Psychiatry behind bars.

The pressing need for psychiatric services within the nation's jails and prisons is well documented. A study sponsored by the American Medical Association in 1973 reported that only 13 percent of the nation's jails had psychiatric services for mentally ill inmates. I This lack is even more disturbing when psychiatric morbidity rates of jailed persons is noted. Rates vary, depending on the nature of the facility and the manner in which psychiatric morbidity is defined. 2 A study of five California facilities in Los Angeles County reported 6.7 percent of all inmates to be psychotic and 9.3 percent of inmates to be suffering from a nonpsychotic disorder. 3 A study of the Alabama state prison system showed 10 percent of inmates to be psychotic, while approximately 60 percent of all inmates had "severe psychiatric disturbances. ,,4 Further support of the need for psychiatric services within jails and prisons is offered by the observed clinical relationship between crime and mental illness, especially with reference to certain subgroups of the mentally ill who are arrested more frequently than average people. An even more complex relationship exists between mental health legislation, psychiatric institutionalization, and the so-called "criminalization" of the mentally ill. 6 Studies suggest that restrictive civil commitment practices have increased the number of mentally ill persons who find their way into the criminal justice system, ultimately requiring psychiatric care.• Despite this well-documented need, psychiatric services within jails and prisons remain "the most necessary but the least available health services for inmates. "II Prison psychiatry, as opposed to the broader and currently more popular subspecialty of forensic psychiatry, remains an underpopulated field. Halleck, in an earlier study as well as in a more recent editorial, pointed out the paucity of psychiatrists available for prison work, which is considered by many to be "neither professionally nor financially rewarding. ,,12.13 This article, based on the author's experience as a staff psychiatrist in a county jail, attempts to define the clinical issues, problems, and deterrents faced by a general psychiatrist working in such a setting. My work was in a 204-bedjail with approximately 850 admissions annually, serving a northeastern county of 479,000 inhabitants. Although this is a county jail, many issues encountered are applicable to work within any "correctional" facility, be it local, state, or federal.