34. Tindog Tacloban! – The Boats


I went this morning to see “the boats.” I had been asked several times if I’d seen them, so I got the sense that it was something to behold. I saw a few photos on the web, but it was hard to place the ships among the heaps of detritus from the storm.

boat 1

The boats are massive. Bigger than the MSF staff housing structure that comfortably sleeps well over 20. Bigger than a standard sized apartment complex. The water surge brought them inland and then left them there after it retreated, simple as that. To ensure that they don’t topple over, stabilizing wedges have been put in. You have to crawl under one section of one boat’s hull to continue down one of the roads. It’s a bit freaky.




A fellow named Manolo came to chat with me. The Filipinos are near uniformly friendly. He asked me where I was from and who I worked with. Oddly enough, when I told him that I worked for MSF and we had a full hospital providing free medical care, notably dispensing no-cost medications, he was unaware of this. We joked about basketball with his friends, and then I set off. He thanked me for coming to his country and helping his people. It still shocks me how gracious the Filipinos are for humanitarian assistance. There are signs randomly strewn around town indicating such salutary sentiment.

(boats3.5) (1 of 1)

It probably speaks to my cautiousness that I suspected the teenager to be a tout, which in most countries means he befriends you, shows an interest, tells you some facts and then asks you for money.



Not here. I walked around for an hour seeing the five or so boats that were abnormally hulking on land. Not once was I asked for anything. But the kids smile and yell out, and adults say “good morning” or some other greeting in a warm manner.

This is not a unique sensation amongst the staff, I’m finding. The consensus is that this is a kind, welcoming, and honest place. To underscore the point, I thought that I had left my cell phone somewhere the day before. I went back there with a local MSF staff fellow to help me translate, and he said something of the order of: “you will probably get it back, people are honest here.” Not since travelling in Japan have I found a place like that.

The contrast between life-as-usual playful staff and friendly interaction, immediately counter-posed with the evident destruction and loss of life in the typhoon, is hard to reconcile. It’s as jarring as a massive boat in the middle of the street. I’ve never been exposed to the aftermath of a calamity, but I did not expect the resiliency of the Filipino community to be this pronounced.

A small convoy of people were coming through the MSF hospital space, and I said hello to a man and woman.  They responded with an American accent on their English, and stopped me to talk. Turns out that they had Filipino heritage, but had grown up in New Jersey. They had donated some money to the project, and were coming by to see it.  The woman asked me if I had found a lot of PTSD (her word), and I stated that there was some, but less than I had expected. She said, “yes, we are very resilient.” A few more minutes of talking revealed that she and her husband were doctors, herself a psychiatrist. She knew from whenst she spoke.

MSF no guns (1 of 1)

There are always some clinical anomalies. Here, it seems that it is trauma-induced psychosis. This is a rather rare phenomenon, showing up for brief periods after rather extreme stresses on the body (lack of sleep, dehydration, sustained high stress). Often this occurs in persons with a vulnerability to psychosis (they have had bouts of paranoia in the past, during periods of high stress, substance use, or just spontaneously).  But I have now seen three cases which developed with seemingly no pre-Typhoon psychiatric history. In otherwise highly functioning people, frank auditory hallucinations and paranoia have developed post-typhoon. Common symptoms to all three involve hearing the voices of dead people, and thinking that someone is going to come and kill them. Family support, sleep, antipsychotic medications, and close follow-up have been effective, but the psychosis is lasting longer than expected. Something to ask the local psychiatrists about when I see them next.

