In a study published in the December 2014 issue of American Journal of Public Health, Jennifer M. Reingle Gonzalez, Ph.D., and Nadine M. Connell, Ph.D., of the University of Texas Health Science Center at Houston interviewed a nationally representative sample of all state and federal prisoners with psychiatric disorders to determine whether they had been screened for services at intake and to assess whether screening led to continuity of community treatment.
The subjects were chosen first by selecting a random sample of correctional facilities of varying sizes, from diverse geographic regions. From those facilities, 18,185 prisoners were chosen from among all those incarcerated on a single day in September 2002. Each subject was interviewed personally but also given computer-assisted interviews at different times to ensure recollection accuracy and the confidentiality of clinical data (Am. J. Public Health 2014;104:2328-33).
In the direct interview, each prisoner was asked if he or she had ever been diagnosed with a mental health condition such as depression, bipolar disorder, schizophrenia, posttraumatic stress disorder, an anxiety disorder, or a personality disorder. If any condition had ever been diagnosed, the inmates were then asked if they were taking a psychiatric medication upon admission to the facility. If they were in treatment at intake, they were asked if they had ever been on medication since that time. Finally, they were asked if they had had a medical examination while incarcerated.
Almost all prisoners (90%) were screened at intake and received a medical evaluation. The researchers found that 5,207 (26.2%) of the inmates received at least one lifetime mental health diagnosis, with depression being the most common. Eighteen percent reported taking medication for a psychiatric disorder at the time of intake, but of these, only about half were taking medication after incarceration. Medication continuance was twice as likely for schizophrenia as for depression, and those who received an intake screen were significantly more likely to be referred to a physician and receive medication. Notably, 27% of state and 16% of federal prisoners received medication only in prison.
The investigators attributed the discontinuity in treatment after incarceration to a lack of trained mental health professionals to diagnose and treat psychiatric disorders, and to a rise in prison populations out of proportion to available treatment services. The findings of this study supported the investigators’ recommendation for all facilities to employ intake screening to identify and refer prisoners in need of psychiatric care.
This research is important to forensic psychiatrists working in correctional systems and to those working as administrators or external court-appointed monitors, because it highlights the importance and efficacy of intake screening for prisoners with psychiatric disorders.
Unfortunately, traditional media coverage of this research was predictably provocative. Headlines blared: “Mental health care lacking in state and federal prisons.” The researchers themselves also implied that failure to continue medication in prison indicated some systemic deficiency. While an evaluation by a physician was correlated with the prescription of medication, this was not a perfect correlation. The authors did not discuss any of the valid reasons why medication might not be continued in prison.
The most common reason medication is not continued is that inmates are more likely to be abstinent from drugs and alcohol, and thus may require less or even no antidepressant medication after detoxification. This could account for as much as half of the treatment discontinuity, because as many as 20% of the prisoners had been diagnosed with depression. Also, evidence is mounting that indefinite medication may not be necessary for all conditions. Following a clinical assessment, a correctional physician may have determined that the prisoner had successfully completed maintenance therapy. The final reason why medication is not continued is that the inmate may simply have refused the offered treatment; some prisoners do choose to go without medication completely rather than risk a change to a different regimen.
All of this assumes that the subjects accurately reported both their psychiatric history and their mental health service contact following incarceration. Without access to current records or past documentation, this remains an open question. In my prison system, our electronic health record does contain some data provided by the public health care system. In rare cases, this information is consistent with what the patient reports, but this is the exception rather than the rule.
Finally, the most telling aspect of this research is what it reveals about free society care: A quarter of the inmates received treatment only in prison. That is the real finding worthy of a headline.
Dr. Hanson is a forensic psychiatrist and coauthor of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.