The plight of people with mental illness in custody – a problem for everyone

In prison, severe mental illness is shockingly ordinary. Schizophrenia, bipolar disorder, post-traumatic stress disorder, and personality disorder are up to ten times as common as they are in the community overall. In New South Wales, up to one third of all new inmates on arrest are suffering from psychosis – a serious mental illness with hallucinations and delusional thinking.

Is prison really the right place for them? As doctors who negotiate this system with our patients, we believe there must be a better way. No system is perfect, but for a patient in this state suffering from psychosis – vulnerable and often in distress – the outcomes of a journey through the criminal justice system are alarmingly arbitrary.

The unwell person who comes to the attention of the NSW Police may be taken to the local hospital, or they may go to police cells and to court. At court, they can be seen by the court liaison service for diversion, but to where? Local hospitals are full and community psychiatric services are woefully underfunded. They may apply for bail, but up to a fifth are homeless and have no address to be bailed to. Specific groups, particularly our indigenous population, are disproportionately incarcerated. 

Once in prison, the wait for their next court date can easily be six weeks. This is an environment known to re-traumatise people with trauma history and make psychosis, an emergency condition, even worse. In addition to psychosis, these people disproportionately suffer from physical health problems, intellectual disability, and drug and alcohol problems. Rates of self-harm and suicide in custody are even higher than the rates of mental illness. 

If their psychosis is recognised, they can wait weeks to get to a prison mental health unit. Within office hours, this unit will have doctors, nurses and some access to psychologists, but is largely staffed by prison officers. None of the other crucial disciplines that make up a modern mental health team – such as social workers, occupational therapists, diversional therapists – are available.

Should a patient decline to accept treatment, medication occasionally needs to be enforced. This is a sad reality of psychiatric care that should only be carried out in a psychiatric hospital. Instead, in NSW, it is done at Long Bay Prison Hospital. This is an area of the prison where many of the services available in a normal hospital are not available. NSW is one of the few jurisdictions in the developed world where prisoners are not transferred out to a psychiatric hospital when necessary. There has been one study to determine whether this method of delivering health care is effective. It isn’t, and not supported by the Royal Australian and New Zealand College of Psychiatrists.

You might think this is a soft-on-crime approach. But it’s important to think about why people, mentally ill or otherwise, are put in prison in the first place: to make society safer, and to reduce the chances of further crime occurring when people are released.

So does the current approach work? The short answer is no. The rate of recidivism, or re-offending, for all inmates in NSW is at least 40%. For those in the justice system with a severe mental illness it is even higher. The recidivism rate for those who receive mental health care in a hospital, albeit initially more costly but with full multi-disciplinary teams, is less than 10%. 

There you have it. For weeks unwell people are placed in a situation known to worsen their mental condition, then put on a pathway that leaves them more likely to re-offend. And this is what happens when the system is working well. The problem isn’t a lack of effort, or care, or passionate and tireless work by frontline health care staff making the best of the situation. It’s an unthinking, senseless and under-resourced system that doesn’t benefit anyone, least of all those unfortunate enough to get caught up in it.  

We propose the following changes. Processes need to be developed for the prompt transfer of low risk custodial patients to receive treatment in nearby psychiatric units. Studies have shown this to be no more dangerous than admission of people off the street. Secondly, the overall community mental health capacity needs to be increased significantly. Amongst myriad upsides, treatment in a hospital has been shown to reduce reoffending, so let’s ensure there are adequate beds for people to be treated in. Finally, once treated, we need to minimise the chances of relapse and reoffending. Stable accommodation is crucial to this, so more money needs allocated to break the vicious cycle of mental illness, homelessness, and offending.

As it stands, the system significantly disadvantages a specific group, and misses an opportunity for society to reduce the risk of reoffending. This is the definition of systemic discrimination, and is to the detriment of everyone.

Dr Calum Smith and Dr Andrew Ellis
Faculty of Forensic Psychiatry NSW Subcommittee
Royal Australian and New Zealand College of Psychiatrists

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For all other expert mental health information, visit Your Health in Mind, the RANZCP’s consumer health information website.


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