Guidelines for psychiatric services in prisons

Recent prevalence studies have found that 8–19% of prison inmates have significant psychiatric or functional disabilities. Efforts to establish adequate mental health systems in prisons within the USA were accelerated during the late 1970s as a result of successful class action lawsuits. These efforts have been assisted by the development of standards for correctional health care programmes by a variety of national organisations. This paper describes a framework for establishing an adequate mental health system within a prison. Basic principles for delivery of psychiatric services in prisons, administrative models for such services, guidelines for correctional based psychiatric treatment, and issues unique for correctional mental systems are reviewed.     

Resource document on the use of restraint and seclusion in correctional mental health care

This resource document discusses the use of seclusion or restraint for purposes of mental health intervention in correctional facilities. Correctional mental health standards essentially state that seclusion or restraint, when used for health care purposes, should be implemented in a manner consistent with current community practice. The community practice was significantly impacted and revised during July 1999, after the Health Care Financing Administration defined rules for the use of seclusion and restraint in facilities that participate in Medicare and Medicaid. Since few correctional facilities are Medicare or Medicaid participants, these rules had little impact on the use of seclusion or restraint for mental health care purposes in correctional systems. Consequently, many correctional health care systems have not developed policies, procedures, or practices that are consistent with current community practice. This document provides guidance in remedying such problems, with a focus on areas relevant to timeframes, settings, and monitoring.     

Commentary: seclusion and restraint in corrections a time for change

Seclusion and restraint are essential interventions in the acute psychiatric care of patients in correctional environments. When administered and monitored properly, they are safe and effective in reducing the risk of harm. However, correctional systems have not developed uniform practices that are consistent with current community standards. There has been no clear national standard of care for the use of seclusion and restraint in correctional mental health care. The need for a national standard of care is discussed, and sources for developing a standard of care are reviewed. The Resource Document produced by the American Psychiatric Association is presented as a significant step toward establishing a national standard of care.     

Isolation and restraint in juvenile correctional facilities

Although mental health and correctional programs for juveniles house similar populations, their approaches to behavioral management can be quite different. This difference is evident in the use of isolation and restraint. Both of these interventions are effective behavioral management tools but are subject to abuse if not closely monitored. The authors, drawing from their experiences as mental health consultants to juvenile correctional programs and as expert witnesses in litigation, review the wide range of isolation and restraint practices in correctional programs and make recommendations for supervision and standardization.     

The mentally ill in prisons: a review

Mentally ill persons who have been charged with crimes present difficult dilemmas for correctional authorities and mental health system administrators. The authors examine the scope of the problem, the legal issues and treatment needs of this population during incarceration, and the obstacles in caring for them after their eventual release from prison. They recommend that mentally ill offenders be afforded the same level of mental health care available to mentally ill residents in other institutions and in the community. The need for postrelease supervision and coordination between mental health and correctional authorities are central issues in reintegrating mentally ill offenders into the community.     

Correctional Mental Health Services in New York: Then and Now

This article chronicles the legislation, litigation, and the agency initiatives which have shaped the New York State correctional mental health system into what it is today. An historical perspective provides a context and framework for the examination of the current and future salient issues and challenges in providing a comprehensive range of mental health services in a correctional setting. The Central New York Psychiatric Center organization, which is comprised of a 206 bed maximum-security forensic hospital and a community support network of 23 prison-based mental health units was established in 1977. This article takes an in-depth look at the organization's 25-year growth and development, the implementation and outcome of some innovative treatment programs, and the unique partnership between the New York State Office of Mental Health (OMH) and the New York State Department of Correctional Services (DOCS).     

A university-state-corporation partnership for providing correctional mental health services

In September 1998 the University of Massachusetts Medical School, in partnership with a private vendor of correctional health care, began providing mental health services and other services to the Massachusetts Department of Correction. The experience with this partnership demonstrates that the involvement of a medical school with a correctional system has advantages for both. The correctional program benefits from enhanced quality of services, assistance with the recruitment and retention of skilled professionals, and expansion of training and continuing education programs. The medical school benefits by building its revenue base while providing a needed public service and through opportunities to extend its research and training activities. Successful collaboration requires that the medical school have an appreciation of security needs, a sensitivity to fiscal issues, and a readiness to work with inmates who have severe mental disorders and disruptive behavior. Correctional administrators, for their part, must support adequate treatment resources and must collaborate in the resolution of tensions between security and health care needs.     

A survey of university-prison collaboration and computerized tracking systems in prisons.

