Nonforensic psychiatrists in private practice rarely expect to be dealing with patients involved in the correctional system, but unexpected things happen even with the most carefully chosen patients. I’m writing this column to offer guidance to clinicians facing this situation for the first time, based upon the most common questions I get asked.
The most common situation I hear about is that a patient has missed an appointment, and the clinician hears from a family member that the patient has been arrested. The conscientious doctor wants to make sure that his seriously mentally ill client doesn’t experience an interruption in treatment, and that an appointment will be ready after release. The first challenge is to locate the patient.
In small communities, or when a family member was present at the time of arrest, it’s relatively easy to figure out which detention center or jail the patient was taken to. If the patient was arrested in a large urban area, or even out of state, this can be more of a challenge. Fortunately, many states and even now some local county or city jurisdictions have inmate locator web pages. The website will provide search capabilities to identify anyone currently in custody, and will generally provide a unique booking or inmate number that should be used in any facility communication, along with a date of birth and the address of the facility. Be aware that a large jail with high turnover may not have real-time data capability, meaning that new arrests may not show up on the website for 24 hours.
For psychiatrists who spend a lot of time tracking down their patients in custody, there is even an iPhone- and Android-compatible app called MobilePatrol, which provides a convenient interface to many inmate locator databases nationwide. MobilePatrol does not provide information about charges or date of birth, so it’s mainly useful if the patient can be identified by age and has a unique name.
The next step is to ensure that the patient has been identified as needing psychiatric care within the facility. Almost all jails and prisons now have routine multilevel screens to identify arrestees with chronic medical or mental health needs, and to assess suicide risk at intake. This is required by any jail or prison accredited by the National Commission on Correctional Health Care. Nevertheless, some patients are reluctant to self-identify out of fear they might be inappropriately or precipitously thrown into a suicide observation cell.
When it comes to transmitting information to a correctional facility, don’t rely on custody staff. They aren’t clinicians, they change with every shift, and they won’t know what questions to ask about the patient. This includes the warden’s office. The best thing to do is call the psychology department to transmit the patient’s name, date of birth, jail or prison number, and any pertinent clinical information. Don’t rely on an administrative assistant or nonmedical therapist to do this for you – I can’t tell you the number of times I’ve gotten a message that "...John Doe is in your jail and he needs to be seen..." with absolutely no information about medication names, dosage, and frequency, or even a diagnosis! An initial phone call will ensure that the patient is found within the facility and scheduled to see the institutional psychiatrist.
Follow the phone call up with a letter. This will ensure that the clinical information is still available on the day the psychiatrist comes in, and for the next institutional physician if the patient is transferred to another facility. The letter should summarize pertinent symptoms, violence or suicide risk factors, and previous medication trials. The past med trial information is particularly important for correctional psychiatrists, given that many jails and prisons require "fail-first" prescribing policies. Outside documentation that supports a current nonformulary medication regimen can be crucial to ensuring a smooth transition of care. But please, resist the temptation to reprimand the correctional psychiatrist in advance for making a medication change – there are many valid clinical reasons for a correctional psychiatrist to alter a treatment regimen upon arrest that have nothing to do with formulary issues.
Finally, encourage the patient’s family members to maintain contact with their incarcerated loved one if that relationship is healthy and supportive. No one knows a patient better than those in his own household, and a family member can be particularly sensitive to early signs of relapse sometimes through nothing more than a patient’s tone of voice during a phone call. Give the primary caregivers contact information for the institutional psychology department and encourage them to call if they observe anything concerning during a visit or court appearance. Court dates are particularly stressful times and may serve as a crisis point for a suicidal inmate. Having an extra pair of eyes on the scene could be lifesaving.