Caring for Convicts and Ex-Offenders

 

Editor's Note: In a recent Medscape interview Dr. Rick Weisler of Duke University and the University of North Carolina offered some alarming statistics on psychiatric illness in the criminal justice system: "35%-54% of prisoners have symptoms of mania, 16%-30% have major depression, and 10%-24% have some psychotic symptoms, such as delusions or hallucinations."

To find out more about the burden of mental illness in the correctional system, along with how community mental health providers can better manage patients with a forensic history, Medscape spoke with Dr. Elizabeth Ford, Director Division of Forensic Psychiatry at the Bellevue Hospital Center in New York.

Caring for Convicts: Introduction

Medscape: In your experience and opinion, how prevalent is mental illness in incarcerated individuals and prior felons?

Elizabeth Ford, MD: By all accounts, the prevalence of mental illness in the United States correctional population is higher than in the general population. The reported rates vary significantly on the basis of research method (eg, jail vs prison, lifetime prevalence vs current symptoms, how mental illness is defined), but there is consensus that correctional populations suffer from more severe and more frequent mental health problems than the general population. According to a large national survey, 26% of American adults have suffered a mental disorder in the past year, with the number dropping to 6% when only serious mental illness is included (generally considered to be major psychotic and mood disorders). [1] In contrast, the Bureau of Justice Statistics report indicated that 40%-60% of incarcerated individuals suffered from a mental health disorder within the past year, with rates of 10%-54% for serious mental illness. [2] A recent, well-respected study from Steadman and colleagues [3] indicated that 14.5% of men and 31.5% of women incarcerated in Maryland and New York jails currently experienced serious mental illness. The numbers are extremely important, but to put all of this in perspective, in the United States there are at least 3 times more people with mental illness in prisons than in mental health hospitals. [4]

Although the rates of mental illness in correctional settings are certainly high, I am also concerned about the limitations on outpatient treatment services when this population re-enters the community and for individuals with criminal backgrounds seeking psychiatric care. A study of 96 outpatients with schizophrenia found that 59% had a history of arrest. [5] A study of users of Veterans Administration services found that 25% of dual diagnosis patients (mental illness and substance use disorder) had a history of incarceration over a 3-year period. [6]

My own experience with outpatient and psychiatric emergency settings in New York City leads me to believe that the rate of criminal justice involvement in the general psychiatric population is underreported. In addition to continuing resistance from community providers to treating patients with a forensic history, there is a general lack of knowledge on the part of community psychiatrists even about how to ask their patients about forensic issues, much less how to address them in treatment. Clinicians are not asking their patients about it, and patients, understandably, may be hesitant to reveal this kind of information. So as a growing percentage of our patients are experiencing the extreme stress of incarceration, an experience that may expose them to significant trauma or even worsen their psychiatric conditions, psychiatrists and primary care providers need to become more aware of and more comfortable managing patients with criminal histories.

Prisons: The New (and Old) Psych Ward

Medscape: Why do you think the rate of mental illness in incarcerated populations is so high? Is it due – at least in part – to the shortage of psychiatrists and psychiatric resources in this country? Might some of these patients receive treatment in the community if resources were available, and be less prone to behavior that could land them in jail?

Dr. Ford: Incarceration of the mentally ill is not a new phenomenon. Prior to the 20th century, jails were commonly used to house the mentally ill. Advocacy efforts on the part of individuals like Dorothea Dix led to the creation of "asylums" and psychiatric hospitals. However, over the past 4-5 decades, as a result of fiscal decisions and civil rights advances of the 1960s and 1970s, those psychiatric hospitals have been closed, leading to a massive reduction in the number of hospital beds available for the care of the severely mentally ill. [7] There were more than 550,000 psychiatric hospital beds in 1955; that number has now been reduced by more than 85%. [8]

Unfortunately, despite what may have been the best intentions, community resources were not in place to meet the mental health needs of those who would otherwise have been patients in these state facilities. Those community resources are still not in place, and even if they were, a question remains about whether resources would be adequate to manage the severity of mental illness and comorbid conditions (medical comorbidities, substance abuse, developmental disabilities, personality disorders) for this de-institutionalized population. Without sufficient community resources or social supports (eg, housing), a growing percentage of mentally ill convicts are being treated in jails or prisons.