Another odd thing. There is no word in Tacloban that I have heard that means “foreigner.”  Kids yell out “sankai” which translates to “friend.” While there may very well be one or more, it is notable that in two weeks of being on the ground, I do not know it. This is contrast with other regions that clearly demarcate in-group and out-group members. In Canada we have a unique politics of identity. It makes very little sense to say that someone is “not Canadian.” If I meet someone on the street or in the hospital and ask them where they are from, and they respond with the only three English words at their disposal: “I am Canadian,” I could very well smile and say, yeah, but where were you before here. Un-Canadian behaviour would be someone who was being unfair or culturally insensitive. The Canada I know seems to pride itself on being inclusive. Or, said differently, we have a rather weak politics of exclusion. The sense of inclusiveness here in the The Philippines is a marvel, and, if I can say, more pronounced than any place I have yet been.

back lane

33. Tindog Tacloban! – Intro

This blog is mirrored from the MSF site. Pictures are added. Date of initial publication: February 18, 2014. 

IMG_3386 DSC00342 DSC00415

This blog is mainly to get word out to friends and family regarding this mission.  There are a lot of questions coming my way, the answers to which may be of interest to some and not others. From conditions on the ground involving lodging, food and security on to the impact of physical and psychological trauma on the local population, and how the project is addressing these needs. Somebody asked me how I brought enough toothpaste for 2.5 months, given that I had a strict 10k checked-luggage weight limit. That’s ok. I’m posting this openly as others may be interested in what an MSF mission to the Philippines is like for a rank-and-file forensic psychiatrist from Toronto.

Happy reading, whoever you are. Your time is appreciated.

But please keep in mind that this blog is personal, and in no way is meant to represent the views or organizational values of MSF.  I wholly support the MSF that I know to be an independent, politically neutral organization that provides medical care irrespective of race, religion creed or political conviction.  If you walk in the door, and are in need of help, MSF does its best to help.  This is my third mission with this organization, and it is a pleasure and an honour to work with them again.


Human-caused climate change likely had something to do with the “super-typhoon” on November 8, 2013 that tore a strip off of regions of the Philippines. Winds of over 300km/h, and gusts well higher, made this the most powerful such storm ever recorded to make land-fall. And it did. It was as if not a single building was left standing in some regions, by reports, photos, and remaining carnage evident. Tacloban was one of those hard-hit regions.  A city of about 200,000 people, it is on Leyte Province, in the Visayas. I arrived on February 8, three months afterward the typhoon.

Filipinos are accustomed to storms with high winds, but this was something new.  Not only were the gale forces well in excess of the near-monthly storms that come through, it was the unexpected rise in sea level, 4 metres high in some regions, that caused so much loss of life and other damage. Tacloban is at the crux of an inlet, so the water brought by the typhoon was amplified.  The death toll is not clear, but it is over 7 thousand. Millions were affected.

MSF was on the ground in in the Philippines within several days, but as is the case in calamities, putting resources on the ground is only half the battle.  Distributing them is the other.  Infrastructure (roads, communications, water and sewage, power sources and lines) were wiped out.

The Wikipedia site describes the scene as follows:

According to estimates on November 13, only 20 percent of the affected population in Tacloban City was receiving aid. With lack of access to clean water, some residents dug up water pipes and boiled water from there in order to survive. Thousands of people sought to evacuate the city via C-130 cargo planes, however, the slow process fueled further aggravation. Reports of escaped prisoners raping women in the city prompted a further urgency to evacuate. One resident was quoted as saying “Tacloban is a dead city.”[61] Due to the lack of electricity, planes could only operate during the daylight, further slowing the evacuations. At dawn on November 12, thousands of people broke through fences and rushed planes only to be forced back by police and military personnel. A similar incident occurred later that day as a U.S. cargo plane was landing.[92]

 On November 14, a correspondent from the BBC reported Tacloban to be a “war zone,” although the situation soon stabilized when the presence of government law enforcement was increased. Safety concerns prompted several relief agencies to back out of the operation, and some United Nations staff were pulled out for safety reasons. A message circulating among the agencies urged them to not go into Tacloban for this reason.[93]

MSF has set up services in a hospital that was previously damaged.  They are fixing the structure so that is is usable and safe for MSF staff, and have hired many who were in its employ prior to the typhoon.  Functioning six days a week, they saw over 2500 patients last week in the outpatient department.  There are about 50 inpatients, which include surgical cases and maternity. Last week there were 57 admissions on the maternity ward, which was over capacity, so several new beds were added.  MSF provides free care and medicine,,so the numbers of people using our services are swelling.

