Mentally ill women in a county jail

We studied 101 inmates of a county jail for women who were randomly selected from those referred for psychiatric evaluation. Eighty-six percent had a history of psychiatric hospitalization; 94% had prior arrest records, 50% of these for felonies. More than half met the criteria for involuntary hospitalization. When arrested more than 40% were transients, and only 7% were employed. Seventy percent had histories of serious physical violence, more than 40% had engaged in prostitution, and 84% of those with children had demonstrated an inability to take care of them. Far fewer mentally ill women than men were incarcerated in county jail. As in our study of male inmates, there appeared to have been some "criminalization" of the mentally ill. There is a need for more mandatory aftercare and ongoing involuntary treatment for this population.     

Class action litigation in correctional psychiatry

Class action litigation has been instrumental in jail and prison reform during the past two decades. Correctional mental health systems have significantly benefited from such litigation. Forensic psychiatrists have been crucial in the litigation process and the subsequent evolution of correctional mental health care systems. This article summarizes information concerning basic demographics of correctional populations and costs of correctional health care and provides a brief history of such litigation. The role of psychiatric experts, with particular reference to standards of care, is described. Specifically discussed are issues relevant to suicide prevention, the prevalence of mentally ill inmates in supermax prisons, and discharge planning.     

Successfully Treating Aggression in Mentally Ill Prison Inmates

The population of prison inmates in the United States is rapidly growing; in 1994 it was estimated that 1.7 million Americans were incarcerated. Changes in the complexion of the prison population highlight the need for successful mental health interventions for special populations. Specifically, increasing numbers of women, middle aged inmates, physically ill inmates, and inmates with severe mental illness have challenged an already taxed system. Many inmates have complex pathology in which substance abuse, psychosis, affective disorders, personality disorders and medical illnesses play overlapping roles. One of the most challenging aspects of care involves management of inmates who are aggressive to themselves or others. This article discusses the approach to managing inmates with aggressive behavior and complex mental health issues. Specific diagnoses are discussed as are the general approaches best used to assess new onset violent behavior in a mentally ill prison inmate.     

Gender differences in jail inmates' symptoms of mental illness,treatment history and treatment seeking

Background Rates of mental illness among prisoners are substantial, but little is known about the unique mental health needs of women in jail, those under pre‐trial custodial remand or serving short sentences. Aims To compare male and female jail inmates along a wide range of symptoms of mental illness using identical assessment methods, and to examine gender differences in treatment seeking before and during incarceration. Methods Soon after incarceration in a county jail, 360 male and 154 female pre‐trial and post‐trial inmates completed the Personality Assessment Inventory, a wide‐ranging measure of psychiatric symptoms. Treatment seeking information was taken from official jail records. Results Women were more likely to report clinically significant symptoms of anxiety, borderline personality features, somatic concerns and trauma‐related symptoms; however, trauma‐related symptoms and borderline features were also common among male inmates. Although both men and women reported high rates of drug‐related problems, alcohol‐related problems were twice as prevalent among male inmates. Female inmates were more likely to seek and be enrolled in jail‐based treatment; there were no differences in reported help seeking prior to incarceration. Conclusions Female jail inmates are especially in need of mental health services. Effective interventions for post‐traumatic stress disorder and borderline personality disorder are needed in jail settings for both male and female inmates during incarceration and upon release. Copyright © 2009 John Wiley & Sons, Ltd.     

