Correspondence

Prisons and Mental Health

N Engl J Med 2007; 356:197-198January 11, 2007

Article

To the Editor:

We believe that physicians have an often unrecognized responsibility to advocate for the reform of systems that are harmful to their patients. The current policies and sentencing laws that result in mass incarceration represent an enormous social experiment in which there is vast racial and economic inequity. For more than two decades, there has been a dramatic and steady increase in the number of people incarcerated in the United States. Much of this increase results directly from inadequate treatment of mental illness and addiction in the community.1,2 The natural history of addiction and mental illness often results in illegal activity, and persistently inadequate treatment perpetuates a cycle of crime and incarceration.

In part because prisoners have a constitutional guarantee of health care, physicians are an essential component of correctional institutions. Yet incarceration can often be harmful to a patient's physical and mental health. In U.S. prisons, rehabilitation has been largely abandoned in favor of punishment, which conflicts with a therapeutic approach and often results in neglect of the psychological and medical needs of patients with mental illness or addiction.3 Even in situations in which treatment has been proved effective, it is often underused in correctional settings. According to a report from the Bureau of Justice Statistics, although 83% of state prisoners reported past drug use and 57% were using drugs during the month before committing their offense, only 20% participated in treatment for substance abuse while in prison. In federal prisons, 63% of all prisoners in 1997 were held for drug offenses, yet only 15% of them reported participation in treatment for substance abuse while incarcerated.1

Although there are some potential health benefits from incarceration, including access to basic requirements such as nutrition, shelter, medical care, and forced relative sobriety, many of these benefits can be provided more efficiently in less expensive, nonpunitive therapeutic settings, such as residential treatment programs and group homes. The current practice of mass incarceration cannot be condoned, in our view, given its effect on the health of individuals and its destabilizing effect on communities.4

We feel strongly that physicians have the ability and the duty to advocate for effective and humane treatment for patients. The correctional system has been ineffective in providing therapy, including proven approaches such as mental health services, expanded high-quality drug treatment, and support services for reentry into society after incarceration.3,5 We believe that it is time for physicians to influence the sentencing laws, policies, and procedures that directly affect the health and well-being of patients and society and to advocate for more humane and effective community-based alternatives for addressing addiction and mental illness.

Scott A. Allen, M.D.
Josiah D. Rich, M.D., M.P.H.
Center for Prisoner Health and Human Rights, Providence, RI 02906
scott_allen_md@brown.edu

5 References

1. 1

   Mumola CJ. Substance abuse and treatment, state and federal prisoners, 1997. Washington, DC: Bureau of Justice Statistics, January 1999. (Report no. NCJ 172871.) (Accessed December 12, 2006, at http://www.ojp.usdoj.gov/bjs/pub/pdf/satsfp97.pdf.)
   

2. 2

   Ill-equipped: U.S. prisons and offenders with mental illness. New York: Human Rights Watch, 2003. (Accessed December 12, 2006, at http://www.hrw.org/reports/2003/usa1003/usa1003.pdf.)
   

3. 3

   Travis J. But they all come back: facing the challenges of prisoner reentry. Washington, DC: Urban Institute Press, 2002.
   

4. 4

   Thomas JC, Torrone E. Incarceration as forced migration: effects on selected community health outcomes. Am J Public Health 2006;96:1762-1765
   CrossRef | Web of Science | Medline

5. 5

   Golembeski C, Fullilove R. Criminal (in)justice in the city and its associated health consequences. Am J Public Health 2005;95:1701-1706
   CrossRef | Web of Science | Medline

Citing Articles (2)

Citing Articles

1. 1

   , Vasoontara Yiengprugsawan, Sam-ang Seubsman, Adrian C. Sleigh. (2010) Health, Well-being, and Social Indicators Among Monks, Prisoners, and Other Adult Members of an Open University Cohort in Thailand. Journal of Religion and Health
   CrossRef

2. 2

   George R. Brown. (2009) Recommended Revisions to the World Professional Association for Transgender Health's Standards of Care Section on Medical Care for Incarcerated Persons with Gender Identity Disorder. International Journal of Transgenderism 11:2, 133-139
   CrossRef