It is conservatively estimated that 8 percent of inmates in U.S. prisons have significant psychiatric impairment. Correctional mental health systems are often unable to provide adequate treatment to such inmates because of staff recruitment problems. Collaboration between universities and departments of corrections can help solve recruitment problems, and needs assessment studies and computerized tracking systems can help obtain needed resources. A national survey collected data on collaborations between universities and corrections departments and on needs assessment and computerized tracking systems in prisons. Results indicated that such collaborations exist in more than half of state prison systems. Of 42 states responding, only ten states reported having systemwide computerized tracking systems, but others are in the process of developing such systems. Two-thirds of the correctional mental health systems did not have an ongoing needs assessment program.     

Commentary: the use of restraint and seclusion in correctional mental health

In contrast to the position taken in the American Psychiatric Association's "Resource Document on The Use of Restraint and Seclusion in Correctional Mental Health Care," this commentary proposes limiting the use of mental health restraints to the stabilization of unsafe situations during the time it takes to transfer an inmate to a psychiatric hospital. Jails and prisons are inherently nontherapeutic environments and are not adequate settings for managing mental health emergencies, such as those that require the use of restraints. Correctional conditions often contribute to the onset, and impede the resolution, of the underlying mental health crisis. Attempts to contain mental health emergencies in a correctional setting with an expanded use of restraints can compromise clinical care, overlook the root cause of many crises, impair the role of mental health professionals by blurring the distinction between mental health and security staff, and can lead to a deterioration in the standards of care.     

Practice parameter for the assessment and treatment of youth in juvenile detention and correctional facilities

This practice parameter presents recommendations for the mental health assessment and treatment of youths in juvenile detention and correctional facilities. Mental and substance-related disorders are significant public health problems affecting youths in juvenile justice settings. Sufficient time is necessary to conduct a comprehensive diagnostic assessment, interview collateral historians, and review pertinent records to identify primary and comorbid conditions. Potential role conflicts (i.e., forensic evaluator versus clinical care provider) need to be clarified before beginning any evaluation or treatment program, and particular attention must be paid to the issue of patient confidentiality. Issues of special concern in correctional health care, such as self-mutilative behaviors, suicide attempts, malingering, mandated reporting, ethical issues, cultural competency, institutional policies affecting clinical care, and the role of the clinician, are reviewed.     

Commentary: the role of mental health services in preadjudicated juvenile detention centers

The role of preadjudicated juvenile detention centers (JDCs) in treating children and adolescents with mental health needs has continued to receive national attention. Legal actions mandating improved health care services over the past decade, coupled with a national focus on detainees' mental health needs, have led to the increased presence of mental health professionals in JDCs. In this context, we must build on the current "call to action" and develop innovative blueprints for the provision of mental health services for detained youth. Although operationalizing this movement is complicated, we must be prepared to sustain its effects by developing effective communication and planning among correctional health care organizations, universities, municipalities, and other stakeholders.     

Connecting science and practice in child and adolescent mental health services research

Collaboration between researchers and stakeholder groups is a potentially powerful mechanism for strengthening the quality of mental health research and for amplifying its public health impact. For stakeholders, collaboration offers opportunities to help shape research questions; participate in data collection and interpretation; and improve local capacity to access and use research findings. For researchers, collaboration can build understanding of what stakeholders want and need from research; enhance capacity to frame research questions and findings in language and metrics of value to stakeholders; and provide opportunities to contribute science-backed knowledge to decision-making processes in real world settings. Key stakeholder groups can include the recipients and providers of care, public and private care systems, health plans, schools, family service and faith-based organizations, correctional systems, and employers providing mental health benefits. This commentary reflects on the path that NIMH has taken in fostering researcher-stakeholder collaboration, particularly regarding child and adolescent mental health research. It describes the goals that NIMH set out to achieve, steps taken to realize those goals, lessons learned from those efforts, and possible next steps.     

The coordination of mental health services at the neighborhood level.

The neighborhood health center is becoming a major locus of mental health care delivery. Because of their strategic position at the neighborhood level, mental health care systems in the comprehensive health center locus have been able to develop linkages with both general health and community mental health systems to provide a broad continuum of coordinated health and mental health care. Four models identified in a survey of 19 neighborhood mental health programs are described. The authors suggest that persistent problems in coordination of care between neighborhood mental health and other caregiving systems would be considerably alleviated by a fiscal reimbursement scheme that rewarded integration rather than fragmentation of care.     

Commentary: evolving toward equivalency in correctional mental health care--a view from the maximum security trenches

Developing and implementing community standards of care in correctional mental health and psychiatric practice will facilitate progress toward attaining equivalency in care in prisons and jails. Specialized therapeutic procedures such as application of restraints and seclusion when properly implemented are valuable tools in the treatment of the chronically mentally ill in prisons. The authors share some useful points for working in maximum-security prisons.     

