Correctional Psychiatry: Room for Improvement

Dr Jeffrey Metzner's brief article, "Evolving Issues in Correctional Psychiatry" (Psychiatric Times, September 2007) related many of the difficulties and complexities of the corrections world; however, it did not mention the greatest problem of all-"deinstitutionalization," which, over the past half century, has resulted in the wholesale diversion of patients with chronic mental illnesses-many of whom cannot be managed as outpatients-from hospitals to jails and prisons.

There seems to be relatively little concern about the matter in the field of psychiatry. Rather, we are involved in implementing the trend touched on by Dr Metzner: "In general, treatment of inmates with serious mental illness should be similar to that available to persons who are not incarcerated." I believe that such an expectation is unrealistic for most jails and prisons, and I believe that corrections facilities are systematically exploited. For example, to achieve "bed reduction," commitment of psychotic and dangerous chronic "consumers" is eschewed and criminal charges are placed by psychiatric facilities. Further, nothing could be more common than the arrest of a patient who has a chronic mental illness within a week of his or her release from a psychiatric hospital.

Dr Metzner responds:

Dr Smith is correct that my brief article did not mention the significant problems associated with deinstitutionalization or the subsequent transinstitutionalization of persons with severe mental illness from the state hospital system to the correctional system. I am not sure that there is relatively little concern about such a process in the field of psychiatry, but I do agree that we have not been very effective in reversing the process.

Ten years ago, I may have agreed with Dr Smith that it was unrealistic for most jails and prisons to provide adequate mental health treatment to persons with serious mental illness. Sheriffs and wardens would commonly say that their institution's mission did not include providing such treatment. However, transinstitutionalization is not a new phenomenon and these officials now commonly recognize (related in part to the large numbers of persons with serious mental illness in correctional facilities) that their mission includes providing these services, understanding that the incarcerated person with serious medical needs (including psychiatric problems) has a constitutional right to treatment, and recognizing that good treatment is also good security, besides being the right thing to do.

I am in agreement that in many cases the correctional system has been put in a position to provide services that should be provided by state mental health departments (or equivalent agencies) outside a correctional environment. The correctional system, for obvious reasons, should not be in such a position. This is all the more reason to join advocates such as the National Alliance on Mental Illness and the American Psychiatric Association and its district branches in attempting to obtain needed community resources to begin to reverse this trend. Unfortunately, for many reasons I am not very optimistic that we will see changes in the short term.

Jeffery Metzner, MD Denver