Looking at the question from a different perspective, although the severely mentally ill are only marginally more violent as a population than the general public, they are more likely to be homeless, impoverished, and to abuse substances. Any or all of these characteristics place them at higher risk for being arrested and incarcerated. Whereas the psychiatrically hospitalized population has dramatically decreased, the incarcerated mentally ill population has dramatically increased.

In addition to limited psychiatric community resources, harsher crime laws, especially related to drugs, are factors that likely contribute to the increased incarceration of the mentally ill.

Another issue to consider, although not as comprehensively reviewed in the literature, is the possibility of incarceration itself triggering symptoms of mental illness. Solitary confinement has been associated with an exacerbation of mental illness, [9] but my experience indicates that the stress of incarceration alone can trigger the onset of mental illness in vulnerable individuals.

This "transinstitutionalization" of the mentally ill is therefore multifactorial and stems from a combination of inadequate community resources, a population at greater risk for arrest as a function of mental illness and related behaviors, and the stresses of incarceration.

The State of Correctional Care

Medscape: What degree of mental healthcare is typically provided in the prison system and is it of the quality provided in the community?

Dr. Ford: The provision of mental healthcare in jails and prisons varies widely and depends in large part on binding litigation and legislation in any given jurisdiction. Prisoners have a constitutional right to minimally adequate mental health treatment [10] but a clear description of "minimally adequate" care has never been established. Although a real effort is made to provide timely medication management, access to individual and group psychotherapy in a correctional setting is much more limited than it is in the community. Access to a consistent care provider is also more limited. I would argue that community mental health treatment still has a way to go to meet the needs of the country's mentally ill, but it's a fair statement that correctional mental healthcare is not up to current community standards.

It is easy to blame this on the quality and quantity of care (correctional health care is not typically considered a desirable position among medical professionals), but the biggest barrier to providing better mental health treatment is the correctional environment itself. Movement of patient-inmates out of their cells for a therapy session or medication administration is a big deal, medication formularies are restricted for security reasons, patient-inmates can be moved to different housing areas as a result of infractions or gang-related activity, and the mission of correctional settings does not involve being therapeutic. Conflict is inherent in trying to provide treatment in a punitive environment.

Recognizing these difficulties, national organizations have established guidelines about appropriate staffing, monitoring, training and quality of correctional mental healthcare. Of note are those issued by the National Commission on Correctional Health Care (NCCHC) in 2008. [11] Although following these guidelines is not required unless a facility wishes to be accredited through the NCCHC, the guidelines highlight how seriously people are thinking about what should be appropriate mental healthcare for prisoners.

What Can You Do?

Medscape: What clinical issues should community psychiatrists be aware of when treating incarcerated patients or former felons? Also for what conditions and/or symptoms is this population most at risk and what forms of intervention should be used?

Dr. Ford: With a growing percentage of psychiatric patients in this country having experience with the criminal justice system and/or incarceration, psychiatrists in the community, whether in private practice or clinic settings, would do well to explore this history with their patients. Much like the sensitive topics of sex and money, incarceration can and should be explored. It is also important to recognize that while there are certainly psychiatric patients with criminal backgrounds who are wise about manipulation and cheating, incarceration on its own does not necessarily make a patient "bad."

The process from arrest to release, regardless of how long that may take (a person can be released at arraignment hours after arrest or sentenced to life imprisonment), is not designed to be comfortable and in some cases, can be quite traumatic. For individuals with mental illness, arrest itself often results in a fear-inducing situation with a lack of access to medications, risk for acute withdrawal (in those who abuse substances), isolation from community support, total control by the officers and for many, no legal assistance. This situation can have a damaging effect on anyone, but is particularly hard on the vulnerable mentally ill. If the individual is retained in custody, the stressors increase. The reality of incarceration for the mentally ill includes a high risk for physical, sexual or emotional assault, a disproportionate risk for being placed in solitary confinement because of "infractions" caused by behavior related to their mental illness, limited medication formularies, and psychiatric care that is limited by resources. An elevated risk for development of post-traumatic stress disorder (PTSD) and depression is a function of the chronic trauma experienced by these individuals.

