I am writing this the night before I am to go visit a prison in Alabama. I am a member of the Medical Advisory Committee, a group of health care providers (physicians, nurse, dentist, and pharmacist) that visits state correctional facilities and makes recommendations to the Alabama Department of Corrections (DOC) on the quality of medical care that we see provided. The state recently settled a huge court case alleging poor mental health care. They have promised to hire 100 new mental health workers as part of the decree settlement. And the state DOC faces another judicial challenge. Although the prison system is overwhelmed in terms of prison population (overcrowded and understaffed), the courts have mandated that convicted inmates must be transferred from county facilities to state facilities within 30 days.

My mental health center also provides contracted-for mental health services for the local city and county jails. The good news is that we have a splendid drug court system, and have just started a mental health court. The bad news is that we struggle with a limited formulary (supplemented by samples we bring in), inadequate mental health staff, time limitations, and a paucity of in-house treatment options. The local jails endeavor to provide for the needs of their inmates. They too are under judicial watch for overcrowding and inadequate health care.

In the cases of both the state and local correctional systems, it is readily apparent that the numbers of those with mental illness are growing, and that neither system is able to provide adequate mental health care. Unfortunately, this is not happening only in Alabama. I would be naive to assume that ignorance or stigma play no role in these inadequate systems of care. However, I am also aware of the day-to-day battles of many mental health care providers in these settings to do the right thing, to provide humane, appropriate care with horribly limited resources. The consequences of inadequate care are huge. They range from costly judicial settlements (with money spent on attorneys and paperwork that could be better spent on care) to experienced staff who leave exhausted or disgusted, to inmates suffering, to victims of crime (because a mental illness or substance disorder was left untreated).

While burn-out and suffering and victims (or those darn old morals and ethics) haven’t seemed to change the system in any significant fashion, it is apparent that financial consequences can propel systems to evolve. Several members of the AACP board are now participating in a Criminal Justice/Mental Health Consortium project sponsored by the Association of State Governors (it would appear that finally government is realizing that not providing mental health care is more costly than providing care). The end product will (hopefully) be a manual of both abstract and concrete, how-to recommendations for law-enforcement, corrections, and the judiciary.

Please join us with this ongoing challenge. Advocate for those with mental illness in the criminal justice system. Advocate for funding and evaluation of diversion projects. Advocate for appropriate treatment within the correctional system, including treatment of substance abuse. Support your colleagues who work in these systems; they are pioneers. Remember how the AACP joined with other advocacy groups to write a letter in support of enhancing care for those with mental illness incarcerated in New York City? That court case won judicial support for considerable improvements. It may seem insurmountable at times, but sometimes our collective efforts can make a huge difference.

Jacqueline Maus Feldman, MD

President, AACP

jfeldman@uabmc.edu