To the Editor: In the August issue, Murrie and colleagues (1) brought much-needed attention to the paucity of research exploring the impact of incarceration in adult prisons on the mental health of juveniles. The authors effectively described the legal and political developments that have contributed to an increase of juveniles housed in adult correctional facilities. Further, they recognize that although this subgroup may be small compared with the large number of youths in juvenile facilities, providing empirical evidence of the need for a systematic approach to addressing treatment and safety needs in this subgroup may lead to numerous mental health benefits and cost savings.
Murrie and colleagues used the Massachusetts Youth Screening Instrument-Version 2 (MAYSI-2), a mental health screening measure widely used in the juvenile justice system, to gather data about the mental health problems of juveniles in adult prisons and compared their responses to MAYSI-2 national normative data for youths in juvenile facilities. However, the authors did not sufficiently address several methodological concerns, such as the potential impact of situational influences and time of measurement on the expression of psychiatric symptoms. Also, multiple sources of data should be used to ensure diagnostic accuracy. These considerations are especially important in this population and could have been anticipated and addressed by the investigators to improve the measurement of their important research questions.
There are several considerations when gathering psychiatric data from inmates. Youths in adult prisons, similar to adult inmates, usually have limited access to various resources, such as stimulant medications, and may mislead medical or mental health staff about the severity of their distress to gain access to these resources. In addition, antisocial and borderline personality disorders are prevalent in correctional settings; inmates may malinger or be motivated by secondary gain (2). Although Murrie and colleagues studied the psychiatric symptoms of juveniles, the influence of these contextual factors on responses to questionnaires by youths in an adult prison should be considered. In addition, environment-specific events may modify the manifestation of "faking bad," or exaggerating symptom severity, such as pending legal cases, changes in housing status (for example, placement in segregation), or a desire to transfer to another facility (3). The authors recognize a temporal dimension when discussing possible explanations for the low rates of self-reported substance use in their sample, but they offer no viable solutions. I suggest using multiple sources of information at different intervals to assess these psychiatric symptoms—for example, conducting brief clinical interviews and administering personality assessments such as the Minnesota Multiphasic Personality Inventory—to better estimate the true prevalence of mental health problems of juveniles in adult prisons.
Also, I suggest that Murrie and colleagues report results by race and ethnicity. Racial-ethnic disparities with regard to diagnosis of mental disorders, treatment, and outcomes are well documented (4). There is value in discerning any disproportional representation of youths from racial-ethnic minority groups in the subgroup of juveniles incarcerated with adults. Addressing potential disparities in the mental health care of this population has important ethical, public health, and criminal justice policy implications. Incorporating these methodological features into their study would have enhanced their findings about psychiatric diagnoses and treatment needs of this population and helped to determine appropriate interventions.
Dr. McGregor is a health policy fellow at the Satcher Health Leadership Institute, Morehouse School of Medicine, Atlanta.
Murrie DC, Henderson CE, Vincent GM, et al: Psychiatric symptoms among juveniles incarcerated in adult prison. Psychiatric Services 60:1092–1097, 2009
Appelbaum KL: Assessment and treatment of correctional inmates with ADHD. American Journal of Psychiatry 165:1520–1524, 2008
Pompili M, Lester D, Innamorati M, et al: Preventing suicide in jails and prisons: suggestions from experience with psychiatric inpatients. Journal of Forensic Sciences 54:1155–1162, 2009
Mental Health: Culture, Race, and Ethnicity—A Supplement to Mental Health: A Report of the Surgeon General. Rockville, Md, US Department of Health and Human Services, US Public Health Service, 2001