I’ll be speaking about the mental health project more, but briefly, there are three components:

  1. Outpatient department (OPD): referrals from other services and our own follow-up
  2. Outreach: counsellors attend evacuation centres, hard-hit regions (baranguays) and other places where mental health needs are concentrated, and provide individual assessment and therapy on-site; we refer complicated persons to our OPD.
  3. School Program: Set up by child psychiatrists and psychologists, this ambitious project works with teachers and caregivers in elementary schools hard-hit by the typhoon.  Just to provide the scope of the destruction caused by the storm, one school which I attended last week had 63 students (30 male, 33 female; and one teacher) killed.  This was from a census of 430 students (grades 1-6) and 17 teachers. (Correction, there were 67 students killed at the school… the final count changed as more bodies were discovered since this number was first written.)

We have one psychiatrist, one psychologist, 8 counsellors and two translators.  Individual assessment and counselling are offered, which makes MSF, I’m told, perhaps the only NGO (non-governmental organization) to offer such services in the region.

When I was at the elementary school, the skies darkened and it started to rain. The winds picked up ever so slightly. A fright that I have never seen before en masse in children set in quickly.  They jumped up and huddled in the corner and cried; school teachers and our staff attended some of the more distraught ones.  One child ran toward her house, inconsolable.

It is hard to transition from such anguish.  But this post is to capture a brief snapshot of the project, and then return to mental health and some other issues more fully.

I’ve never seen an MSF project that was not ambitious.  This project is ambitious.  Some details.

There are, now, around 15-20 expat staff (like me who have been brought in from outside the country), and a much larger number of local doctors, nurses, midwives, pharmacists, etc. I should get numbers, but suffice it to say that this is fair-sized facility.

The logistics of putting so many supplies on the ground, navigating the decimated infrastructure, and arranging these medical services, is nothing short of staggeringly impressive.

Two quick examples.

The hospital’s electrical system was shot through when the typhoon hit.  In addition to the electrical grid in the city going down, and all the hospital damage, the water level hit the second floor of the hospital.  MSF rigged a complete second system of wiring and outlets within days of being in the building.

Second example: a few days ago I wrote on a requisition form that Mental Health Services (MHS) could use a flipchart and second whiteboard for teaching purposes, in addition to the markers, erasers and such that go along with this.  Within less than 24 hours, a flipchart and 2 paper rolls, as well as a whiteboard, were set up in our group meeting room.  The flipchart stand was constructed after the requisition was put in.  That this is seen as standard service is, I say again, hellava impressive.  Logistics is the unsung hero of MSF (at least from the outside; inside the NGO world and by all who work for the organization, their praises are sung).

The MSF project expat staff now live in a structure that used to be a hotel.  Everybody except for the 4-5 staff (surgeon, anaesthesiologist, midwife, obstetrician, emerg doc; they’re on call, so that’s the rationale) share rooms.  It’s a pretty swish location for MSF standards, with the local generator providing power for several hours in the morning and evening.  We have people who cook, clean and provide security, so food is pretty healthy and plentiful, the house is safe, and so on.

Most of the staff are out of the house by about 7am, and arrive at the hospital within 15 minutes or so.  We have several vehicles that provide transport, some of which are larger buses with open bench seating in the back, and more modest rickshaw-type units.  The end of the day seems to be around 5-8pm, depending on the need.  I’ve not left before 7pm, despite some messy jet-lag (it’s 13 hours ahead of Toronto).  This was not really my desire, but things have been busy.

So there it is.  I’m going to try and attach pictures, but internet is really spotty.  We don’t have it at the house, but seemed to have had it for several hours yesterday at the hospital… narrow bandwidth.  Not having internet is like having phantom limb discomfort.  You just feel like that appendage should be there.

