Psychiatry behind bars: Practicing in jails and prisons

Screening and evaluation

Correctional facilities need a systematic screening process that is conducted on all inmates. This preliminary entry or “receiving screening” is intended to identify urgent medical and mental health concerns and persons in need of immediate treatment. A nurse or corrections staff officer who has been trained by medical staff could conduct this screening. Screening consists of observing the inmate’s current condition and conducting a structured inquiry into medical and psychiatric symptoms, psychotropic medications, drug and alcohol use history, and suicide risk. A positive screen leads to immediate action such as instituting drug or alcohol detoxification or initiating suicide precautions or an emergency medical referral and assessment.^4,6

Within a few days of an inmate’s arrival, a mental health professional should conduct a more detailed mental health screening to identify non-emergent psychiatric needs. The mental health screening includes:

• a review of accompanying mental health information received from the county jail or arresting/transporting officer
• a self-reported history of psychiatric treatment, such as hospitalization, pharmacotherapy, or outpatient counseling
• current or prior suicidal thoughts or attempts
• intellectual functioning
• history of violence and/or victimization
• a brief mental status examination.⁴

Records from previous incarcerations should be reviewed. Also, if relevant, obtain the inmate’s consent to collect outside treatment records and/or speak with family or significant others. The results of this brief mental health assessment could prompt a referral for further evaluation and determine the need for psychotropic therapy.

Although usually not directly involved in this systematic screening and evaluation, psychiatrists should be familiar with how and why referrals are made to be sure that they are appropriate and to reduce unnecessary evaluations, leaving more time for medication follow-up, treatment planning, and suicide risk assessment. An efficient and effective mental health screening and assessment process helps ensure that limited psychiatric resources are used to maximal benefit.

Suicide prevention

Suicide prevention programs often include teaching corrections staff to identify suicide risk factors and instructing them to screen at-risk inmates at any time during incarceration. These programs should implement steps to keep inmates safe, such as increasing intensity and frequency of monitoring by corrections staff, removing or limiting access to items that could be used to harm oneself, and moving inmates to a housing area where the means and opportunity for self harm are reduced.^4,6 Suicide prevention programs also should include delivery of appropriate mental health interventions to improve the inmate’s clinical condition, resolve the crisis, or otherwise lower suicide risk. These interventions include:

• increased frequency of interaction with mental health staff (more than a brief daily interaction conducted at the cell front)
• treatment of drug and/or alcohol withdrawal
• referral for evaluation and assessment of the need for psychotropic medication or dosage adjustment (Table 2).⁶

A correctional facility’s policy should allow a low threshold for corrections staff to initiate a suicide prevention watch—it is better to err on the side of caution and institute a watch than to expect non-mental health professionals to conduct clinical risk level assessments. Full assessment of an inmate’s clinical condition and the decision to reduce or discontinue the watch should be left to a trained mental health professional. This function may fall within the psychiatrist’s duties and it is important to be aware of the ramifications of watch discontinuation, such as:

• what type of property is returned
• where the inmate will be housed
• how often the inmate will be monitored by custody staff
• when the next mental health follow-up will occur.

Failure to articulate your expectations to staff members can lead to catastrophic consequences if watches are discontinued without an appropriate plan for monitoring and follow-up.

Psychiatrists can help train corrections staff on signs of suicide risk and also should review suicide attempts and/or completed suicides. This often can be a challenge because a psychiatrist’s time at a facility may be limited, but is an important consideration for quality improvement efforts.

Table 2

Components of a correctional suicide prevention program