

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Suicide risk assessment, psychotropic management are mainstays of clinical work


 

References

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Over the last 2 decades mandatory prison sentences, longer prison terms, and more restrictive release policies have lead to a dramatic increase in the number of persons in jails and prisons. Currently, more than 2 million individuals are incarcerated in the United States.1 Psychiatric illness is over-represented in correctional populations compared with the general population—more than half of all inmates have a mental health diagnosis.2 Correctional facilities are legally obligated to address the medical and mental health needs of the persons committed to them. As a result, more psychiatrists are practicing in jails and prisons.

This article explains correctional facilities’ obligation to provide for inmates’ mental health needs and describes correctional mental health processes and how psychiatrists can play a role in screening, evaluation, and suicide prevention.

Lack of training

Despite the increasing number of psychiatrists working in correctional institutions, most have had little or no training, education, or even orientation to these settings. Forensic psychiatry fellowship requirements include experience in treating acutely and chronically ill patients in correctional systems.3 Although general psychiatric training doesn’t preclude correctional experience, it is not required. The forensic component of general psychiatric residency is limited to evaluation of forensic issues, report writing, and testimony.

Professional organizations—including the American Psychiatric Association,4 the American Public Health Association,5 the National Commission on Correctional Health Care,6 and the American Correctional Health Services Association7—have developed standards and position statements on providing medical and mental health care in correctional facilities. Although psychiatrists’ work in correctional settings generally has been reserved for consultation and medication management, it is important for these clinicians to understand and appreciate the wider landscape and environment in which they practice. Psychiatrists can help develop and implement mental health processes that lead to better services and improved clinical outcomes.

Right to treatment

Convicted persons have a constitutional right to medical and mental health treatment under extension of the Eighth Amendment of the U.S. Constitution, which prohibits cruel and unusual punishment.8 In 1976, the U.S. Supreme Court concluded that “deliberate indifference to serious medical needs of prisoners constitutes the ‘unnecessary and wanton infliction of pain’… proscribed by the Eighth Amendment.”9 This coverage was expanded to mental health needs when the court found “…no underlying distinction between the right to medical care for physical ills and its psychological or psychiatric counterpart.”10 Correctional facilities also are obligated to provide medical and mental health treatment for persons in custody who are not yet convicted of an offense.8 In subsequent litigation, the court formulated 6 components of a minimally adequate correctional mental health treatment program; these are described in Table 1.11

Table 1

Components of minimally adequate mental health system in correctional facilities

A systematic screening and evaluation program to identify inmates requiring mental health treatment
Treatment that encompasses more than simply segregating the mentally ill inmate and increasing correctional supervision
Treatment by trained mental health professionals in sufficient numbers to identify and treat inmates suffering from serious mental disorders
Maintenance of accurate, complete, and confidential records of the mental health treatment process
A suicide prevention program
Appropriate use of psychotropic medication (prescription and monitoring by appropriately trained and licensed staff to treat bona fide mental disorders rather than solely as a means of behavioral management)
Source: Reference 11

Jails vs prisons

The type of psychiatric treatment provided differs based on whether the facility is a jail or a prison, how long inmates are confined, and whether the facility serves a special mission or population, such as serving as a reception center for a prison system or housing only juveniles. Jails generally house inmates for short periods—often <1 year—experience rapid population turnover, and receive admissions day and night. Jails vary in size from a few holding cells to several thousand beds. These factors have implications for screening and evaluation processes, suicide prevention, and coordination of care with community treatment providers. In jails, clinicians’ work focuses on rapid identification of psychiatric illness, assessment, stabilization, and re-linkage to treatment providers in the community. Access to inpatient and ongoing psychiatric care also should be available.

In contrast, prisons house people who have been convicted and sentenced to serve time, generally for >1 year. Turnover is less rapid, admissions and discharges are more predictable, and there is greater opportunity and obligation to develop a continuum of mental health care. Prison systems generally provide or make arrangements for crisis intervention, residential treatment services, and inpatient and outpatient psychiatric care. These services may be provided on the prison grounds, or the inmate may be transferred to another prison within the system that offers specialized treatment or to a community hospital, where the inmate is under the constant supervision of corrections officers. Residential treatment includes intensive, coordinated, and structured mental health services and consists of group and individual therapies, psychoeducation, and therapeutic activities; these services are analogous to intensive day treatment or partial hospitalization programs in the community. In prisons mental health care emphasizes ongoing treatment. As in the community, treatment teams in correctional settings often include mental health professionals such as psychiatric nurses, psychotherapists, and psychology staff in addition to psychiatrists.

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