Current Issues in Correctional
Psychiatry
or (if you want to be cynical) …so what else
is new?
Jeffrey L. Metzner, M.D.
Clinical Professor of Psychiatry
University of Colorado School of Medicine
A new textbook…
Patients in State and County
Hospitals

1979: 140,355
63/100,000

1997: 54,015
20/100,000*
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Transinstitualization/criminalization hypothesis**
*RW Manderscheid and MJ Henderson, eds. Mental Health United States 1998 and
Mental health United States 2000. DHHS Pub. #(SMA) 99-3285, Washington, DC:
US Government Printing Office, 1990 and 2001.
**Erickson, Rosenheck, Trestman, Ford, Desai. Risk of Incarceration between
Cohorts of Veterans with and without Mental illness Discharged from Inpatient Units.
Psychiatric Services: 59,178-183, Feb. 2008.
Prisons (2013)

California (135,981), Texas (168,280), and
the Federal system (201,697) together
have 37% of all the prisoners in the nation.

The 21 smallest jurisdictions accounted for
7.8% of the total population under
jurisdiction at midyear 2006.
Prevalence rates of mental
disorders

Studies and clinical experience have
consistently indicated that 8-19% of prison
inmates have psychiatric disorders that
result in significant functional impairments.

Another 15-25% of inmates will require
some form of psychiatric intervention
during their incarceration.
Right to treatment
Landmark cases
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Cooper v. Pate 278 U.S. 546 (1964)
Estelle v. Gamble 429 U.S. 97 (1976)
Bowring v. Godwin 551 F.2d 44 (4th Cir. 1977)
Bell v. Wolfish 441 U.S. 520 (1979)
Ruiz v. Estelle 503 F. Supp. 1265 (S.D. Tex.
1980)
Miller v. French (2000) (Prison litigation reform
act)
Coleman v Brown & Plata v. Brown (131 S. Ct.
1910, 1923 (2011)
Three essential elements required to
establish a constitutionally adequate
correctional mental health system are as
follows:

Adequate physical resources regarding
treatment program space and supplies;

Adequate human resources concerning
numbers of properly trained and/or experienced
mental health staff who will identify and/or
provide treatment to inmates with serious mental
illnesses; and

Adequate access for inmates to the
physical and human resources within a
reasonable period of time (Cohen 1993).
Cohen F: Captives’ legal right to mental health care.
Law and Psychology Review. 1993; 17:1-39.
Standards and/or guidelines for
correctional health care
programs
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American Psychiatric Association
American Public Health Association
National Institute of Corrections,
National Commission on Correctional
Health Care
American Nurses Association
Association of Correctional Psychologists
Current issues in correctional
psychiatry

Mental health issues relevant to lockdown
units (e.g., segregation, disciplinary,
supermax, etc.).

Mental health input into the disciplinary
process.

Discharge plans for inmates with serious
mental illness.

Special Needs of Female Inmates

Research ethics (see IOM reporthttp://books.nap.edu/catalog/11692.html)
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Substance Abuse Treatment
Segregation Housing Issues
Mentally ill prisoners in
segregation
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Security housing unit (SHU) (“Supermax”)
Administrative segregation
Disciplinary (punitive) segregation
Pre-hearing detention
Protective custody
Other?
Types of segregation

Disciplinary segregation, which is based upon
what the inmate did, is typically ordered as
punishment for an institutional infraction, and is
often of relatively short duration.

Administrative segregation is typically imposed
based upon what the inmate will do. That is,
administrative segregation is prospective in
nature, and designed to protect other inmates
from a danger believed to be posed by the
inmate.

It is often administrative segregation, a
classification status, which has now
commonly led to the imposition of longterm segregation.

The use of supermax confinement is
overutilized within correctional facilities in
the United States. The use of this type of
program, because of its extreme
limitations on liberty and its potential for
harm, should be reserved for cases in
which there is no less restrictive way to
remedy an unsafe situation.
The major problems relevant to the
mentally ill in segregation involve
issues related to the following:

Definition of mental illness

Duration of confinement in segregation

Conditions of confinement

Clinical assessment of the above 3 factors
American Psychiatric Position
Statement

Prolonged segregation of adult inmates with serious
mental illness, with rare exceptions, should be avoided
due to the potential for harm to such inmates. If an
inmate with serious mental illness is placed in
segregation, out-of-cell structured therapeutic activities
(i.e., mental health/ psychiatric treatment) in appropriate
programming space and adequate unstructured out-ofcell time should be permitted. Correctional mental health
authorities should work closely with administrative
custody staff to maximize access to clinically indicated
programming and recreation for these individuals.
Segregation Housing

General
Pop
37%
Seg
63%
More than half
of prison
suicides occur
in segregation
units
Federal Bureau of Prisons Study (1983-1997)
Segregation Housing (cont.)
Seg
General
Pop

Yet segregation
accounts for less
than 10% of
prison beds
Zubek, Bayer, and Shephard:

conceptualize segregation units to have
three main characteristics:
social isolation,
 sensory deprivation, and
 confinement.
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