Mental Health of Prisoners: Identifying Barriers to Mental Health Treatment and Medication Continuity

Objectives. We assessed mental health screening and medication continuity in a nationally representative sample of US prisoners.Methods. We obtained data from 18 185 prisoners interviewed in the 2004 Survey of Inmates in State and Federal Correctional Facilities. We conducted survey logistic regressions with Stata version 13.Results. About 26% of the inmates were diagnosed with a mental health condition at some point during their lifetime, and a very small proportion (18%) were taking medication for their condition(s) on admission to prison. In prison, more than 50% of those who were medicated for mental health conditions at admission did not receive pharmacotherapy in prison. Inmates with schizophrenia were most likely to receive pharmacotherapy compared with those presenting with less overt conditions (e.g., depression). This lack of treatment continuity is partially attributable to screening procedures that do not result in treatment by a medical professional in prison.Conclusions. A substantial portion of the prison population is not receiving treatment for mental health conditions. This treatment discontinuity has the potential to affect both recidivism and health care costs on release from prison.Mental health disorders among prisoners have consistently exceeded rates of such disorders in the general population, and correctional facilities in the United States are often considered to be the largest provider of mental health services.1–3 Despite court mandates for access to adequate health care in prisons (these mandates are even further limited to “severe” and “serious” mental illness treatment requirements in prison settings), inmate access to health and mental health care has been sporadic.4,5 Treatment decisions often depend on the limited available resources, public support of correctional treatment, and correctional management decision-making.4,5 Some studies report that at least half of male inmates and up to three quarters of female inmates reported symptoms of mental health conditions in the prior year (compared with 9% or fewer in the general population).3,6–8 These rates underscore the importance of access to mental health treatment for inmates, because lack of access to treatment can have important policy implications, particularly when financial resources are limited for correctional intervention and treatment.Individuals with untreated mental health conditions may be at higher risk for correctional rehabilitation treatment failure and future recidivism on release from prison.2,9,10 In fact, Baillargeon et al.10 found that after release from prison, former inmates who received a professional diagnosis of any Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, mental health disorder were 70% more likely to return to prison at least once than were those who were not given a diagnosis. Furthermore, among those who have been previously incarcerated, the rates of recidivism are between 50% and 230% higher for persons with mental health conditions than for those without any mental health conditions, regardless of the diagnosis.The limited treatment options in many prison settings are directly reflected in the greater number of disciplinary problems, rule violations, and physical assaults among those who have mental health disorders,11 often compounded by the resulting solitary confinement as punishment for these behaviors.1 Although all prisons are required to provide some level of health care, we know very little about whether mental health treatment is actually available to inmates on a case-by-case basis.3,9 In fact, Wilper et al. found that most prisoners, even those who have chronic medical conditions (such as diabetes or hypertension), had limited access to health care in prison.3 Therefore, we used a nationally representative sample of US prisoners to assess whether all persons with a history of mental health conditions were screened and evaluated by a medical professional for these conditions and whether medication use was continuous from the community setting to the prison setting.Mental health conditions represent a different level of need when compared with physical health needs among prisoners. For instance, tuberculosis transmission is a physical health hazard to all inmates and staff. Therefore, correctional administrators ensure that individuals suspected of having tuberculosis obtain proper assessment and subsequent access to health care. Symptoms inherent to many mental health disorders, however, may be less obvious to prison staff, especially without assessment by trained mental health professionals. In addition, a report on mental health care in prison emphasized the need for screening and treatment of mental health conditions among inmates from both a legal and a humanitarian perspective.12 Specifically, several US Supreme Court decisions have supported the rights of prisoners to receive health care, including mental health care (see Bowring v Godiva, 551 F2d 44 4th Cir 1977]; Laamon v. Helgemoe, 437 F Supp 269 DNH 1977]; and Ruiz v Estelle, 503 F Supp 1265 SD Tex 1980]). To date, however, a great deal of variation remains in screening for and treatment of mental health disorders in prison settings.13,14 The use of pharmacotherapy, in conjunction with counseling and self-help groups, to treat mental health conditions in correctional settings has been largely accepted in the correctional community; however, many medications are expensive and, therefore, not offered widely within institutions.4,12,13,15Several practical issues might explain why an individual in the correctional system would have difficulty receiving (or continuing to receive) pharmacotherapy for mental health conditions. First, psychologists and psychiatrists who may properly diagnose disorders are in short supply,12 and the screening tools that are typically used in prison settings are not diagnostic tests. Instead, the purpose of these tools is to gauge the security risk of a new inmate at the institution.4 Second, the continuously declining correctional budget may limit treatment access to those with only the most serious mental health conditions.5 In an ideal situation in which a licensed professional properly diagnoses inmates, specialized treatment programs (rarely located inside of prison facilities) are available. Unfortunately, the use of these outside treatment programs is limited, because correctional budgets do not have the extensive resources necessary to manage inmates enrolled in off-site treatment or to handle the logistics (such as secure transport) involved.15The incarceration experience itself poses a challenge to mental health treatment. Untreated mental health (and physical health) conditions are known to result in poor adjustment to life in prison.12 Furthermore, crowded living quarters, lack of privacy, increased risk of victimization, and solitary confinement within the institution have been identified as strong correlates for self-harm and adaptation challenges for those with mental health conditions in prison settings.16,17Given the strong relation between mental health and criminal behavior,18 the public health system has a great deal to gain from better mental health treatment among inmates, particularly in reducing the costs associated with high recidivism rates.5,10,19 Therefore, this study extends previous research on prisoner health conducted by Wilper et al.3 by assessing the continuity of pharmacotherapy (e.g., medication used to treat a mental health condition in prison), beyond the prevalence rates of pharmacotherapy in prison. Furthermore, we examined potential explanations for both continuity and discontinuity of treatment in the inmate population. Specifically, this study will contribute to the literature by evaluating 3 specific aims: (1) to assess medication continuity for a mental health condition since admission to prison; (2) to assess the correlates of medication continuity, medical screening, and receipt of examinations by medical personnel; and (3) to assess the degree to which medication continuity is predicted by screening prisoners for mental health conditions at intake to prison.