Current and lifetime psychiatric illness among inmates not identified as acutely mentally ill at intake in Connecticut's jails

This study presents estimates of current and lifetime psychiatric illness among inmates not identified as acutely mentally ill at intake into all five of Connecticut's adult jails (four male facilities and one female facility). Diagnoses were assessed with the Structured Clinical Interview for DSM-IV (SCID), Clinician-Administered PTSD Scale, and the Global Assessment of Functioning (GAF) and are reported by gender and race/ethnicity. The results showed that more than two of three inmates met the criteria for at least one lifetime psychiatric disorder, almost half for an anxiety disorder, and more than one-third for an affective disorder. Overall, estimates of psychiatric morbidity in the women were higher than those in the men, with the exception of antisocial personality disorder (ASPD). Of particular note, borderline personality disorder was diagnosed in 23.2 percent of women and 12.9 percent of men. An allegation of a violent offense was not associated with the presence of mental illness or with a specific diagnosis. Lifetime history of any mental illness was associated with significantly reduced scores (range, 12-15 points reduction) on the Global Assessment of Functioning. The study showed that current and lifetime psychiatric morbidity are elevated among newly incarcerated adults who do not exhibit obvious signs of severe mental illness and are associated with functional impairment. While such disorders do not necessarily require treatment, unrecognized mental illness may place offenders at greater risk while incarcerated than offenders without mental illness. This study reinforces the need for appropriate screening and referral for treatment at intake into jail.     

Treatment prospects for persons with severe mental illness in an urban county jail

OBJECTIVE: A retrospective study of inmates with severe mental illness in a large, urban county jail aimed to obtain information about their psychiatric and criminal histories and status, the psychiatric services they used while incarcerated, and the challenges they might present in psychiatric treatment after release. METHODS: The authors ascertained demographic characteristics, diagnoses, psychiatric and legal histories, and current psychiatric condition and treatment from jail psychiatric records of a random sample of 104 male inmates with mental illness and from electronic county mental health records and state records of criminal histories. RESULTS: Seventy-eight inmates (75%) were diagnosed as having a severe mental illness. Of these, 59 (76%) required inpatient care or its equivalent for part of their time in jail for the current offense. Of the inmates with severe mental illness, 92% had a history of nonadherence to medications before this arrest, 95% had prior arrests, 72% had prior arrests for violent crimes against persons, and 76% were known to have a history of substance abuse. CONCLUSIONS: A large percentage of persons with severe mental illness received their acute psychiatric inpatient treatment in the criminal justice system rather than in the mental health system. The persons with severe mental illness in this study would present a major challenge in treatment in any setting given their psychiatric and criminal histories. The resources of the mental health system need to be greatly expanded, with priority given to treating persons who are criminalized or who are in danger of becoming criminalized.     

The role of mental health in the inmate disciplinary process: a national survey

An effective system of inmate discipline is an important aspect of a safely run prison or jail. Historically, mentally ill inmates have had few or no protections against discipline routinely applied to their non-mentally ill peers. Arising from recent class action lawsuits challenging the quality of mental health care delivery in the nation's prisons, prison mental health professionals have been called on to play an increasing role in the inmate disciplinary process. Referral questions include whether an inmate is competent to proceed with disciplinary proceedings and whether mental illness may have contributed to the rule violation. Prison mental health professionals participating in inmate disciplinary proceedings must therefore be familiar with relevant clinical, legal, and ethics issues. Little has been written in the psychiatric literature, however, examining this important role for prison mental health professionals. After first reviewing core legal and constitutional concepts, the author presents the results of a nationwide survey examining the role for mental health professionals in the inmate disciplinary process. To the author's knowledge, this is the first study to provide a comprehensive review of this subject.     

