This fall the department of psychiatry at Dartmouth Hitchcock Medical Center in Hanover, N.H., will begin implementing a program to provide psychiatric treatment for inmates throughout the New Hampshire state prison system. Whether or not there are more psychiatric patients in prisons than in mental hospitals, as the conventional wisdom has it, corrections officials across the country worry about increasing numbers of prisoners with diagnosed mental illness in their institutions.
Agreements like Dartmouth’s are becoming more common as the overall prison population rises and, with it, the numbers of prisoners identified as mentally ill. Other states have contracted, directly or through managed care intermediaries, with academic centers for overall medical care of prisoners, including psychiatric treatment (see box). However, Dartmouth’s contract, valued at $1.3 million a year, may be unusual in that it is between a single department and an entire state prison system.
Dartmouth’s contract with the New Hampshire Department of Corrections arose from 12 years of providing psychiatric services at the New Hampshire Hospital in Concord, the state’s only public psychiatric hospital. Work in that institution’s secure unit for severely mentally ill prisoners led to much interaction with the Department of Corrections, said Peter Silberfarb, M.D., chair of the psychiatry department at Dartmouth.
Now the department will expand its services to New Hampshire’s main prison in Concord and three smaller prisons, one of which houses only women. The Concord facility includes the Secure Psychiatric Unit (SPU), which houses not only severely mentally ill prisoners but other involuntarily committed patients as well. Dartmouth will hire a forensic psychiatrist to direct the program and put together a team of psychiatrists, clinical psychologists, social workers, and others.
Silberfarb cited many benefits of the program. "It is the right thing to do clinically, and it could save society a lot of money," he said. According to the U.S. Bureau of Justice Statistics, prisoners with some history of mental health problems serve longer time than other prisoners with the same sentences.
The program will also include a forensic psychiatric fellowship, serve as a training site for medical students and residents, and will be a "gold mine" for research, he said. Silberfarb expects that logical areas of exploration will include research on questions like the psychiatric needs of geriatric prisoners, those with schizophrenia, or prisoners with a mental illness combined with drug or alcohol abuse.
"Forensic ‘exposure’ is required as part of the medical school curriculum," said Silberfarb. "The only way to learn is to take care of sick people. . . .A rotation through a prison exposes future doctors to [a range of] psychiatric illness at all levels."
"These kinds of agreements work well for both parties," said Jeffrey Metzner, M.D., a clinical professor of psychiatry at the University of Colorado Health Science Center and president of the American Academy of Psychiatry and the Law. "Prisons get high-quality psychiatric services, and association with an academic medical center can overcome some of the problems prison systems have in recruiting professionals."
According to a 1999 report from the U.S. Bureau of Justice Statistics, 16 percent of all inmates in state prisons or local jails said they had a mental or emotional condition or had at least one overnight stay in a mental hospital. Only 6 of 10 mentally ill state prisoners, however, reported receiving mental health treatment since admission to prison.
Metzner agrees that 10 percent to 14 percent of the total prison population can be considered part of the mental health caseload at any given moment and that 15 percent to 20 percent have been treated at some time. Prisoners are the only group in the United States with a constitutional right to treatment of mental illness.
"Seriously mentally ill [prisoners] must have reasonable access to services," said Metzner, who is also chair of APA’s Council on Psychiatry and Law.
How states provide such access varies widely. Some states hire their own professionals. Others contract with private companies, which then hire physicians, he said, while non-M.D.s remain state civil service employees. A few other states contract with nonprofit companies run by university medical centers, gaining their expertise without for-profit baggage. In Texas, for instance, the University of Texas Medical Branch at Galveston covers the eastern portion of the state (and 80 percent of the prisoners), while Texas Tech University handles the west.
Prior to signing with Dartmouth, New Hampshire’s Department of Corrections contracted with individual psychiatrists for treatment of mentally ill inmates, said Linda Flynn, M.S., A.R.N.P., director of the department’s Division of Forensic and Medical Services, which looks after 2,400 prisoners. However, the drawbacks of that practice became increasingly apparent.
"Individual contracting created difficulties in staffing, since each doctor worked a different number of hours or had conflicting time commitments," said Flynn. "We became concerned about responsiveness and service delivery.
"This is a challenging patient population. Incoming inmates are at a crisis point in their lives and may be depressed in view of their circumstances. And there are many with dual diagnoses—mental illness and substance abuse. Once they enter prison, they can no longer use those substances to self-medicate. We needed a change."
Flynn said Dartmouth’s program has been slow getting off the ground because of delays in hiring a director. Once that person is on board, she expects that the needs of the inmate population at each facility will get a close look, followed by appropriate planning for patient needs.
Perhaps any changes in the prison psychiatric system will mirror the ones brought about at the New Hampshire Hospital (NHH) after Dartmouth’s psychiatry department became responsible for care there 13 years ago.
"We would expect to see an increase in the number of psychiatrists and their level of expertise, which would allow nurses, psychologists, and social workers to function at a higher skill level," said Robert Vidaver, M.D., medical director at the NHH and a professor and vice chair of the psychiatry department at Dartmouth. "The use of drugs, psychotherapy, groups, and programming changes came to reflect academic levels of sophistication. This led to better diagnosis, improved therapies, a dramatic improvement in the ambiance."
The arrangement should benefit those providing care as well, said Vidaver.
"If they are not put off by stigma and fear, I think our students and residents will find that patients who are prisoners are ordinary human beings. Any time you can give medical students a sense of what goes on in these facilities, you expand their vision, and perhaps a small proportion of them will take jobs in the public sector." ▪