Recommendations for Implementation

The purpose of a screening instrument is to identify inmates with mental illness immediately upon their arrival at the institution and to prompt referral for further assessment of those inmates' mental health needs.[2] Screening instruments typically are paper-and-pencil forms that may be completed by the inmate or used as a structured interview protocol by any trained staff person. It should take no longer than 10 to 15 minutes to conduct a screening.

There are no validated instruments for mental health screening in adult populations. Most correctional settings use a series of questions that seek information on past psychiatric services or current medications. Systematic attention to current psychiatric symptomatology is often cursory. The New York State Office of Mental Health has developed Suicide Prevention Screening Guidelines that have face validity as a screening measure for suicide, and the state trains its correctional staff in the application of this tool.[3]

Recognizing the need for a reliable screening tool, the National Institute of Justice has recently funded research at the University of Maryland to develop and test a nine-item Brief Jail Mental Health Screen. Correctional settings in Maryland and New York are participating in this study. Until a validated instrument emerges, correctional administrators should work with their mental health staff to ensure questions are asked early on in the process that are sensitive to critical mental health issues. The discussion that follows addresses other issues essential in an effective screening instrument.

Self-assessment should never entirely replace critical observations by staff. Use of a self-administered intake screening instrument does not absolve correctional or clinical staff of the responsibility to query and observe for mental illness at the time of intake. Training staff for such responsibilities is essential. (See Policy Statement 30: Training for Corrections Personnel.)

In general, when an effective screening instrument is implemented properly, staff will more often incorrectly identify someone as exhibiting signs or symptoms of mental illness than overlook someone who truly has a mental illness. Erring on the side of caution at the outset increases the likelihood that high-risk cases are discovered; only a relatively small percentage of mental health assessments are conducted when they are not needed. A useful screen will send a significant percentage of inmates (perhaps as many as 25 percent) forward for a more comprehensive evaluation.

Example: Screening Instrument, Oregon Department of Corrections

In Oregon, staff administer a group-led pen-and-pencil instrument to all offenders admitted at the time of intake. This instrument generally identifies 30 percent of the population as having a mental illness. When this 30 percent are referred for professional assessment, the percentage assessed as having a significant mental illness is reduced to 17 percent.[4]

A screening instrument should use an objective scoring system. Many jurisdictions use a straightforward numeric scoring system, resulting in a "red flag" or "green flag" determination of the possible presence of a mental illness. Though effective screening instruments currently in use vary considerably, each tool must address the following: suicidality; depression; use of narcotic drugs and alcohol; anxiety; history of hospitalization for psychiatric problems; trauma history; and the use of any medications prescribed for a mental illness.

Substance abuse greatly influences symptoms of mental illness. For this reason, and because the majority of people with mental illness who are incarcerated have a co-occurring substance abuse disorder, staff should screen for substance abuse in tandem with mental health. Subsequent assessments should allow clinicians to observe the individual in a drug-free state over time in order to separate the causes and effects of substance abuse on mental health.

Ideally, the intake process would be seamless, incorporating health screening, mental health screening, classification procedures, and other protocols. This process could be captured in a single, integrated instrument, such as the one being developed by the University of Maryland.

In some states, properly trained correctional officers - especially those with close and sustained contact with inmates during the first few days of incarceration - serve as initial, informal screeners. They may be in the best position to observe behavior and to identify signs and symptoms of mental illness, particularly when such symptoms emerge several days after intake. Although this measure may seem inefficient, given the screening that mental health staff will perform later, such redundancy is in fact cost-efficient; it effectively narrows the pool of inmates who receive a professional assessment to those who are most likely to have a mental illness.

