Healthcare professionals working in a custodial environment are typically exposed to a confronting set of symptoms and conditions, not limited to: anxiety, panic attacks, hearing voices, low or depressed mood, crying, screaming, delusions and paranoia. Often these people – patients or inmates – are in an acute state of mental instability. A multidisciplinary team consisting of nurses, medical and allied healthcare professionals collaborates to provide mental health support by engaging other stakeholders, assessing the mental health status of the inmate and implementing strategies that reduce the risk of the inmate harming themselves (JH&FMHN., 2010).

So what is a mental health disorder and how is it defined in a prison or custodial setting? Mental health problems incorporate a wide range of behaviours including substance use, mood disturbances, anxiety and disturbances in thought and perception (Neugebaur, 1999). According to the information published by the Australian Health and Welfare Report (2012) 46% of prisoners in Australia were diagnosed with mental health issues on entering the criminal justice system. A high proportion of persons entering the criminal justice system can appear to the local community and stakeholders to be mentally disordered. Therefore, it is understandable that each stakeholder forms a different understanding and definition of persons appearing to have a mental health disorder.

It is well documented that people with mental health disorders are over-represented in the criminal justice system (McCausland et al., 2013). An Australian study measuring the prevalence of mental health disorders among offenders nationally highlights this argument (Forsythe & Gaffney 2012). The data collected by The Australian Institute of Criminology Drug Use Monitoring in Australia (DUMA) program captured the drug use of 690 detainees. Interestingly, half of the detainees reported having been diagnosed with a history of mental health disorder (Australian Government; Australian Institute of Criminology 2012).

The Mental Health Act 2007 (NSW) contains specific legislation that governs how mental health patients/inmates are managed in a custodial setting. It also permits the Police and Magistrates to recommend mental health assessment by specialists such as psychiatrists prior to incarceration. This process enables mentally disordered persons the opportunity to be correctly diagnosed and treated appropriately. However, this is not always the case with people displaying unstable mental health symptoms. In my experience, when individuals in custodial environments are appropriately assessed by mental health specialists they are often determined to not be mentally disordered, despite being difficult to manage in the context of a police or prison environment. For individuals already suffering from a mental health condition, incarceration can impose a significant additional stress factor which can further undermine the mental health of the inmate and culminate in a particularly difficult healthcare environment.

Psychosis, either drug induced or otherwise, is often a factor in short-term custodial settings and can be associated with a range of behaviours including aggressiveness, inappropriate laughing and talking, and delusions.  Moreover, paranoia is a common difficulty that may lead to the inmate being convinced the healthcare professional is “out to get them”.

The most important consideration for nurses or other healthcare professionals providing support or care to mentally unstable patients in acute settings such as police cells is to minimise the risk of harm to themselves, colleagues or the patient. Risk management systems, procedures and strategies must be in place, and all healthcare workers in the custodial setting must be appropriately trained.

Appropriate safety precautions will generally include placing a corrective services officer to monitor and observe the inmate closely (typically hourly observations) until further assessment by the mental health team can be completed. Inmates that become acutely unstable will typically be transferred to a hospital for a medical and mental health assessment. More often than not, the inmate returns to their police cell where Corrective Services are advised by the appropriate healthcare professional to continue to observe the patient closely and to document the patient’s movements.

Evidence-based scientific research, which governs clinical practice in health settings, continues to provide healthcare professionals with an understanding of the efficacy of mental health interventions such as: providing the resources for correct diagnosis, compliance with medication and engaging community mental health services to deliver best practice (APS. 2010).

Prisoners have significant health issues with high rates of mental health problems
37% of prisoners about to be released said their health was a lot better than when they
Entered prison……..Australian Institute of Health and Welfare 2013

REFERENCES:
AIHW 2012. The mental health of prison entrants in Australia: 2010. AIHW bulletin no. 104. Cat. no. AUS 158. Canberra: AIHW. Viewed 22 August 2014 <http://www.aihw.gov.au/publication-detail/?id=10737422201>.
Australian Psychological Society (APS), 2010, Evidence-based Psychological Interventions in the Treatment of Mental Disorders: A Literature Review: third ed. Available, https://www.psychology.org.au/Assets/Files/Evidence-Based-Psychological-Interventions.pdf
Australian Institute of Health and Welfare 2013. The health of Australia’s prisoners 2012. Cat.no. PHE 170. Canberra: AIHW.
Forsythe, L & Gaffney, A 2012, Mental disorder prevalence at the gateway to the criminal justice system, Trends and issues in crime and criminal justice, no. 438, ISSN 1836-2206 Canberra: Australian Government; Australian Institute of Criminology 2012. Available, http://www.aic.gov.au/publications/current%20series/tandi/421-440/tandi438.html
Health, Justice Health & Forensic Mental Health Network (JH&FMHN), Vison & Values, www.justicehealth.gov.nsw.au
McCausland R, Baldry E, Johnson S, Cohen A, 2013, People with mental health disorders and cognitive impairment in the criminal justice system, www.humanrights.gov.au  
Mental Health Act 2007 (NSW)
Neugebaur R, 1999, Mind matter: The importance of mental disorders in public health’s 21st century mission, American Journal of Public Health, 89(9), 1309-1311.