It must be said early on that the Filipinos have been a warm, welcoming, and generally wonderful population with whom to work.  This is not the case everywhere, really.

OK. Toothpaste. I brought 50ml, assuming that since this was a large-ish city, I could find some here when I ran out.  This is true now, but for the first month that MSF staff were on the ground, this was not the case.  Finding food, clean water and other basics was a challenge for the first wave of MSF staff on the ground. I don’t know what they did.  An emergency relief mission is a different thing than what we’re doing now.  I greatly respect the efforts of the many staff (expat, local, distant) that carved out the project that allows me to fly in and immediately focus on mental health work.

À bientôt.

32. Tindog Tacloban! (link to MSF blog)




These are the counsellors. Jil, Meliza, Russel, Jen, Jess, Melot, JG, Phrex.


31. Correctional Psychiatry in Canada – Commentaries

Commentary #1: Bridging the Gaps for Former Inmates with Serious Mental Illness

Anthony C. Tamburello, MD, and Zoe¨ Selhi, MA, MD

Serious mental illness is a prominent and vexing problem within the correctional systems of North America. Simpson and colleagues draw attention to the epidemiology, special characteristics, and management problems relevant to Canadian inmates with serious mental illness. Of great interest to those in the forensic psychiatric field is the matter of continuation of care for mentally ill prisoners, in that untreated or under-treated psychiatric problems are strongly associated with poor social functioning and criminal recidivism. In this commentary, we expand on the discussion in Simpson et al. of the effectiveness of assertive community treatment teams for those former inmates at greatest risk for future involvement with the criminal justice system. We also propose outpatient civil commitment as one strategy to facilitate the successful return of select inmate patients to the community.

J Am Acad Psychiatry Law 41:510–3, 2013

Simpson and colleagues1 draw our attention to the epidemiology, special characteristics, and management of inmates with a serious mental illness (SMI) within the Canadian prison system. We think that this article identifies important shared clinical and academic interests for correctional psychiatrists in both the United States and Canada. First and foremost is their conclusion that SMI is common in correctional settings. As the authors point out, the seriously mentally ill are more likely to be incarcerated than admitted to a hospital2–4 for treatment. The corollary to this conclusion, confirmed by epidemiological research in both the United States and Canada, is that SMI is more prevalent in a correctional setting than it is in the community.5–9 As the SMI represent those most in need of psychiatric care for poor functioning, whether in a community10 or a prison setting,11 meeting these  needs is critically important to all stakeholders.

Some aspects of the review by Simpson et al. limit its generalizability to prison systems. Most relevantly relevantly, their use of the term prison inmate refers to both pretrial detainees and those serving a sentence after criminal adjudication. Thus, data are included in their review on inmates who might be housed in a jail or detention center. Although the article at times points out which type of inmate was included in the cited study, interpretation of this information requires awareness of the differences between pretrial and sentenced inmates. First, the rate of mental illness in general, and serious mental illness in particular, may be moderately higher in jails than it is in prison. The most recent survey by the Bureau of Justice comparing the rate of mental illness in U.S. jails and prisons illustrates this point: psychotic symptoms were reported by approximately 24 percent of jail inmates versus 15 percent of state prisoners. 12 A second, related point mentioned by Simpson et al. includes the acuity level of mental illness in these two populations. Pretrial detainees are more likely to experience symptoms of their illness, given the predictable psychosocial stressors related to their recent incarceration and the uncertainty about their legal fate. The stress of their situation may explain the higher suicide rate observed in jails compared with that in prisons.13 Finally, although substance abuse was not the focus of Simpson et al., the rate of substance use disorders appears to be higher in inmates in jail than in their counterparts in state prison.14

