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A recent BMJ article on the treatment of mentally disordered offenders triggered a range of responses, writes Birte Twisselmann
Becky Sales and Nigel MacKenzie propose that the new Mental Health Bill be amended and a time limit imposed for transfer of mentally ill offenders from prison to hospital to guarantee equivalence of care and basic human rights (BMJ 2007;334:1222, doi:10.1136/bmj.39237.692975.94). They also propose that the bill should contain statutory obligations to ensure that patients who are judged as needing hospital treatment while in police custody or in the court system cannot be sent to prison. Prison capacity is not great enough, and, at the same time, more prisoners are awaiting hospital beds.
Andrew Fraser, director of health and care in the Scottish Prison Service, and his colleagues point out that all mentally ill offenders in Scotland have to be transferred to hospital because of a lack of inpatient prison facilities. However, the prison population is bigger in England and the number of psychiatric beds is greater in Scotland, while the configuration of mental health services is different in the two countries. They add that adequate services, clear purpose, and good understanding between prisons and secure hospitals are needed.
Peter O'Loughlin, a drug and alcohol recovery specialist in Kent, agrees that mentally disordered offenders do not belong in prison. He reminds us, however, that they are in prison for the crimes they have committed. Should those crimes be ignored, or the offenders be found not guilty, for the sake of treating their disorder?
Ciaran Regan, psychiatric specialist registrar in Pentonville Prison in London, is concerned that the fact that mentally disordered prisoners are detained—but cannot be treated adequately in prison facilities—reinforces society's view that detention is all that is needed for people with mental health disorders, thus emphasising the disparity between physical and mental health care. Labelling personality disorders as untreatable is questionable, adds Martin Zinkler, consultant psychiatrist in London, and can increase stigma and the feeling of hopelessness that surrounds many such patients.
Nisha Shah, locum consultant psychiatrist in London, suspects that imprisonment also reinforces negative attitudes towards offenders. Crucially, she blames political expediency for the lack of willingness to change legislation—because such a change may well not win votes.
The full text of these reponses is available at www.bmj.com/cgi/eletters/334/7605/1222