Psychiatric care in prisons: towards the inevitable integration of regional health services to manage inmates with mental health problems.

38 The prevalence of mental disorders in prisons both in Spain and abroad has clearly increased in recent years1-6. The causes leading to this increase in the number of inmates are many and varied: from the psychiatrisation of day to day problems (as is the case in the community), to the high levels of substance abuse prior to entering prison and during the prison sentence, the effects of prison life and the existence of a mental illness presented prior to the legal proceeding that was diagnosed (or not) during same. There are several studies that indicate that the general public commits proportionally more crimes7-9, but it is no less true that in situations where alcohol or drugs are consumed and during periods of delirium tremens or the start of a paranoid psychosis, the resulting episodes of violence may help to explain why a part of the prison population in ordinary prisons is labelled as such10. However, the aim of this editorial is not to offer a detailed analysis of the causes of such a high prevalence of mental disorder, but rather on how to deal with this important problem as effectively and ethically as possible. Prison healthcare in Spain is the responsibility of the Ministry of Home Affairs, which means that the prison primary healthcare teams that answer to the ministry are responsible for caring for inmates. When diseases requiring specialised care are identified, the teams carry out the traditional inter-consultation process with the reference hospital in the province where the prison is located. This entails a degree of coordination with specialists and transfer of the inmate by the police. The most common medical problems that require specialist care are usually linked to dental, mental health and physical trauma issues11. The most commonly observed mental pathologies are schizophreniform disorders, affective disorders and inmates with type B traits B (impulsiveness, low tolerance to frustration, emotional instability), drug consumption, and in many cases there is a dual pathology5,6,12. In response to the growing frequency of these disorders, the Ministry of Home Affairs designed a comprehensive care programme for the mentally ill (PAIEM in Spanish), which contains a protocol that establishes the bases for correct identification of a case, treatment and monitoring through an internal social-healthcare process13. The psychiatric consultation system continues to be the predominant approach used in Spain, with the exception of Catalonia and the Basque Country, who have transferred competences in healthcare matters and whose organisation is very different. The consultations, carried out by external psychiatrists (usually self-employed professionals contracted by the prison) rarely consist of more than 3-4 visits a month, which is insufficient if the aims of the PAIEM are to be met, and beyond this, to offer high-quality, comprehensive care of the Editorial