In many correctional systems, a different mental health screening instrument is employed at each prison in the system. Such variation among the prisons is complicated and compounded by the procedures in use at county jails, where staff at each facility typically employ a distinct instrument and process (if one is used at all) to screen inmates for mental illness. Although it may be a challenge, particularly in states with an elaborate network of independent county jails, state officials should require the use of the same screening and assessment instruments and protocols at all correctional facilities in the state. The American Psychiatric Association recommends standardizing mental health screening procedures and instruments so that the responses can be documented in a consistent fashion.[6]

Uniformity in screening procedures has numerous advantages. It can provide valuable information about the impact of transfers, the incidence of inmate decompensation, and identify trends occurring over time. It also enables state correctional systems to collect data needed to inform research and evaluations and to support legislative advocacy and public education. To achieve uniformity, directors of state departments of corrections may be able to issue an administrative order. In other states, however, leadership from mental health agencies or statewide legislative advocacy may be necessary, especially when county government officials are unwilling to assume the financial implications of implementing such an order.

Example: Screening Instrument, New York State Office of Mental Health

In an attempt to encourage uniformity of mental health screening, assessment, and referral procedures, the New York State Office of Mental Health (OMH) has been developing model policies and instruments for use in New York's county and municipal jails. First, in 1985, OMH developed and field-tested a suicide screening protocol for use in the jails. The New York State Commission of Correction, which accredits and oversees the development of new technology for jails and prisons in the state, adopted the suicide screening protocol and now requires all county jails and penitentiaries and state prisons to employ it.

More recently, OMH, in association with the New York State Office of Alcoholism and Substance Abuse Services (OASAS), has been involved in sponsoring jail validation studies of two receiving screening instruments developed by the Nathan Kline Institute for Psychiatric Research for use in community settings. One, the "MINI Screen," was designed to identify individuals with substance abuse problems who are receiving services in community mental health settings. The second, the "DALI Screen," was designed to identify individuals with mental health problems who are receiving treatment in substance abuse settings.[7] At the time of publication of this report, the jail validation study involving 400 newly admitted detainees and offenders at New York State county jails had just gotten under way.

In states and localities where correctional institutions are located at considerable distance from one another, some jurisdictions have relied on information technology to ensure consistent screening and assessment methods.

Example: Suicide Screening Initiative, Alaska Department of Corrections

There are 13 correctional facilities and pretrial facilities in Alaska, a state where geography and low population density present particular challenges. To ensure consistent, comprehensive inmate mental health screening, the Alaska Department of Corrections has developed a screening tool that trained, nonmedical staff can download, administer, and return completed almost immediately to the department's central office using handheld personal desk assistants or Palm Pilots. Mental health professionals in the central office can then make assessments and recommend or initiate appropriate interventions, if needed.

The Palm Pilot serves not only as an electronic means of keeping medical records, but as a platform for the entire management information system. All clinicians perform the same, standardized exam on the Palm Pilot. The information is then uploaded to a statewide computer network and becomes available for printing of medical files. The system makes it possible to generate information in summary and/or aggregate form, thereby facilitating quality assurance and research.

As is the case in many correctional facilities, Alaska's Suicide Screening Initiative relies exclusively on inmate self-reported information. It is important, however, to use sources other than the inmate alone to supplement self-reported mental health information. Self-reports are not always reliable, and they rarely provide a complete picture of an inmate's mental health treatment history; sometimes, they also fail to shed light on co-occurring disorders. It is essential to obtain this information during the assessment phase, and it helps to inform decisions regarding classification and treatment plans.

When the screening results in a "red flag," staff should seek additional information, such as an existing treatment plan or information about medications the inmate has been prescribed, from supplemental sources. For example, the mental health professional conducting the subsequent mental health assessment should review information and reports from other criminal justice staff, such as the pretrial investigator, the presentence investigator, and county/municipal detention staff, who have previously had contact with the inmate. Reports from other criminal justice system personnel such as law enforcement or jail officials will provide details of mental health and behavioral issues pertinent to the screening and evaluation process of the inmate. Additionally, state departments of correction may wish to consider gathering supplemental information from the local or county corrections authority. It might be advisable for states to require county jail officials to inform receiving state correctional authorities if a person has been receiving mental health services. Such information is not considered confidential, and may well prove to be critical for the health and well-being of inmates with mental illness.