It is hard to argue about the point that Simpson and colleagues make that SMI is a major problem for correctional psychiatrists and the systems in which they serve. The untreated or under-treated mentally ill are at greater risk for unemployment, homelessness, needing emergency services or hospitalization, substance abuse, suicide, being victims of crime, engaging in violence toward others, and poor quality of life.15,16 They have a shorter life expectancy, most likely related to a combination of under-treated medical problems, unhealthful lifestyle, suicide, accidents, and victimization by others.17 The mortality of persons with SMI is much higher than would be expected after release to the community, most often related to drug overdose, cardiovascular disease, suicide, and homicide.18 Notwithstanding the moral imperative and professional duty of physicians and other mental health workers to alleviate suffering and reduce risk, the treatment of mental illness in incarcerated individuals is mandated by the U.S. Constitution19 and by federal regulations in Canada.20 We have no doubt that a prison sentence has saved the lives of some persons with serious mental illness. It is not uncommon to hear of a returning inmate patient who did not connect with aftercare services (or dropped out of treatment), became noncompliant with medication, and resumed using illegal substances as a prelude to violating parole or committing another crime. Whether incarcerated or in the community, patients with SMI may lack the insight, understanding, or appreciation of their condition that is necessary to make a well-reasoned decision to accept or decline health care services. As discussed by Simpson et al., Lennox et al.21 reported that only 4 of 53 SMI patients with an aftercare plan including the involvement of a Community Mental Health Care team were still in contact with their team six months after release.

Despite the fact that prisoners with SMI are often lost to follow-up, Simpson et al. highlight the important role that mental health providers in correctional settings play in preparing their patients to return to society. Discharge (or re-entry) planning has long been regarded as a standard of care by the National Commission for Correctional Health Care22 and the American Psychiatric Association.23

Simpson et al. describe the use of assertive community treatment (ACT) teams in re-entry planning for former Canadian inmates with SMI, but they point out that traditional ACT services have not yet been shown to reduce recidivism.24,25 They suggest that the forensic assertive community treatment (FACT) model may be better, with a focus on pretrial diversion by taking referrals from jails, adding probation officers to the team, providing housing assistance, and offering treatment for co-morbid substance use disorders. Similar specialized programs geared toward the re-entry of SMI patients may also show promise. For instance, the Forensic Transition Team (FTT) in Massachusetts seeks to attend to the needs of persons with SMI exiting the correctional system and offers coordinated care services to both pretrial and sentenced inmates. Despite the voluntary nature of the program, outcome data26 show that 46 percent of former inmates with SMI were engaged in services after three months in the community. Of interest, patients who had misdemeanour charges for which they typically served six to nine months were the most likely to be lost to follow-up and to return to the criminal justice system.

Prison systems have advantages over other settings for the management of patients with SMI who are unwilling or unable to accept necessary psychiatric treatment voluntarily. Convicted individuals in the United States may be eligible for involuntary psychiatric medication in an administrative procedure modeled after Washington v. Harper.27 These inmates may be asymptomatic or greatly improved as they approach release, thanks to structure created by the presence (or likelihood) of nonemergency forced medication. When released from prison, they are no longer subject to the findings of a Washington v. Harper-type panel. Local civil regulations for forced medication are typically stricter and usually require inpatient civil commitment. Given the stability brought about by forced medication in prison, many of these patients will not meet criteria for inpatient civil commitment. Although some jurisdictions such as California have a formal process for the civil commitment of inmates with SMI who would otherwise be a danger in the community,28 such processes are the exception rather than the rule. Civil commitment imposes restrictions on liberty grievous enough, and different enough vis-a`-vis incarceration, to deserve additional due process.29 The typically strict standards for inpatient civil commitment often render hospitalization a short-term solution for those who, with treatment, will not become dangerous in the foreseeable future.30 Even when psychiatric medications mitigate the symptoms and behavioural problems associated with SMI, improvements in insight and judgment may lag behind other gains.

