CHPR: Let’s start with an overview. How common are mental health disorders among the incarcerated population?
Dr. Mehta: In the past 10-15 years, we’ve seen a significant increase in the number of incarcerated individuals receiving mental health treatment—from just over a quarter of all incarcerated people to about a third. And this figure does not include substance use disorders, which are widespread among the incarcerated population. 

CHPR: So, a large proportion of people who are incarcerated require mental health services. How does incarceration affect their mental health? 
Dr. Mehta: Being incarcerated certainly creates its own set of challenges. There’s relatively little privacy, separation from family and friends can strain bonds, and incarcerated individuals often find it difficult to extricate themselves from negative influences within prisons. Additionally, both incarcerated and formerly incarcerated people often face marginalization and alienation from mainstream society. These challenges can make it very hard for our patients to maintain a focus on rehabilitation and self-improvement.  But on the flip side, everyone has access to mental health, nursing, and other medical services at all times. Out in the community, our patients often haven’t engaged much with mental health services, but when they are in our system, due to the number of eyes that are laid on them over the course of a day, they receive a lot of monitoring. If a patient is decompensating or behaving unusually, we will generally hear about it quickly. 

CHPR: You mentioned that substance use disorders are widespread among the incarcerated population. How do you address this issue?
Dr. Mehta: California has developed a program that is the largest of its kind in the country and far ahead of what most incarcerated settings are able to offer. This includes the wide availability of agonist therapy (eg, buprenorphine) and credits toward reducing time served for completion of cognitive behavioral treatment programs (https://tinyurl.com/j69jthx9). And because of our focus on harm reduction, nearly every individual receives an emergency naloxone (Narcan) kit upon release from prison. 

CHPR: When it comes to prescribing medications, how does the process differ in a prison setting compared to a community setting? 
Dr. Mehta: We don’t have to deal with some of the common challenges for community providers, such as requiring prior authorization from insurance companies or worrying that patients will lose coverage partway through their inpatient stay. State prisons are effectively a single-payer system. However, we do have some restrictions to our formulary. Benzodiazepines are only used short-term for critical indications, like catatonia or the rare case of alcohol withdrawal. Sedative-hypnotics for insomnia and stimulants for ADHD are virtually never prescribed in our setting; we teach patients sleep hygiene or cognitive behavioral therapy for insomnia. For ADHD, we may use an antidepressant with crossover benefit to attention, and occasionally prescribe some non-formulary medications when clinically indicated.  

CHPR: Do you encounter a problem with medication diversion? If so, how is this problem handled?Dr. Mehta: It takes a balance of trust and control. As part of patients’ rehabilitation, we want to respect their autonomy and provide opportunities for them to develop good habits that they can carry forward after their release. So, for some medications, they are entrusted with a month’s supply to keep in their cells, and they are expected to remember to take their dose daily and get refills when necessary. Other medications are administered directly by nursing staff to ensure compliance and minimize diversion, especially among patients with a history of overdose or trouble remembering to take their pills. Our doctors work to build strong relationships with their patients, especially with the most vulnerable, and talk to them about any bullying or soliciting that may occur. We then work closely with our custody partners to protect our patients in those instances, even if it means moving a patient from that environment to a new one. 

CHPR: What psychiatric medications are at most risk of being diverted?
Dr. Mehta: They’re not what I would have expected before working in prisons. Because of the difficulty accessing conventional drugs of abuse, medications that are relatively safe and common in the community can become a hot commodity. Diphenhydramine (Benadryl) can potentiate the effects of opioids like morphine, so it’s in high demand even though it’s available over the counter outside prisons. Bupropion (Wellbutrin or Zyban) has been referred to as “poor man’s cocaine,” since it can cause a rush if it is insufflated rather than taken orally. And then there are medications that individuals seek for their genuine mental health benefits but prefer to avoid entering the mental health system to obtain. 

CHPR: And how is suicide risk assessed in this population?
Dr. Mehta: The prison population is at a particularly high risk of suicide, though less than jails or local lockups. All incarcerated individuals are screened by nursing and allied health staff upon entry into the system, and then repeatedly thereafter. These screenings connect to a rapid referral system for full mental health assessments. Any patient can also self-refer into this pathway, and any staff—from the correctional counselor to the cook—can place a referral for a patient they have concerns about. 

CHPR: How do you manage acutely suicidal patients in prisons?
Dr. Mehta: For acutely suicidal patients, we assign 1:1 observers and move them to licensed inpatient beds. We maintain over 1,300 inpatient beds within our own facilities, and over 300 more beds within our Department of State Hospitals for low-security patients. For self-injurious behaviors, we either manage them onsite or send patients to community emergency rooms with security escorts for any injuries beyond our capabilities. 

