Psychiatry behind bars: Practicing in jails and prisons
Suicide risk assessment, psychotropic management are mainstays of clinical work
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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
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.
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 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.
Components of a correctional suicide prevention program
Training for staff on verbal and behavior cues indicating suicide risk and appropriate response
Identification of potentially suicidal inmates
Referral to mental health providers or facilities
Evaluation by qualified mental health professional
Housing in safe area of the institution
Treatment to address the cause of or reasons for suicidal thoughts
Monitoring procedures that permit regular, documented supervision
Communication procedures between health care and corrections personnel
Intervention procedures addressing how to handle a suicide attempt in progress
Notification procedures to ensure appropriate correctional authorities, outside authorities, and family are contacted
Reporting procedures for documenting attempted or completed suicides
Review of suicides and serious attempts by health care and administrative staff
Critical incident debriefing offered to affected personnel and inmates in event of completed suicide
Source: Reference 6
Traditionally, the primary role of psychiatrists working in correctional facilities has been psychotropic medication management. Understanding the correctional context and procedures permits more informed prescription choices and recommendations for psychotropics to be included in the formulary.
Antipsychotics, antidepressants, and mood stabilizers should be included in a facility’s formulary. Considerations concerning types of psychotropic medication within a formulary depend on the facility’s size and mission, psychiatric illnesses encountered in the population, and lengths of inmates’ stay.12 A mechanism should be in place to prescribe off-formulary and access other types of psychotropic medication on a case-by-case basis to ensure inmates are not denied appropriate treatment. A psychiatrist may have to advocate strongly for these principles.
Most correctional facilities require that staff administer every dose of psychotropic medication directly to the inmate for whom it is prescribed. In some facilities, only nursing personnel can administer medication, while others use trained corrections staff to deliver medication. Psychiatrists who prescribe psychotropics in correctional institutions must be familiar with the facility’s medication administration procedures, which may impact medication choice and form, dosing frequency, timing of laboratory studies, and inmate medication compliance. Prescribers’ capacity to order emergency or “as needed” medications may be limited or nonexistent if nursing staff is unavailable.
Appropriate use of psychotropic medication for treating psychiatric illness is the standard of care, but is only 1 component of an effective treatment plan for inmates with serious mental illness. Others include group and individual therapy, psychoeducation, and therapeutic activities such as recreational therapy, activity therapy, and opportunities for education and work within the correctional system.
- Scott CL, ed. Handbook of correctional mental health. 2nd ed. Arlington, VA: American Psychiatric Publishing, Inc.; 2009.
- Thienhaus OJ, Piasecki M, eds. Correctional psychiatry practice guidelines and strategies. Kingston, NJ: Civic Research Institute, Inc.; 2007.
- National Commission on Correctional Healthcare. www.ncchc.org.
- Society of Correctional Physicians. www.CorrDocs.org.