Correctional health: Mental health in prisons



The Mental Health Care Act , Act 17 of 2002 states that a mental health care user or patient is a person receiving care, treatment and rehabilitation services or using a health service at a health establishment aimed at enhancing the mental health of a patient, a state patient or mentally ill prisoner

Another practical description of mental disorder is mental illness, incomplete or arrested development of the mind, psychopathic disorder or disability of the mind

In prison there is a high prevalence of psychiatric disease. In my experience as many as 2% of prisoners suffer from schizophrenia, 30% of depression, high percentages of anxiety-related disorders and high percentages of personality and delusional disorders

High levels of mental health disorders in a prison imply high prevalence of attempted suicide and self-harm. Prison authorities strive to prevent suicide and self-harm.

Suicide is the act of killing oneself intentionally. Suicide is not a crime but aiding, abetting or procuring a suicide is. Doing nothing to stop someone else from suicide is not abetting it, but euthanasia (mercy killing) may amount to aiding

If an inmate is at high risk of suicide, “suicide watch” has to instituted. If the suicide risk is very high the inmate is admitted in the prison hospital for continuous observation

Suicidal risk factors

  • Suicidal ideation
  • Threats to commit suicide
  • Depressive mood
  • Previous attempts
  • Mental illness (especially psychotic phenomena)
  • Admission in mental institutions

Other predisposing risk factors

  • Guilt about crime
  • First time incarcerated
  • Early in incarceration
  • Underlying drug withdrawal or alcohol withdrawal
  • Accompanying illnesses such as HIV or cancer
  • Writing a suicide note
  • Underlying aggressive, impulsive or manipulative personality

The advantages of observation in the prison hospital is

  • the inmate is physically in close proximity and can be watched closely
  • the hospital staff can observe any deterioration in mental health status and let the correctional medicine practitioner know
  • the inmate is engaged at regular intervals and half-hour watches are instituted to prevent self-harm
  • observations on condition and behaviour are charted in clinical notes
  • the prison psychiatrist can be contacted if necessary

It is important that any ligatures be removed from the holding cell


It is important that custody staff has some basic knowledge of mental health. They must be able to identify some basic psychopathology so that the inmate can be screened by the Correctional Nursing Practitioner. If the custody staff is trained the risks of unnecessary harm to inmates are also reduced

Some conditions discussed with custody staff and correctional nursing practitioners include:

  • Affective disorders (bipolar, depression)
  • Schizophrenia and delusional disorders
  • Neurotic, stress-related, somatoform disorders, obsessive-compulsive disorders, PTSD and hypochondriasis
  • Dementia and delirium
  • Personality and behavioural changes due to brain damage
  • Personality disorders and psychopathy
  • Psycho-active substance-related disorders
  • Eating, sleeping disorders

The schizophrenic inmate, the acute psychotic inmate, hypomanic inmate, demented or delirious inmate, decompensating schizo-affective inmate or decompensating border-line personality disorder can present with dramatic pseudo-violent and destructive behaviour. It is not necessary for riot-control or high-security teams to necessarily use excessive force on these inmates. Such psychiatric decompensating inmates can be transported to isolation facilities or the prison hospital without use of excessive force

The correctional medicine practitioner must strive to see the known mental health inmate as soon as possible after admission in the isolation ward or hospital

Prisons exacerbate or activate mental health disease. All inmates after years of incarceration develop some form of “burn-out”. This leads to depression and anxiety disorders that may even progress to psychosis or delusional disorders

In my experience it is not uncommon to see PTSD among inmates. The fact that they may have initiated the crime, does not mean that they are necessarily immune to PTSD

There is a high prevalence of inmates with antisocial personality disorder.

Mentally ill inmates are at higher risk of being bullied, sexually and otherwise abused in prison. They are more vulnerable in the prison setting. It is important that a system of DOT (Direct Observed Treatment) be instituted where it can be ensured that the inmate takes every dose correctly; the right dose, at the right time, the right way, at the correct interval

The problem is that if DOT is not performed judiciously, scheduled medicine gets hoarded in the prison cells. This hoarded medicine then becomes “currency” in the prison with which other contraband can be traded. There is also the risk that the hoarding of tablets can lead to a successful overdose and suicide. During DOT it is important to see that the tablet is swallowed completely and not hidden away in the gum or cheek after ingestion