Mental health needs of aging prisoners is a fruitful area for coverage

By Katti Gray

All but a relative handful of incarcerated persons in the United States do go home again. But those sentenced to longer – if not lifetime – prison stays mainly account for an increasingly older population in state and federal correctional facilities.

While the federal Bureau of Justice Statistics has been tracking that surge, it has not tallied the prevalence of mental illness among prisoners who are aging. Moreover, aging persons — imprisoned or not — are at greater risk for certain mental illnesses.

A comparatively small coterie of university researchers, alongside physicians and others providing care for those behind bars, say older inmates’ mental illnesses run the gamut. These researchers and clinicians have begun, even if incrementally, to try to empirically measure mental health problems among aging inmates, adding, they say, to what is a relatively small body of research about this group of individuals.

Epidemiologist Lisa Barry, Ph.D., M.P.H., an assistant professor of psychiatry at the University of Connecticut Health Center Center on Aging, was the lead author on a September 2016 study on this. The study looked at whether older inmates’ age-related physical decline — many of them had entered prison with a variety of chronic physical illnesses—fueled depression and suicidal thoughts.

“What we’ve done in the short-term is look at whether there is an association between the prison activities of daily living — the uniqueness of being older and infirmed and walking to chow hall, climbing on and off a top bunk, standing in line for medication — and inmates’ depression or suicidal ideation,” said Barry, whose research focuses on inmate health.

The International Journal of Geriatric Psychiatry published that study, which enrolled 167 men who were at least 50 years old and confined to Connecticut’s state prisons. UConn’s health center is the sole health-care provider in all of that state’s jail, prisons and halfway houses. “We still don’t definitively know if the depression is caused by the [physical] disability,” Barry said of those recent findings. She is preparing for a follow-up study.

For journalists covering mental health care among aging inmates, this 1995 seminal study of depression and anxiety among 95 federal prisoners still is a must-read. The study, led by Harold Koenig, M.D., who teaches psychiatry, behavioral science and medicine at Duke University Medical Center, concluded that 53.7 percent of those 95 inmates had a psychiatric disorder, a rate substantially higher than that of men in a never-incarcerated study control group. Psychiatric Services, the American Psychiatric Association journal that initially published the research, republished the research online in 2006.

Additional resources for reporters include:

• Two-Volume “Correctional Psychiatry: Practice Guidelines and Strategies,” published by the Civic Research Institute.
• Physicians and others at the National Commission on Correctional Health Care, which in July 2016 co-hosted a Correctional Mental Health Care Conference with the Academy of Correctional Health Professionals, American Psychiatric Association and American Psychological Association.
• Physician and public health researchers and practitioners at the Center for Prisoner Health and Human Rights at the Brown University Alpert Medical School and Miriam Hospital, one of the Alpert school’s partnering medical facilities.
• University of Kansas Medical Center Landon Center on Aging, which consults on the care of geriatric inmates in rural America, where prisons and jails face some added challenges. Chief among them is difficulty recruiting psychiatrists, social workers, nurses and other mental health care providers willing to work with inmates.

Absent any enforced, national standards of mental health care for geriatric inmates, correctional systems are making do — or not — in a patchwork of ways, said Linda Redford, Ph.D., R.N., a nursing professor and associate director of the Landon center.

“If an inmate’s overriding issue is chronic mental illness, they are more likely to be managed in units for people with chronic mental illness, particularly if they are of some harm to themselves or others,” Redford said. “But I am not aware of much effort to handle those who may be old, frail and have mobility issues … in any kind of special units for aging inmates who are chronically mentally ill. I do suspect that, at some point, those kinds of units will happen.”

Reporting on the overall surge in aging inmates has come from several news organizations — USA Today, The Wall Street Journal and The Washington Post, for example — that coverage has not spotlighted geriatric prisoners who also are mentally ill.

National, regional and local reporters, most specializing in criminal justice or health care, last year were part of a John Jay College’s Center on Media, Crime and Justice conference and related fellowship on the theme “An Imprisoned Mind: The Mentally Ill and the Criminal Justice System.” The 2015-16 fellows after the conference went on to examine mental health care innovations – or the lack thereof – in various areas across the country.

While none of their coverage singularly focused on elderly inmates, their work is a good starting point for those interested in covering mental health and health care among the incarcerated in general.

Research Needs

More research is vital to ensuring that mental health care in prisons is better tailored for older inmates. “There is,” UConn epidemiologist Barry said, “so little research on older prisoners, and almost no longitudinal studies on them. Right now, it is more of a chicken-and-the-egg problem.” What we can do, though, as we wait for more research, is focus on some [medical, structural and environmental] interventions … that may be used to modify the daily activities of prisoners … Those modifications may not necessarily eliminate the depression, but we believe there is the potential to do so.”

Brie Williams, M.D., founding director of the University of California Criminal Justice & Health Consortium and an associate professor of medicine at the University of California, San Francisco, Division of Geriatrics, was the lead author of two papers in 2012 on this subject.

One study, which looked at the impact on the criminal justice system of aging inmates, appeared in the Journal of the American Geriatrics Society. A policy paper published in the American Journal of Public Health also urged a national standard of care for all older inmates.

As “we age our health concerns are more complex than, say, a younger person who may just have schizophrenia and major depression,” Williams said. “An older one may have schizophrenia, plus major depression and diabetes and heart failure — in a prison setting where treatment of mental illness is not much of a priority.”

A 2012 roundtable of 29 doctors, nurses, researchers and related correctional health care professional assembled by Williams, recommended the establishment of geriatric wings — with a full menu of nationally standardized health/mental health services — to serve enfeebled, older inmates. The reformers also urged more research dollars be spent to study aging inmates and their comparatively higher costs of health care inside and outside of prison. They also suggested a more precise definition of who is an aging inmate. Back in 2012, depending on the state, an inmate became labeled as aged anywhere from 50 to 70 years old.

Freelancer Katti Gray mainly covers health and criminal justice news. She coordinated the “An Imprisoned Mind” and “Health Behind Bars” Fellowships that John Jay’s Center on Media, Crime and Justice offered to 44 journalists between 2013 and 2016. In 2014-15, she was a Rosalynn Carter Mental Health Journalism Fellow.