Critical time intervention for reentry from prison for persons with mental illness

Critical time intervention (CTI) is a nine-month, three-stage intervention that strategically develops individualized linkages in the community and seeks to enhance engagement with treatment and community supports through building problem-solving skills, motivational coaching, and advocacy with community agencies. It is an empirically supported practice shown to enhance continuity of care for people with mental illness after discharge from homeless shelters and psychiatric hospitals. This article describes CTI as a promising model to provide support for reentry from prison for people with mental illness. A conceptual model is presented for evaluating the impact of CTI on the transition from correctional settings to the community. The model is potentially useful for further development of mental health service-driven models of reentry process and outcome. Although CTI is a potentially useful model for reentry services for this population, challenges remain in adapting it to specific correctional facilities, justice systems, and community contexts.     

Antipsychotic prescribing patterns in the Texas prison system

Although prison inmates are reported to exhibit elevated rates of psychotic disorders, little is known about antipsychotic pharmacotherapy in correctional settings. Therefore, the purpose of this study is to describe antipsychotic prescribing patterns in one of the nation's largest prison systems. The study population consisted of 3,750 Texas Department of Criminal Justice (TDCJ) inmates diagnosed with schizophrenic disorders, nonschizophrenic psychotic disorders, or both. In 1998, among inmates diagnosed with schizophrenic disorders, 14.6 percent were prescribed atypical antipsychotic agents, and 85.4 percent were prescribed typical antipsychotic agents. Among inmates diagnosed with nonschizophrenic psychotic disorders, 89.3 percent were prescribed typical antipsychotic agents, while 10.7 percent were prescribed atypical antipsychotic agents. Black males and females were prescribed atypical antipsychotic agents less frequently than their counterparts. Understanding such prescribing patterns is integral to the efficient and cost-effective planning of correctional mental health care.     

A model for the provision of jail mental health services: an integrative, community-based approach

Although a considerable amount of attention has been paid to the development and implementation of mental health services in prisons, relatively little work has focused on the provision of such services to jails. Jails generally serve two purposes: (1) they hold inmates awaiting arraignment or trial and (2) they serve as short-term correctional facilities for individuals who have been assigned relatively short sentences (no longer than one or two years). Because inmnates in the first category usually remain in jail for a short period of time, it is particularly challenging to provide them mental health services. This article describes an innovative program that has recently been developed for assessing the mental health needs of inmates awaiting arraignment or trial, and providing them with mental health services.     

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.     

Juvenile justice mental health services

As the second century of partnership begins, child psychiatry and juvenile justice face continuing challenges in meeting the mental health needs of delinquents. The modern juvenile justice system is marked by a significantly higher volume of cases, with increasingly complicated multiproblem youths and families with comorbid medical, psychiatric, substance abuse disorders, multiple family and psychosocial adversities, and shrinking community resources and alternatives to confinement. The family court is faced with shrinking financial resources to support court-ordered placement and treatment programs in efforts to treat and rehabilitate youths. The recognition of high rates of mental disorders for incarcerated youth has prompted several recommendations for improvement and calls for reform [56,57]. In their 2000 annual report, the Coalition for Juvenile Justice advocated increased access to mental health services that provide a continuum of care tailored to the specific problems of incarcerated youth [58]. The specific recommendations of the report for mental health providers include the need for wraparound services, improved planning and coordination between agencies, and further research. The Department of Justice, Office of Juvenile Justice and Delinquency Prevention has set three priorities in dealing with the mental health needs of delinquents: further research on the prevalence of mental illness among juvenile offenders, development of mental health screening assessment protocols, and improved mental health services [59]. Other programs have called for earlier detection and diversion of troubled youth from juvenile justice to mental health systems [31,56]. Most recently, many juvenile and family courts have developed innovative programs to address specific problems such as truancy or substance use and diversionary or alternative sentencing programs to deal with first-time or nonviolent delinquents. All youths who come in contact with the juvenile justice system should be screened and, when necessary, assessed for mental health and substance abuse disorders. The screening should occur at the youth's earliest point of contact with the juvenile justice system and should be available at all stages of juvenile justice processing. Whenever possible, youth with serious mental health disorders should be diverted from the juvenile justice system [58]. If delinquent youths do not receive the necessary evaluation, treatment, and rehabilitation, they face the real prospect of further incarceration in adult correctional facilities. Improved screening and treatment require better interagency collaboration, established standards of care, and continuing research on the mental health needs of youth in the juvenile justice system. Better mental health care for youth in the juvenile justice system supports the goal of rehabilitation. Mental health professionals should support these efforts as the appropriate response to meet the challenges of the new century.     

Patient-oriented models for linking primary care and mental health care

Although there has been much importance attached to the relationship between mental health care and general health care, there have been few attempts to systematically describe the nature of the relationships between these two domains of health care. The author reviews other attempts to develop models of interaction between the two systems, describes the dimensions of a patient-oriented set of models for the linkage between mental health and general health care providers, and suggests how these models fit into the overall context of clinical services research at the interface between these two systems of care.