CHPR: What steps are taken to reduce the risk of suicide?
Dr. Mehta: The rate of suicide per 100,000 incarcerated people varies from year to year between about 15 and 30. The best approach is to have a strong prevention system in place and then monitor that system, while exhaustively examining any completed suicides to uncover potential gaps. We publish an annual report of all of our suicide reviews for both the court system and the state legislature. Those are posted publicly so anyone can analyze the data and learn the lessons we learn, available here: www.cdcr.ca.gov/about-cdcr/reports/. Also, the California Department of Corrections and Rehabilitation holds an annual statewide Suicide Prevention Summit, where speakers review the latest research and share updates on best practices or legal precedents. We are currently working to expand this into a national conference on Suicide Prevention in Correctional Environments and hope to offer it in the next couple of years. Moreover, we are always working to make our facilities as safe as possible by meeting the latest standards, addressing issues like tie-off or ligature points, unbreakable fixtures, and even removing floor tiles, as they can be broken and used to inflict self-harm. 

CHPR: Beyond crisis interventions, how do mental health services help with rehabilitation? 
Dr. Mehta: The people who become our patients often didn’t have access to treatment in the community or didn’t seek it. Incarceration can provide an opportunity to address the deep-seated issues like trauma or neglect that often brought individuals into the correctional system in the first place. We find that there is practically always a history of trauma, abuse, or neglect and it’s hard to overstate the impact that clinicians can have—many patients are able to radically change their lives with some fundamental psychoeducation and skill-building. The gains they make also lead to indirect benefits that trickle out to their families and communities when they are released. 

CHPR: It’s good to hear about the influence that mental health clinicians can have on patients’ lives. What challenges do correctional psychiatrists face? 
Dr. Mehta: One major hurdle is overcoming the stigma and public perception that this population is undeserving of care or just have personality-disorders that won’t be responsive to treatment. In reality, many of our patients have been underserved from a young age, and if they had accessed more mental health services earlier in life, many of them would likely never have found themselves in prison. But now that they are here, we have the opportunity to treat conditions, like depression and PTSD, that often respond well to therapy and medication. While we do encounter challenging cases, like antisocial personality disorder and malingering, these are in the minority, and we can still make meaningful progress by following structured treatment plans and maintaining clear boundaries. And by offering genuine care and support, which these individuals have often lacked, we can make a huge impact on them when they return to the community.  

CHPR: It sounds like there are both challenges and opportunities in this work. What’s a typical day like for a psychiatrist working in the correctional system?
Dr. Mehta: Other than the security gates, we try to make the working conditions as similar as possible to community or hospital treatment. The incarcerated population in this country is very large but is typically hidden from view. We do our best to treat them the same as any other patients. Surprisingly, I’ve found that the psychiatrists can conduct more therapy with the prison population than they typically can in a fast-paced private practice.

CHPR: Given the focus on rehabilitation, what steps are taken to ensure patients reintegrate smoothly back into society when they are released? 
Dr. Mehta: We provide referrals to substance use programs and linkages to community services to ensure a seamless transition. We recognize that this is one of the most important things we can do, not only for our patients but for the community. Our system operates at a large scale, with nearly 100,000 people in detention and over 33,000 of them requiring mental health treatment, so managing this reintegration requires extensive coordination between various statewide departments and external agencies.

CHPR: Shifting focus slightly, what issues arise when correctional psychiatrists provide treatment to patients undergoing forensic assessments, such as evaluations for competency to stand trial?
Dr. Mehta: This can be a complicated area, as we are bound by two potentially conflicting sets of ethical principles. Our first principle, as physicians, is to do no harm to our patients and work to maintain their autonomy within the boundaries of the healthcare system. At the same time, when called upon to testify as part of the criminal justice system, we participate in a legal process to determine culpability and punishment through the fair application of the law. Whenever possible, we try to have forensic evaluations done by providers who work completely separately from the treatment team. Evaluations for criminal responsibility and competence to stand trial are also typically performed by clinicians employed by the court, the prosecutor, or the defendant, so our institutional physicians are not directly involved, though their notes may be reviewed. Sometimes it’s difficult or impossible to separate the treatment team from the issue at hand, such as the need for involuntary medication or hospitalization. In those cases, the treating psychiatrist seeks to employ as much tact and empathy as possible to preserve the therapeutic relationship while doing what is ultimately best for the patient.  

CHPR: Finally, in what ways do you think the correctional system could be improved to better address the mental health of people in prison? 
Dr. Mehta: Having more clinicians come and work with this population! We have a loud voice in promoting the humane and ethical treatment of incarcerated people and making sure that these patients get the highest quality care possible. More physicians make for a louder voice and contribute to an increased awareness about the needs of these often disenfranchised people. California is working hard to learn from the best practices across the world. We’ve started implementing the “California Model,” influenced by correctional practices from Norway, where their focus on rehabilitation and humane treatment of people in prison has been shown to result in lower recidivism rates (https://tinyurl.com/jcmkpfb6). The core principle lies in rehabilitation (www.cdcr.ca.gov/the-california-model/). The loss of their liberty is punishment enough; we want to build positive relationships, model professional behavior, and move people towards healthy autonomy. Mental health can contribute a lot to that rehabilitation, with better outcomes for everyone. 

CHPR: Thank you for your time, Dr. Mehta.