For select cases, involuntary outpatient commitment (IOC) may close the gaps in legal protections that create a revolving door of hospital and correctional recidivism. Most provinces in Canada have provisions for outpatient commitment in the Community Treatment Order (CTO). CTOs in Ottawa have been shown to reduce the number and duration of inpatient stays and to increase access for SMI patients to housing and mental health services.31 Outpatient commitment is legal in 45 states, although its implementation in the United States has been inconsistent. 32 The best example of the benefits of outpatient commitment in the United States is New York’s Kendra’s Law or assisted outpatient treatment (AOT). Research has shown that outpatient commitment reduces arrests, the number of hospitalizations, inpatient length of stay, homelessness, violent acts, and suicidal behaviour; improvements were noted in medication compliance and social functioning.33–36 For those enrolled in AOT for at least seven months, these improvements were maintained even after the patient was no longer mandated to outpatient treatment by court order.37 We believe that outpatient commitment, especially when it links former inmates with SMI to intensive treatment services, community support, and housing, would be a formidable tool to reduce recidivism and improve health care outcomes.

Involuntary outpatient treatment is not without controversy. A Cochrane review in 2011 concluded that the existing evidence from randomized controlled trials on outpatient commitment at the time was weak regarding outcome measures such as reducing hospital admissions, homelessness, and arrests.38 Criticisms of outpatient commitment include concerns about inadequate funding, diversion of public funds away from voluntary outpatient services, liability associated with managing dangerous persons outside of a hospital, unwillingness of judges and police to enforce the conditions of outpatient commitment, and the violation of a patient’s rights by using coercion to enforce compliance.32,39 Economic analyses to date suggest that, even with the cost of providing comprehensive outpatient services pursuant to Kendra’s Law in New York State, such services are cost effective32 and need not siphon resources from voluntary outpatient services.40 Similar to inpatient commitment, civil rights are protected by jurisdiction-specific criteria and the need for a court order for outpatient commitment. Whether a patient is appropriate for outpatient commitment is a clinical judgment requiring the same level of skill necessary for decisions to medicate, to reduce observation status, or to discharge from the hospital. It does not replace the option to hospitalize, but rather allows for the management of appropriate patients who are stable with treatment (yet reluctant to comply), in a less restrictive environment. Psychiatrists, especially forensic psychiatrists, can play a role in educating law enforcement and the judiciary about outpatient commitment and in advocating for appropriate enforcement.

Other strategies to alleviate the burden of serious mental illness in correctional facilities may also be worth considering. Mental health courts authorized to order a person with SMI into treatment in lieu of incarceration have shown promise for reducing recidivism and violence.41–43 Warrants for emergency room evaluations of suspected seriously mentally ill persons, such as the emergency petition process in Maryland, may serve as an early diversion from the correctional system.44 A post-conviction approach would be to coordinate with the parole department when developing an aftercare plan for an inmate with SMI. Defining treatment compliance as a condition of parole could have the same effect as outpatient commitment in reducing recidivism for those former inmates apt to respond to structured consequences for noncompliance. The difference unfortunately is that a violation of parole would be expected to result in reincarceration, rather than potential hospitalization in the event of a violation of the terms of an outpatient treatment order. Simpson et al. point out research showing that those with SMI are already at greater risk of recidivism because of technical violations of parole.45

In summary, we agree that serious mental illness in correctional settings in North America is a common and important problem. Bridging the effective management of SMI from the prison clinics to treatment centers in the community has implications for general and forensic psychiatrists in all settings. Providing comprehensive community services for these patients, whether through FACT teams, outpatient civil commitment, mental health courts, or other creative means, is a promising approach to maximizing functioning and minimizing risk, at the least possible cost to civil liberties for those already well familiar with not being free.

Screenshot 2014-02-19 15.57.54



Commentary #2: Mentally Disordered Offenders in Prison—Old Problems That Still Require Solutions

Carla Rodgers, MD, and John A. Baird, MD

We commend Simpson et al. for addressing an important topic: the care and treatment of prisoners with serious mental illness. We welcome the authors’ conclusions, but we identify some problems that can often frustrate attempts to improve services to this group.