Prevalence of psychiatric disorders in New Zealand prisons: a national study

OBJECTIVE: The paper describes the methodologies and results obtained on a large cohort of prison inmates in New Zealand who were screened for psychiatric disorder. METHOD: All women and remanded male inmates in New Zealand prisons, and a randomly selected cohort of 18% of sentenced male inmates were interviewed. Interviewers used the Composite International Diagnostic Interview - Automated to establish DSM-IV diagnoses, and the Personality Disorders Questionnaire to identify personality disorder. All prisons in New Zealand were visited. RESULTS: The results indicate markedly elevated prevalence rates for major mental disorder in the prison population when compared with community samples. This is especially the case for substance misuse, psychotic disorders, major depression, bipolar disorder, obsessive- compulsive disorder and posttraumatic stress disorder. Of particular concern is not only the increased prevalence rates for schizophrenia and related disorders but also the high level of comorbidity with substance misuse disorders demonstrated by this group. While 80.8% of inmates diagnosed with bipolar disorder were receiving psychiatric treatment in the prison, only 46.4% of depressed inmates and 37% of those suffering from psychosis were receiving treatment. Maori inmates were grossly overrepresented in the remand, female and male sentenced inmate population compared with the general population. CONCLUSIONS: A significant increase in provision of mental health services is required to cope with the high number of mentally ill inmates. The level of need demonstrated by this study requires a level of service provision that is quite beyond the capacity of current forensic psychiatry services, Department of Corrections Psychological Services or the prison nursing and medical officers. The elevated rates of common mental disorders argues for the use of improved psychiatric screening instruments, improved assessment and treatment capacities in the prison and an increased number of forensic psychiatric inpatient facilities to care for those psychotic inmates who are too unwell to be treated in the prison.     

Assessing the "criminalization" of the mentally ill in Canada.

This paper is an overview of the conceptual and methodological problems encountered trying to assess the hypothesis that the mentally ill, as a consequence of deinstitutionalization, are being "criminalized". Generalizations are difficult to make, in large part because most of the studies are American and do not fit well into the Canadian scene. Relevant Canadian findings are reviewed and compared to the US data. There is some evidence that Canadian patients may be diverted from the criminal justice system more often than in the US, where there are fewer resources. However, this conclusion must be tempered by the fact that Canadian surveys have found high rates of mental disorder among prison and jail inmates.     

A study of offenses committed by psychotic inmates in a county jail

Following deinstitutionalization, several studies have documented an increase in the number of mentally ill inmates in prisons. The authors reviewed all referrals to a mental health clinic in a county prison and categorized each case as psychotic or nonpsychotic. The psychotic inmates were four times more likely to have been incarcerated for less serious charges such as disorderly conduct and threats, and they committed fewer sex offenses, property crimes, and drug offenses than nonpsychotic inmates. The authors conclude that the increased number of mentally ill prison inmates does not reflect a greater incidence of serious criminal activity in this group but an increase in the criminalization of psychotic behavior.     

Psychiatry and the homeless mentally ill: a reply to Dr. Lamb.

Homeless mentally ill persons are highly visible subjects of ongoing public discussion and potent symbols of a host of contemporary social problems. They present psychiatry with a scientific challenge that calls for further elucidation of the sources of their mental illness and for fashioning possible solutions to their problems. They also present a moral challenge that requires psychiatrists to acknowledge the cultural, political, legal, and economic context of the mental problems of the homeless in the course of deciding what should be done to help them. H. Richard Lamb has proposed a program of aggressive outreach and psychiatric hospitalization for the homeless mentally ill. The authors believe that his proposal misconstrues the problems and needs of homeless mentally ill individuals; it would also needlessly infringe upon their freedom, further stigmatize them, and probably not help them. The authors offer an alternative understanding of the plight of the homeless mentally ill which places their problems within a larger context of social trends and domestic issues that society has been reluctant to confront. Psychiatrists can help the homeless mentally ill by championing their liberty rights and by focusing public discourse on the broad national need for improved access to medical and psychiatric care.     

The homeless mentally ill in the general hospital: a question of fit

The evolution of general hospital psychiatry and the growth of the homeless mentally ill population in the United States have coincided temporally. Although the two have many points of confluence, their interaction has largely been of a last-resort variety, sometimes occurring by default and rarely adequately planned. The general hospital psychiatric unit has an important role to play in serving the homeless mentally ill--a role that is consonant with its mission of providing care to individuals whose service needs include special treatment interventions in short-term settings. That role may be most effectively implemented in a pluralistic service system, where the general hospital psychiatric unit is one of many facilities responding appropriately, but differentially, to the needs of individual members of the homeless mentally ill population.     

