Evolving Issues in Correctional Psychiatry

The psychological impact of long-term confinement on inmates who do not have a preexisting mental illness is less clear and more controversial. Despite claims to the contrary, it is not clear whether, how often, and under what circumstances such confinement causes persons to develop serious mental illness (eg, psychotic symptoms, disabling depressive or anxiety disorders). The literature is sparse and provides conflicting perspectives on this.^28-33

While current, scientifically sound studies do not support claims that long-term segregation causes particular kinds of psychological harm to inmates who do not have preexisting mental illness, concerns raised by clinicians and advocates have resulted in a significant improvement in mental health services in correctional facilities. The long-term psychological effects of such environments are not known and await studies using sound methodology.

Class action litigation relevant to this issue has been a driving force in attempting to clarify the answer and in establishing standards of care.^34,35

Correctional systems have procedures for punishing prisoners who violate jail or prison rules and for removing inmates from the general population for disciplinary or safety reasons. Major infractions can bring about significant punitive consequences for an inmate such as loss of good time (ie, a decrease in the sentenced time that needs to be served), transfer to a lockdown unit, or a referral to the district attorney for consideration of filing criminal charges.

Krelstein³⁶ provides a useful summary of recent class action lawsuits challenging the quality of mental health care in the nation's prisons. As a result of this report, prison mental health care professionals have been called on to play an increasing role in the inmate disciplinary process.

Krelstein's national survey revealed that referral questions include whether an inmate is competent to proceed with disciplinary proceedings and whether mental illness may have contributed to the disciplinary infraction. Issues of responsibility were also found to be relevant in some jurisdictions.

There is considerable diversity among states' prison policies on the role of mental health services in the inmate disciplinary process.³⁷ The policies are often poorly written, especially concerning relevant definitions and the nature of the required mental health assessments. For example, the definition of nonresponsibility is frequently vague or absent. The procedures are often unclear about whether the required mental health assessments are based only on a review of records or necessitate a face-to-face interview with the inmate. In addition, the prison's mental health clinicians frequently lack the forensic skills needed to address the issues of competency and responsibility, which exacerbates the problems associated with these policies and procedures. Hearing officers are also not properly trained in the use of mental health assessments in the disciplinary process.

Despite the problems associated with mental health input into the disciplinary process, many hearing officers find that input relevant to mitigating circumstances and dispositional recommendations is helpful. However, because of mental health staff resource and training issues, state officials should proceed with caution before incorporating mental health defenses (eg, not guilty by reason of insanity [NGRI]) into prison disciplinary proceedings. NGRI assessments require forensic training and are time-consuming. Similar to the low rate of successful NGRI pleas in the nonincarcerated population, it is rare that inmates would meet most nonresponsibility standards in prisons that have constitutionally adequate mental health services.

Policies and procedures should be developed that ensure notification of mental health staff when a caseload inmate is issued a serious (ie, major) rule violation notice, because the inmate's actions leading to the violation are often clinically significant. Such a process should also help provide mental health input, when indicated, to the disciplinary process. Mental health staff should be available to consult with the disciplinary hearing officers when a noncaseload inmate appears to be demonstrating symptoms of a serious mental illness.

Mental health systems are now recognized to be an essential component of correctional systems in the United States. Standards of care specific to the correctional setting continue to evolve, and many opportunities remain for psychiatrists to contribute to this very rewarding specialty of psychiatry.