J Am Acad Psychiatry Law 41:514–5, 2013

Simpson and colleagues1 are to be congratulated for highlighting again a topic of great importance in forensic psychiatry. Within that part of the speciality that is responsible for the care and treatment of mentally disordered offenders, concern for the inmates’ mental status should not be overlooked. Experience gained through work of this kind will be helpful and complementary to the role of expert witness, assisting psychiatrists in speaking with greater confidence and authority during testimony. The authors highlight the rising number of prisoners who have serious mental illness (SMI) and the disproportionate increase in the number of prisoners from ethnic minorities who have higher rates of SMI. They pose several questions that arise from these trends.

One particular minority group to which reference is made in the review is Canadian First Nations people. The authors discuss the challenges that the increasing number of inmates from First Nations groups represents for mental health services. They helpfully exclude personality disorders and substance misuse from consideration, in that these are better treated as separate topics. They include suicide and attempted suicide in prison, which is perhaps an important and related topic. They conclude that SMI is becoming more common in the prison population. They discuss the effects of imprisonment on SMI and find that these effects are less severe than postulated. They question whether treatment in prison is effective, concluding that particular problems arise when prisoners are returned to the community but lost to mental health follow-up.

The rate of serious mental illness among prisoners has been of interest since the specialty of forensic psychiatry started to develop a strong identity during the middle years of the 20th century. For example, an early study in Scotland2 found significant rates of SMI in a Scottish prison at a time when the large Victorian psychiatric hospitals were still in existence and inpatient psychiatric beds were readily available. The process of deinstitutionalization has since led to an increased number of people who have SMI returning to the community without adequate followup. It is inevitable that some of these individuals will find their way to prison. Also, in view of considerable research that identifies that SMI increases the risk of certain types of offending,3 it is to be expected that the number of persons with SMI in prison will be greater than the number in the community.

Jurisdictions vary considerably in whether an offender with SMI is more likely to be committed to prison or to a secure hospital. Jurisdictions also vary in the options for transfer of a prisoner with SMI to a secure hospital, if there is a clinical need to do so. People in the community who have SMI often receive assistance from family and friends, but how can this support be replicated within a prison? Confidentiality and stigma are much more complex difficulties to deal with in prisons. Finally, can prisons ever be a safe and suitable location for the administration of medication without consent?

Forensic services could never meet the needs of all SMI prisoners and should not be responsible for doing so, since the bulk of offenders in custody with SMI are minor offenders who do not require specialist forensic care. Community services may be reluctant or downright unwilling to become involved with patients with SMI who have offended, even if the offence is minor. In some jurisdictions, effective aftercare can be arranged when prisoners with SMI come to the end of their sentences and are not fit for release. The prison health care service may refer them to local hospitals in the same way as if they had a physical condition. Further organizational complications arise within a health service that is predominantly in the private sector, as in the United States. These hindrances help explain the failure of community aftercare that Simpson and his colleagues identify.

Another aspect of the stigma faced by the SMI inmate is worthy of mention. It is often believed that prejudice in mental health services against mentally disordered offenders is a recent phenomenon, but that is not the case. There is evidence that such discrimination goes back a long way. In Scotland in the mid-19th century, when the first modern cellular prison was commissioned, it was found from the outset that mental hospitals or, as they were known then, asylums, in the surrounding community were unwilling to accept prisoners for treatment who were deemed to be insane.4 Another example of there being nothing new under the sun.

Despite these organizational challenges, the future, as Simpson et al. conclude, must ensure improvements in the quality of the mental health care of SMI prisoners. The challenges in working to achieve these advances are considerable and vary from one jurisdiction to another but, as the authors emphasize, they must be resolved.

Screenshot 2014-03-20 14.54.55