Social and independent living skills for psychiatric patients in a prison setting. Innovations and challenges

There is a tremendous need for mental health services in correctional settings. An innovative psychosocial rehabilitation program that emphasizes skills training has been implemented by a state mental health agency within a large state prison. Preliminary results indicate that the treatment is effective in teaching social and independent living skills to mentally ill inmates. However, durability of treatment effects ultimately depends on the ability to track and to provide follow-up services for inmates after they are discharged to the general prison facility or to parole settings. Recommendations for developing and implementing effective systems of delivering mental health services in prisons are offered.     

Chronic mental illness and the criminal justice system

A total of 260 family members responded to a survey seeking information about their mentally ill relatives' contacts with the criminal justice system. Reports by family members indicated that the mentally ill relatives were mainly men in their early thirties with a diagnosis of schizophrenia or bipolar disorder; they had had an average of four admissions to a state mental hospital. The majority had been arrested, but only a fifth had been convicted of a crime. Substance abuse and noncompliance with psychiatric medications were significant predictors of arrest. Family members overwhelmingly attributed the arrests to psychiatric crises, and in about half the cases a failed attempt at commitment had preceded the arrest. However, only a minority of the mentally ill relatives were taken to a hospital at the time of the arrest. The findings highlight the need for closer collaboration between mental health specialists and law enforcement personnel.     

The use of the insanity defense as a jail diversion mechanism for mentally ill persons charged with misdemeanors

Heightened awareness and concern regarding the large number of mentally ill misdemeanants in jails has led to a search for alternatives to jail and to the development nationwide of jail diversion programs for offenders with mental illness. Two such mechanisms-diversion to civil commitment and the use of mental health courts-are briefly reviewed. In Oregon, however, a rather unique mechanism is used to defer mentally ill misdemeanants (in addition to felons) from the criminal justice system: the insanity defense, with subsequent placement of the individual under Psychiatric Security Review Board jurisdiction. Statistics regarding such use from 1978 to 2001 are provided. The authors compare and contrast this jail alternative with both mental health courts and diversion to civil commitment, and discuss questions related to the feasibility of larger-scale use of this mechanism.     

A second labour market?

In Germany, the vocational rehabilitation of chronically mentally ill people is concentrated on the sheltered labour market, supplemented by special programmes for the care and reintegration of mentally ill people on the open labour market. Our investigation covered 502 representatively selected patients in sheltered employment (outpatient work therapy, firms for mentally ill people, workshops for the disabled). The sociodemographic, anamnestic and psychopathological data reveal that these are chronically mentally ill people with significant disabilities, making comprehensive social care and psychiatric treatment essential. Most of the subjects intend to remain in sheltered employment; only 20% hope to change to the open labour market. The level of subjective job satisfaction is surprisingly high despite generally inadequate pay, though it has to be pointed out that many long-term patients are presumably resigned to their circumstances. In conclusion, the relationship of the open labour market to sheltered employment is the subject of critical discussion.     

