As mental health care has become increasingly deinstitutionalized in recent decades, there have been greater numbers of individuals with mental illness in the criminal justice system. According to one review, there are more individuals with serious mental illness in correctional institutions than in all US state hospitals.1 This presents unique treatment challenges both during patients’ incarceration and following their release.
“We know that people who are incarcerated are more likely to suffer from mental, physical, and substance misuse health problems,” according to Lamiece Hassan, PhD, a researcher at the University of Manchester in the UK. “In theory, time in custody can be seen as a unique opportunity to engage a population that does not always engage well with health services in the community, with the hope of returning them to the community in a healthier state than they arrived,” she told Psychiatry Advisor.
Entry and release from confinement are highly sensitive time periods in which continuity of care may be disrupted. “The key challenge is to improve the management of transition points — when an individual is released from prison and when someone is detained in custody from the community,” said Seena Fazel, MD, a professor of forensic psychiatry at the University of Oxford in the UK, who has studied the topic extensively.
The point at which an individual’s confinement begins is understandably an emotionally challenging time in general, whether mental illness is present or not. In a 2011 study published in the British Journal of Psychiatry, Dr Hassan and colleagues screened 3079 prisoners within 3 days of entry into custody and again at the 1-month and 2-month marks.2 They found that the prevalence of psychiatric symptoms was highest in the first week of confinement, and while it decreased over time for individuals with depression, it remained steady in those with other mental disorders. There was also a linear decline in symptoms among men but not women.
“Indeed, this is a high-risk period for suicide, and too often people go without their routinely prescribed, often long-standing, medicines during that initial period, which adds to their distress,” explained Dr Hassan. “Mental health practitioners and others working with incarcerated individuals can help to ease that transition by ensuring that they quickly establish the medical history of individuals and identify medicines that should be prescribed, making links with practitioners in the community where appropriate.”
During confinement, there may be issues with prescribing psychotropic medications. “As is the situation in the community, there is probably some overprescription of medication to individuals who do not need them, and also some underprescription in those persons at highest levels of need,” Dr Fazel told Psychiatry Advisor. One major concern in many prison systems is the illegal and improper use of such drugs, including diversion of prescribed medication. “Prison staff have to be aware that certain psychotropic medicines have a street value and can be misused, traded, or even used in overdose,” noted Dr Hassan. “Therefore, as well as health benefits, prescribers must weigh a complex interplay of factors including security and safety, [and] must take steps to minimize those risks.”
It may be the case the women prisoners in particular are overprescribed psychotropic medications. In another study by Dr Hassan and colleagues, published in BMC Psychiatry in 2016, they discovered that approximately 48% of women and 17% of men in prison received prescriptions for one or more psychotropic drugs. Compared with the general population, rates were 6 and 4 times higher, respectively.3 Additionally, roughly 35% of prescriptions were associated with undocumented or unapproved indications. “It is well known that incarcerated women have higher rates of mental illness than men. However, it can sometimes be difficult to distinguish between mental illness and other types of distress,” said Dr Hassan.
Compared with men, women may experience more acute distress as a result of incarceration, as they are more likely to lose their homes and children. In some areas, there is also a shortage of facilities that house female prisoners, which may mean women are housed further away from their families. “I think that prescribers often have more limited options than they would in the community — under the circumstances, they may feel that prescribing something that might work is better than doing nothing,” she said. “Better access to support and psychological therapies for vulnerable women in custody could be one way to provide other options and reduce reliance on psychotropic medicines.”
Ensuring access to appropriate care is also crucial in the period of time surrounding prisoners’ release, and it is important to identify individuals in need of continued care. Dr Fazel says that an essential need is the implementation of scalable approaches that would identify prisoners on release with mental health needs. He and his colleagues have developed one such approach, called OxRec.4 “This would allow prison healthcare staff to identify those prisoners that most need linkage with community services, and provide information on the basis of future reoffending risk to leverage these links,” he said.
A new study reported in JAMA by Dr Fazel and colleagues found that rates of violent reoffending among prisoners on release in Sweden were lower during periods when they received medication for psychiatric and addictive disorders than during unmedicated periods.5 “Links between healthcare providers in corrections and the community need to be enhanced so that individuals can move without major disruptions to their healthcare — and that will include prescription and titration of psychotropic medication.”
Though the implementation of electronic medical records systems would pose significant challenges, they could substantially facilitate the tracking of patients with mental health problems both between different prisons and between the community and prison. Overall, improving psychiatric care for incarcerated individuals during confinement and after release presents a “complex picture that will require updated guidelines, close liaison between community and prison healthcare, and possibly academic medical links to evaluate programs and lead innovations,” said Dr Fazel.
- Daniel AE. Care of the mentally ill in prisons: challenges and solutions. J Am Acad Psychiatry Law. 2007; 35(4):406-10.
- Hassan L, Birmingham L, Harty MA, et al. Prospective cohort study of mental health during imprisonment. Br J Psychiatry. 2011; 198(1):37-42.
- Hassan L, Senior J, Webb RT, et al. Prevalence and appropriateness of psychotropic medication prescribing in a nationally representative cross-sectional survey of male and female prisoners in England. BMC Psychiatry. 2016; 16(1):346.
- Fazel S, Chang Z, Fanshawe T, et al. Prediction of violent reoffending on release from prison: derivation and external validation of a scalable tool. The Lancet. 2016; 3(6): 535-43.
- Chang Z, Lichtenstein P, Långström N, Larsson H, Fazel S. Association between prescription of major psychotropic medications and violent reoffending after prison release. JAMA. 2016; 316(17):1798-1807.