While New Hampshire will provide psychiatric care for its prisoners by contracting directly with Dartmouth’s department of psychiatry, Massachusetts has chosen a different path. There are 10 major prisons and 14 smaller units in the Massachusetts system. Out of 10,000 inmates, about 18 percent have open mental health cases, said Kenneth Appelbaum, M.D., director of correctional mental health programs at the University of Massachusetts Medical School in Worcester. Bridgewater State Hospital contains 300 inpatient beds and is used for forensic evaluation.

Beginning in 1992, the state contracted with the medical school for all mental health services as part of an overall agreement for medical services with a private contactor. The contract was awarded to Correctional Medical Systems (CMS) of St. Louis in 1994 and again in 1998. Over time, the psychiatry department has gained a greater degree of functional control over the delivery of psychiatric services, within the terms of the subcontract.

The department of psychiatry provides the same mental health services available in a community mental health center, using multidisciplinary mental health teams at every major prison in the state, said Appelbaum. These teams include a psychiatrist, as well as clinical psychologists, social workers, other licensed clinicians, and psychological rehabilitation professionals and services. Their job begins with the identification and screening of all incoming inmates within seven to 14 days of entry into prison. Those who screen positive for mental illness are then given a comprehensive mental health evaluation.

Prisoners get case management, psychopharmacology, crisis management, and other programming on an outpatient basis (outpatient being a relative term). There are residential treatment units for individuals with serious and persistent mental health disorders, including hospitalization. At present, 12 percent of the prisoners are on psychotropic medications and are being followed by a psychiatrist.

"Staffing levels are often better than in the community," said Appelbaum. "Perhaps 150 patients on medication are looked after by one full-time psychiatrist."

Appelbaum noted that the correctional system benefits from the subcontracting arrangement because the university psychiatry department can help encourage new psychiatrists to work in the corrections system following residency.

Besides benefiting financially from the subcontract, said Appelbaum, the department of psychiatry (part of the state’s only public medical school) provides health care to an underserved population and gains opportunities for research and training.

But there are challenges, he said. Practicing psychiatry in prisons is not for everyone. Some people feel uncomfortable, but most are pleasantly surprised. Inmates are often extremely appreciative at receiving good care. Since prisons are in the business of providing security, civilian staff members are not placed in vulnerable positions and may be more secure than working in other settings.