In addition to the conditions that may worsen or trigger mental illness, the culture of incarceration is one in which coping skills that would ordinarily be considered maladaptive (eg, cheating, lying, fighting, self-injury, paranoia) may be advantageous. The longer a patient is exposed to this culture, the harder it may be for him/her to accommodate to behavior expected in the community. Re-entry is an important phenomenon to consider in this population.

The biggest issues for community psychiatrists are first, to find out about their patients' criminal justice backgrounds, including any time spent in solitary confinement; second, to be as empathic and as nonjudgmental as possible about this history; and third, to be aware of issues of PTSD and mood disorders that may have been exacerbated or triggered by incarceration.

In terms of treatment modalities, patients with correctional histories can benefit, in general, from the same types of treatment as the outpatient psychiatric community. Similar issues arise: establishing trust, identifying target symptoms and tailoring treatment, and recommending appropriate adjunctive treatment such as group therapy. It is important that the psychiatrist be comfortable enough to admit to unfamiliarity with the experiences a patient may describe about incarceration. Allowing the patient to "teach" the psychiatrist can be a useful way to establish a strong treatment alliance.

References

1. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Arch General Psychiatry. 2005;62:617-627.
2. James DJ, Glaze LE. Mental Health Problems of Prison and Jail Inmates. Bureau of Justice Statistics Special Report, September 2006. Available at: http://bjs.ojp.usdoj.gov/content/pub/pdf/mhppji.pdf Accessed January 16, 2011.
3. Steadman HJ, Osher FC, Robbins PC, Case B, Samuels S. Prevalence of serious mental illness among jail inmates. Psychiatr Serv. 2009;60:761-765. Abstract
4. Abramsky S, Fellner J. Ill-Equipped: US Prisons and Offenders with Mental Illness. Human Rights Watch. 2007. Available at: http://www.hrw.org/en/node/12252/section/2 Accessed January 16, 2011.
5. Lafayette JM, Frankle WG, Pollock A, Dyer K, Goff DC. Clinical characteristics, cognitive functioning, and criminal histories of outpatients with schizophrenia. Psychiatr Serv. 2003;54:1635-1640. Abstract
6. Rosenheck RA, Banks S, Pandiani J, Hoff R. Bed closures and incarceration rates among users of Veterans Affairs mental health services. Psychiatr Serv. 2000;51:1282-1287. Abstract
7. Metzner JL, Dvoskin JA. Correctional Psychiatry. In Simon RI and Gold LH (Eds) Textbook of Forensic Psychiatry., Washington, DC: American Psychiatric Publishing; 2010:395-411.
8. Slovenko R. The transinstitutionalization of the mentally ill. Ohio North Univ Law Rev. 2003;29:641-660. Abstract
9. Metzner JL, Fellner J. Solitary confinement and U.S. prisons: a challenge for medical ethics. J Am Acad Psychiatry Law. 2010;38:104-108. Abstract
10. Bowring v. E. Godwin, 551 F.2d 44. OpenJurist. Available at: http://openjurist.org/551/f2d/44/bowring-v-e-godwin Accessed January 16, 2011.
11. National Commission on Correctional Health Care. Standards for Mental Health Services in Correctional Facilities. Chicago, IL: NCCHC; 2008.

Authors and Disclosures

Interviewer

Bret Stetka, MD, Editorial Director, Medscape Features Group, has disclosed no relevant financial relationships.

Interviewee

Elizabeth Ford, MD, Clinical Associate Professor, Department of Psychiatry, New York University School of Medicine; Director, Division of Forensic Psychiatry, Bellevue Hospital Center, New York, NY, has disclosed no relevant financial relationships.

-From “Caring for Convicts; Mental Healthcare in Current and Past Prisoners--An Expert Interview With Elizabeth Ford, MD”, by Bret Stetka, MD, Medscape Psychiatry & Mental Health , Posted: 01/21/2011, http://www.medscape.com/viewarticle/735988, retrieved 1/16/11.

 

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