Treatment of offenders with mental disorders: focusing on prison psychiatry

Forensic mental health services exist in a nebulous space at the intersection of two different systems-criminal justice and mental health-and the entanglement of these systems poses intricate problems for psychiatrists. This article discusses the present circumstances of forensic mental health services in Japan, focusing on trends in prison psychiatry. In the traditional Japanese system, offenders with mental disorders were treated within general psychiatry as involuntarily admitted patients, or within the prison system as mentally ill inmates. As a consequence of recent legal reform, however, this situation has radically changed. The Medical Treatment and Supervision Act of 2005 aimed to provide intensive psychiatric treatment to offenders with mental disorders, attaching great importance to their reintegration into society. Under the new system, a person who commits a serious criminal offense in a state of insanity or diminished capacity shall be referred by the public prosecutor to the district court; following a treatment order of the court, the person shall be treated in psychiatric facilities established by the law. While the new system is expected to play a role in the context of specialist forensic psychiatry, its distinction from general psychiatry remains unclear. For example, persons who commit serious crimes, such as assault, in an acute psychotic state are occasionally admitted to general psychiatric hospitals, even if they meet the criteria for a treatment order under the Medical Treatment and Supervision Act. The relationship between prison psychiatry and specialist forensic psychiatry is still more problematic. Compared to the intensive, rehabilitation-oriented care provided under the Medical Treatment and Supervision Act, mental health services in penal institutions have a number of disadvantages, and it is unlikely that mentally ill prisoners have benefited from the recent progress in forensic psychiatry. Statistics show that the number of sentenced prisoners with mental disorders has steadily increased during the last decade. Although a majority of these individuals are substance abusers, the number of patients with schizophrenia who are unable to serve a sentence due to severe illness is not insignificant. Although patients are sometimes transferred to medical prisons, a substantial number of inmates with mental disorders remain in general prisons, most of which lack adequate medical staff. Accordingly, the growing number of mentally ill inmates is imposing a heavy burden on the penal administration system. Provisions of the Mental Health and Welfare Act pertaining to general psychiatry are not applicable to patients in penal institutions. The Psychiatric Review Board established in each prefecture does not intervene in the management of these facilities. As a result, legal safeguards against the violation of patients' rights are not sufficiently guaranteed in penal institutions. There are no legal provisions for transferring patients with severe mental disorders from prisons to psychiatric hospitals. Once sentenced to imprisonment, offenders with mental disorders are treated almost exclusively within the prison system. This situation is particularly serious in the case of patients with long-term sentences. In addition, the continued availability of psychiatric care after discharge from prison, which is crucial for preventing relapse of illness and recidivism, is not assured. When a mentally ill inmate is discharged, the head of the institution is required to report the discharge to the prefectural governor, in accordance with the Mental Health and Welfare Act. Recently, although the number of such reports has sharply increased, in actuality many of the persons reported are not admitted to hospitals because they do not meet the criteria for involuntary admission, and the provisions of the Medical Treatment and Supervision Act do not apply to them. In conclusion, more attention should be paid to the reform of prison psychiatry. Coordination of the separate functions of general psychiatry, specialist forensic psychiatry, and prison psychiatry is also important.     

Thioproperazinbehandling,en “pilot study”

Nordentoft M. Deinstitutionalization and homelessness among the mentally ill – a historical review.

The number of psychiatric beds has decreased dramatically in the Western world during the past three decades. At the same time there has been a shift in psychiatric care from being mainly custodial in big asylums to a more active, often psychotherapeutically oriented treatment in the psychiatric departments of general hospitals or in community mental health centers. This development has benefited many psychiatric patients, but during the same period severely ill psychiatric patients, mostly schizophrenics, have dropped out of psychiatric care and are now in increasing numbers to be found in jails, in board-and-care homes, or homeless in the streets. It is stressed that there is a need for analysis of the cause of homelessness among psychotic patients and of development of aid programs that can be accepted by this specific group of patients.     

Self-survey of family organization

A self-survey was undertaken among 512 members of the California Alliance for the Mentally Ill (CAMI), a statewide family support organization. The typical CAMI member is the parent of a mentally disabled son or daughter who has been ill for an average of 13 years with multiple hospitalizations and therapists. The employment record of the disabled individuals was poor; more than two-thirds had been involuntarily committed at some time, and half had been in jail. Family members see the most serious unmet need to be social rehabilitation housing with planned programs.The assistance of Katherine Hess, Scott Lee Johnson, Sandra Nelson, and Barbara Sommer is gratefully acknowledged.     

Community mental health care in India

Recent times are witnessing methods in the various forms of community care for the mentally ill in India. Non-governmental organizations (NGO) play a pivotal role in filling the gap in the existing mental health services in India and the substantial need for these services. Various strategies that have been employed in community care have attempted to utilize existing community resources for implementation. Informal manpower resources incorporated with specialist psychiatric care and integrated with existing health care facilities have been general strategies. While the feasibility and cost-effectiveness of the NGO operated community outreach programs for the mentally ill have been demonstrated, various factors are seen to influence the planning and execution of such programs. This paper elucidates some critical factors that would need to be considered in community mental health care in India.