There is no disputing that the rapidly escalating rate of incarceration during the past decade in the United States has been associated with an increasing number of imprisoned individuals with a mental illness.1,2 Research indicates that as many as 20% of inmates in jail or prison are in need of psychiatric care, frequently because of a serious mental disorder.3-12 James and Glaze2 reported the following:
- Symptoms of mental disorders were higher in jail inmates than in prison inmates.
- Over 70% of inmates who had a mental health problem met criteria for substance dependence or abuse.
- Jail inmates who had a mental health problem were 3 times as likely as those who did not to report being physically or sexually abused in the past.
- Women had higher rates of mental health problems than men.
- State prisoners who had mental health problems were twice as likely as those who did not to have been homeless before their arrest.
- State prisoners who had mental health problems had longer sentences than those who did not.
- Rule violations and fight injuries were more common among inmates with mental health problems.
Although there are many similarities between persons with mental illness in jails and those in prisons, there are also significant differences related to the more rapid turnover in jails than in prisons and the higher rates of acute intoxication in persons newly admitted to jails. It is beyond the scope of this article to address the resultant differences in the mental health service delivery systems within these 2 types of correctional institutions. Despite the clear legal status differences between pretrial detainees in jails and inmates in prisons, the term "inmate" will be used throughout this article to refer to both.
There are numerous agencies and organizations that provide a wealth of information relevant to correctional health care systems, including the US Department of Justice's Bureau of Justice Statistics, the National Commission on Correctional Health Care (NCCHC), the Criminal Justice/Mental Health Consensus Project (established by the Council of State Governments), and the American Psychiatric Association (APA). Literature specific to correctional mental health care, which assists administrators and clinicians in establishing adequate mental health services within jails or prisons, is readily available.4,7 Unfortunately, the lack of resources (eg, mental health staff allocations, office and programming space, correctional officers for escorting purposes) has resulted in constitutionally inadequate mental health care in many correctional systems, which has led to inhumane conditions for many inmates with mental illness.13,14
This article will provide a brief summary of the following correctional psychiatry issues that have forensic implications and/or are very problematic within the correctional setting:
- Treatment of inmates with serious mental illness.
- Suicide prevention programs.
- Discharge planning services.
- Psychological effects of lockdown units.
- Input of mental health professionals during the disciplinary process.
In general, treatment of inmates with serious mental illness should be similar to that available to persons who are not incarcerated. The 3 essential elements required to establish a constitutionally adequate correctional mental health system are sufficient program space and supplies, enough trained and/or experienced mental health staff to identify mental illness and provide treatment, and inmate access to these resources within a reasonable timeframe.15
A variety of guidelines for correctional health care programs have been developed by national organizations, including the APA and the NCCHC.3,16,17 A useful framework for establishing mental health systems that address the issue of access to treatment is provided by these guidelines. The emphasis of the guidelines varies, based on the size and type of correctional facility and the particular focus of the organization making the recommendations.18
Essential components of a comprehensive correctional mental health system include appropriate access for inmates to various levels of mental health care, including a crisis intervention program, acute care program, a residential care program, and outpatient treatment services.19
Because of the inherently nontherapeutic environment of jails and prisons, the need for residential care has become apparent, especially in prisons and larger jails. These housing units within the correctional setting are for inmates with serious mental illness who do not require inpatient treatment but do require a therapeutic milieu because of their inability to function adequately within the general population. These units may be known as residential treatment units, intermediate care units, supportive living units, special needs units, psychiatric services units, or protective environments. They are frequently designed to house 30 to 50 inmates per housing unit, which allows cost-effective staffing.19-21
There is little controversy concerning the need for these units in providing treatment for inmates with a serious mental illness, compared with the inmates who are housed in segregation units known as administrative segregation, disciplinary segregation, or prehearing detention units. These segregation units, which are often without programming space for out-of-cell activities (eg, educational classes, anger management classes), are characterized by the inmate being locked in a cell for 22 to 24 hours per day, with the duration of stay ranging from days to years. Inmates with a serious mental illness are frequently overrepresented in these lockdown units for reasons that often include inadequately treated mental illness. The suicide rate is also disproportionately higher for persons in these units.