A court-ordered expansion of California's mental health system for prisoners could help close a long-running deficit of psychiatrists in the system and affect funds earmarked to pay psychiatrists in public health systems throughout the state.

The state has scrambled to improve mental health care for inmates since U.S. District Judge Lawrence karlton in Sacramento ruled in 1995 that prison officials showed deliberate indifference to the needs of mentally ill prisoners. Soon after the ruling, the judge appointed Michael keating as special master of mental health for the state prison system. In April, still unhappy with mental health care in California prisons, Karlton ordered the state to spend more than $600 million to improve mental health services, including building new hospitals with space for 695 inmates.

Karlton's latest order, which came in July, required Gov. Arnold Schwarzenegger (R) to ask state lawmakers for the money to hire 552 additional mental health staff, ranging from psychiatrists to therapists and nurses. Although the governor had not proposed a breakdown of how many employees would be hired in any mental health staff category as of press time, state officials estimated the new hires could cost more than $30 million annually.

The increased focus on filling new and existing mental health staff positions would be a drastic change from the state's standard hiring practices and incentives, which resulted in a 23 percent vacancy rate among prison psychiatrists. The system has about 300 full-time psychiatrists and about 90 vacancies, according to the Union of American Physicians and Dentists (UAPD), which represents public psychiatrists in the state.

Gary robinson, executive director of UAPD, said the state was unlikely to fill the open positions or new psychiatrist positions had salaries not been increased in July. At that time, the prison psychiatrists got a 13.5 percent court-mandated salary increase—the first since 2003—which raised the starting salary from $160,000 to about $175,000 a year. Psychiatrists are slated to get another 5 percent boost January 1, 2007.

"Salary has been a big barrier; that's why [judges and state officials] had to go for this 13.5 percent raise," Robinson said." There is not a lot of psychiatrists who want to work in a prison. It's a tough job."

Robinson said it is "entirely possible" for an increase in prison psychiatry salaries to lead to an increase in psychiatrist salaries across the public health care system so that other care settings remain competitive. The Department of Mental Health (DMH) has since requested a 10 percent increase for DMH psychiatrists.

"For many years there haven't been psychiatrist salary increases, and they fell behind," he said. "This is catch up now," Robinson said about the prison system to Psychiatric News.

During the August special legislative session—called to address a variety of prison health care issues raised by law-suits—UAPD opposed the construction of new prisons, preferring that the money be invested in more rehabilitation programs and halfway houses and an expansion of the parole system. If new facilities are funded, UAPD urged the construction of new prison hospitals so that the number of prisoners who can be treated for mental illness and other chronic health conditions can be increased. The union also pushed for full funding of previously approved mental health staff positions.

Schwarzenegger proposed building or contracting for community correctional and "re-entry" facilities that would provide mental health care and other services. An estimated 4,500 female inmates would be moved to similar facilities, which would free a women's prison for use by male inmates at a cost of $2 billion.

Phil Angelides, Democratic candidate for governor, promised to boost education, training, and treatment programs for inmates if he wins in November.

Schwarzenegger previously announced plans to build two prisons and new units in existing prisons to relieve extreme inmate overcrowding, estimated to cost $6 billion, according to Acting Corrections Secretary James Tilton.

In a July report, Keating, the court-appointed master, criticized the state prison system's mental health effort, saying that the state's Department of Finance had not sought the necessary resources to bring prison mental health staffing in compliance with the judge's requirements.

The special master's report did not delineate what positions would be needed or how much they would cost. It did state that the number of suicides in the prison system is "soaring." Prisoner advocates said 40 inmates committed suicide last year, and the number increased to 25 inmates in the first six months of 2006. The number of suicides in 2005 exceeded the previous record of 36 in 2003.

Many of the suicides occurred in the prisons' "administrative segregation units" or solitary-confinement cells, where those with mental illness are often kept.

Randall Hagar, the California Psychiatric Association's director of government affairs, told Psychiatric News that "obviously the state's efforts to recruit and retain psychiatrists have failed."

Hagar said the psychiatrist salary increases and additional positions will likely "create a squeeze elsewhere" in the state public health system, such as in hospitals and community health centers.

"We expect a domino effect on salaries throughout the health care system," Hagar said. "We already find vacancy rates throughout the public health sector that are fairly high and limit access to mental health care."

Some prisoner-rights advocates have called for creation of a new department for prisoners with mental illness, or as an alternative that the state move them to DMH facilities. The only prisoners now treated by DMH are those who have completed their sentences but are deemed a continuing threat and are civilly committed. Almost all of the roughly 5,000 patients in state mental hospitals are forensic patients, said Hagar.

"We feel that mentally ill prisoners ought to be afforded special facilities to accommodate them," Hagar said. "It's bad enough they are incarcerated, but at least they need to be cared for adequately."

Information on Schwarzenegger's proposed prison system health care funding increases is posted at<www.ebudget.ca.gov/Revised/BudgetSummary/CLE/8875412.html>.▪