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The problem is significant, long-standing, and well-recognized:  our jails and prisons are overcrowded with people with mental illness. Jails and prisons have replaced state psychiatric hospitals as the location where the largest number of people with mental illness reside. Jails in New York, Los Angeles and Chicago are now the three largest institutions providing psychiatric care in the U.S.(1) 

According to the U.S. Department of Justice,  

  • About 37% of prisoners and 44% of jail inmates have been diagnosed with a mental illness
  • About 14% of state and federal prisoners and 26% of jail inmates reported experiences that met the threshold for serious psychological distress.  These rates are about 3 to 5 times the rates in the general population.(2)

Numerous factors contribute to the high rates of incarceration, especially among people with mental illness. Lack of accessible mental health services and unmet mental health needs make people vulnerable to arrest and incarceration. Untreated mental illness, which can lead some people to self-medicate with alcohol and illicit substances, has been a trigger for arrest. There is a risk that behaviors associated with mental illness will be misinterpreted as criminal behavior, especially in communities in with high concentrations of poverty and where policing is particularly aggressive.

Lack of Mental Health Care in the Correctional System

People with mental illness who are incarcerated often have limited access to mental health services and inadequate care.  In a Department of Justice study, among prisoners with serious psychological distress, only about 36% of prisoners and 30% of jail inmates were receiving treatment. Prescription medication was the most common treatment among these prisoners and jail inmates.

Several states are being compelled to make improvements because of court actions. Alabama is currently under court order to improve mental health care for inmates. Last year a federal court ruled that the mental health care in Alabama prisons violates the U.S. Constitutions’ ban on cruel and unusual punishment. In March, Alabama approved an $85 million increase for the state’s prison system. The Illinois Department of Corrections is currently under a consent decree to improve services to its 20,000 inmates with mental illness.

Factors contributing to Lack of Mental Health Care in Correctional System and Judicial Action

Among the reasons for inadequate care of prison inmates are the lack of identification of mental health needs, overcrowding of inmates, and lack of psychiatrists and other mental health professional personnel. Dr. William Puga, Chief of Psychiatry for the Illinois Department of Corrections sees the lack of providers as the biggest obstacle to mental health care in the Illinois correctional system.

Many factors contribute to the provider shortage. There is a national shortage of psychiatrists and the shortage of psychiatrists is particularly acute in prison settings. The rural location of many prisons and psychiatrists’ concerns about safety in prison setting contribute to difficulties recruiting psychiatrists. Mardoche Sidor, M.D., President of the Sweet Institute and former director of a special unit working with individuals with challenging mental health conditions at Ryker’s Island Correctional Facility, notes, “One of the biggest challenges facing mental health care in corrections is that it is very hard to make meaningful change when people don’t feel safe:  both the individuals who are incarcerated as well as individual mental health clinicians.”   

Stigma is also a major barrier to mental health care in the correctional system, notes Otis Anderson III, M.D., a psychiatrist working in Mississippi correctional institutions: “Stigma is evident inmate to inmate, as well as between correctional officers and inmates. Inmates shy away from mental health care because they get castigated by other inmates and correctional officers if it is known that they are receiving mental health services in prison.”

Bridging the Gap with Telepsychiatry

Among the possible ways to help meet the mental health needs of people in prison is telepsychiatry. Telepsychiatry permits psychiatrists and other mental health professionals to evaluate and treat inmates remotely. Research has found telepsychiatry as an effective means of delivering treatment, comparable to in-person treatment, and it improves access to mental health services for inmates.

While telepsychiatry offers many advantages in the community, it especially has the potential to address barriers to care in correctional settings. Because providers do not need to be in the prison or jail, the significant travel time to often remote facilities is eliminated. Less time traveling and dealing with security issues means more time treating patients. Working remotely can also alleviate safety concerns and minimize the potential tensions and pressures among custody staff, healthcare staff and inmates (e.g., intimidation, prison culture). Some patients may actually prefer working with a remote provider.

While the use of telemedicine and telepsychiatry has been increasing in recent years, it has been used for many years in several correction systems. For example, the University of Texas Medical Branch in Galveston, TX has been providing mental health care to inmates in Texas through telepsychiatry since the 1990s. (3) In Georgia five prisons receive telemedicine care from the Augusta Correctional and Medical Institute. In Ohio, more than 4,000 inmates in the correctional system are served each year through telepsychiatry and other telemedicine provided by the Ohio State University Medical Center in Columbus, Ohio. (4)

Access to patient information through electronic health records (EHRs) is a necessary component of effective telepsychiatry. EHRs help facilitate continuity of care and quality of care. They allow consistent access to records and can also help reduce potential errors from legibility problems with paper records.  Dr. Puga notes that without digital records, it’s often difficult to access old records, charts are often illegible or incomplete, it slows us down, and “some things end up falling through the cracks.”

EHRs can provide real time mental health status and treatment information at the time a patient comes in from or is released to outside mental health providers. Electronic patient discharge summaries can facilitate quality mental health care for patients released from prison or jail. Efficient coordination of all related resources such as patient side clinical presenter, patient, equipment, exam rooms, etc., is also important to effective care in prison settings.

Advances in technology and systems continue to improve the efficiency and effectiveness of services provided via telepsychiatry.  The telemedicine market overall is advancing and growing and hopefully, telemedicine will increasingly be applied to meet the growing needs for quality mental health care in prisons and jails.

References

  1. Alisa Roth. Insane: America’s Criminal Treatment of Mental Illness. 2018. National Public Radio.  https://www.npr.org/sections/health-shots/2018/04/25/605666107/insane-americas-3-largest-psychiatric-facilities-are-jails
  2. Bronson J, Berzofsky M. Indicators of Mental health Problems Reported by Prisoners and Jail Inmates, 2011-2012. U.S. Department of Justice, Bureau of Justice Statistics. Special Report.
  3. UTMB. Impact Newsletter. May 17, 2016. A Day in the Life of a CMC Telepsychiatrist
  4. Deslich, SA, et al. Telepsychiatry in the 21st Century: Transforming Healthcare with Technology. American Health Information Management Association
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