Staff should also obtain assessment and treatment history information from community mental health treatment providers. In at least some corrections systems, staff encourage the inmate to sign a release of records form, which allows correctional staff including clinicians to obtain mental health records from previous treatment providers in the community. In other cases, staff at the corrections center request the assistance of community mental health officials in cross-referencing the names of their clientele with the jail population. (see Policy Statement 13: Intake at County / Municipal Detention Facility)

The individual charged with conducting the screening is most often the booking or receiving officer, intake nurse, or intake clinician; in general, any properly trained individual can administer a straightforward screening instrument and gather necessary information. As state mental health agencies become more involved in assisting, overseeing, and/or providing mental health services within the criminal justice system, professional credentialing and licensing requirements are more likely to be consistently enforced when addressing the needs of people with mental illness in correctional settings. A low-cost, high-quality solution involves making arrangements with educational institutions that can place graduate-level clinical psychology or social work student interns at facilities to conduct screening and assessment of inmates.

The extent to which any of these staff implement the screening procedures effectively, however, depends in large part on whether they understand their responsibilities and execute them properly. In short, training on issues such as the screening protocol, the appropriate use of information gathered, confidentiality issues, and cultural and gender sensitivity is key. (See Policy Statement 30: Training for Corrections Personnel.)

An effective screening tool should enable screeners to distinguish between inmates in need of immediate mental health attention and inmates currently on medication or in treatment who will require a complete assessment within 24 hours of their screening. When staff members conducting the screenings determine that inmates are in need of immediate attention, they should ensure that these inmates are transferred to a specialty facility for 24-hour observation and care or placed on suicide watch until more suitable arrangements can be made. They should also check whether there is any indication that the newly admitted inmate is currently taking psychotropic mediation and ensure that he or she receives it when ready for the next dose.

Inmates who display significant mental health disorders should receive a professional mental health assessment as soon as possible after admission. The APA recommends that a brief mental health assessment for individuals who screen positive for mental illness should be conducted within 72 hours, with a provision for immediate evaluation in cases of increased urgency.[8]

These brief assessments may be conducted by qualified health professionals (e.g., general practitioner nurses or physicians) where specialty mental health staff are not available daily. After this brief assessment, the inmate should be placed on a medication review protocol and scheduled for a full treatment plan review within 30 days.

Staff can implement various mechanisms at the facility level to ensure that the instrument and protocols are successfully identifying inmates who have significant mental health issues and following up appropriately:

• Inter-rater reliability review. Comparison of the outcomes of screenings conducted by different staff.
• Feedback from assessment results. Determination of the rates at which a positive screening successfully identified an inmate with mental health needs and the rates at which a positive screen incorrectly flagged a mental illness or mental health problem.
• Interdisciplinary review. Interdisciplinary communication (i.e., among health and custody staff) about mental health screening issues.

Another key element in evaluating the effectiveness of screening and referrals is to determine the extent to which the screening instrument is sensitive to cultural variations and that those who administer the process are sensitive to inherent cultural biases. Inmates with mental illness are disproportionately African American, Hispanic, and Native American. Given the reality, it is incumbent on those who oversee and carry out the care and supervision of defendants and offenders with mental illness to ensure that the procedures undertaken and the services provided are done so in a nondiscriminatory way, while at the same time are sensitive about and responsive to cultural and linguistic differences. Similarly, the growing number of women who have a mental illness and who come to the attention of the criminal justice system deserve gender-specific and gender-competent care and treatment.

No matter how culturally competent or how culturally neutral a screening instrument may be, it will not substitute or supercede personnel's abilities when it comes to asking questions and making observations. It is critical that, in addition to training around the signs and symptoms of mental illness, specifics about screening, and preliminary assessment protocols, staff need to be trained to move toward cultural competency.

A comprehensive mental health evaluation should include, at a minimum, the following:

• mental health history
• prior treatment
• medication history
• relevant psychosocial history (i.e., family, social, legal, relationships)
• functional assessment
• current situational stressors
• mental status examination
• current diagnosis
• relevant medical diagnoses
• current medication
• substance abuse status

The evaluation should include a structured interview with inmates and a review of any available mental health records and collateral information, including behavioral observations by institutional staff. The evaluation should result in a diagnosis and a preliminary treatment plan.