• Forensic psychiatry specialist Dr. Chittahari Abhayanayaka explained that prisoners’ mental health needs differ depending on where he/she is within the legal process, especially in relation to uncertainty, structure and future outlook

In the wake of several deaths reported within prisons in recent years, including the latest incident involving a death-row inmate linked to the killing of a Parliamentarian, attention has once again turned to the mental health and well-being of people living within the country’s correctional system.

People within prisons and correctional centres face pressures very different from those experienced outside. Overcrowding, uncertainty surrounding court proceedings, separation from families, substance use disorders, stigma, violence, and the loss of personal freedom can all have a serious impact on mental health. Maintaining the mental well-being of prisoners is important not only for the inmates themselves, but also for prison staff, families, and the society at large, since most inmates eventually return to the community.

To better understand the situation, The Daily Morning spoke to forensic psychiatry specialist and the co-author of the South Asian Perspectives in Mental Health and Psychology' Forensic Psychiatry and Prison Mental Health in South Asia' Forensic Psychiatry and Prison Mental Health in Sri Lanka Chapter (Number Six), Dr. Chittahari Abhayanayaka about mental healthcare within the country’s correctional system, the mental health conditions commonly seen among inmates, the challenges faced by prison healthcare professionals, and the reforms needed to improve prison mental health services.

How would you define correctional psychiatry?

Correctional psychiatry is about providing mental healthcare to people living within the prison system. It doesn’t necessarily mean that only specialist psychiatrists should provide these services, but, working in this setting requires additional skills and a clear understanding of how the prison environment functions.

Mental illnesses seen in prisons are not different from those found in the wider community, and the basic principles of treatment remain the same. What changes is the environment in which the care is delivered. Treatment takes place within a secure and highly regulated system, which creates practical challenges such as safety concerns, limited resources, and the need to work within institutional rules. So, correctional psychiatry is about adapting mental healthcare to a very different setting.

What are the most common mental health conditions identified within the correctional system?

One of the key findings, both in Sri Lanka and internationally, is that mental health conditions are far more common among people in prison.

For example, depression affects about four per cent of the general population, but, within prisons, the figure rises to around 10.5%. Psychotic disorders affect about 1% of the community, but, the rate increases to around 3%–4% in prisons. Overall, studies suggest that around one in seven prisoners has a severe mental illness. In Sri Lanka, research has shown that nearly 30% of newly admitted inmates experience significant psychological distress.

Substance use disorders are among the most common conditions identified within prisons. Studies suggest that between 30%-70% of inmates struggle with alcohol or drug-related problems. A large number of offences are also linked to substance use. For example, around half of remand prisoners and nearly two-thirds of convicted prisoners are connected to drug-related offences. This happens partly because people with substance use problems are more likely to enter prison, but also because prison conditions themselves can increase the vulnerability to these issues.

Depression and anxiety are also very common, particularly due to stress, isolation, and uncertainty about the future. Severe mental illnesses such as psychotic disorders are seen more frequently than in the general population. Personality disorders, especially those associated with impulsivity, are another important category.

Self-harm and suicidal behaviour are also major concerns. In Sri Lanka, studies suggest that around 27% of inmates have shown some form of suicidal behaviour, although this does not refer to completed suicides. Overall, the high rates of mental illness within prisons reflect both pre-existing vulnerabilities and the stressful nature of the prison environment itself.

Why are people with mental health conditions overrepresented within prisons?

A common misconception is that many people assume that individuals with mental illness are more likely to commit crimes, but, this is not true for most mental health conditions. The increased risk is mainly linked to substance use disorders and certain personality disorders, rather than mental illness in general.

There are several reasons why people with mental health conditions are overrepresented in prisons. Some are linked to legal and social systems. For example, laws related to vagrancy or homelessness can disproportionately affect vulnerable individuals, including those living with mental illness. This is not unique to Sri Lanka and is seen in many countries. It raises questions about whether some legal provisions may indirectly criminalise poverty or mental illness.

At a procedural level, people with mental illness may also face disadvantages such as limited access to legal support and weaker social networks, which can affect their ability to obtain bail or navigate the legal system.

There are also shortcomings within mental health systems themselves. Limited psychiatric services, shortages of inpatient beds, and underdeveloped community mental health services can result in people not receiving timely care. In some countries, reductions in long-term psychiatric facilities have been followed by an increase in mentally-ill individuals within prisons.

Once inside prison, conditions can further worsen mental health. Overcrowding, substance use, conflict, and the loss of freedom all act as major stressors. The loss of daily structure, separation from family, and reduced social roles can contribute to emotional distress and a loss of identity. In Sri Lanka, overcrowding remains a major issue. The prison system was originally designed for around 10,000-15,000 inmates, but currently holds close to 40,000. These conditions clearly have a negative impact on mental well-being.

How do the mental health needs of suspects, accused persons, remand prisoners, convicted inmates, and death-row inmates differ from one another?

Mental health needs differ depending on where a person is within the legal process, especially in relation to uncertainty and structure.

Suspects, who are usually held in Police custody, often experience acute fear and anxiety because they are just entering the system and have little idea about what will happen next.

Remand prisoners face ongoing uncertainty about their cases. Repeated court appearances and long delays can create significant psychological stress. Many also experience a sudden loss of routine and meaningful activity. In Sri Lanka, this group is particularly large, making up nearly two-thirds of the prison population, and mental health problems and suicidal behaviour are especially common among them.

Convicted prisoners generally have more structure in their daily lives, including work programmes and routines. However, they may experience institutionalisation, hopelessness, especially in relation to long sentences, and continued struggles with substance dependence. Limited contact with family members can also affect their mental well-being.

Death-row prisoners face a very different psychological reality. Although they may have access to religious or educational activities, they are often excluded from work programmes. The prolonged uncertainty and the seriousness of their situation can lead to severe psychological distress, including depression and anxiety.

Overall, mental health needs exist across all groups, but, the type and severity of distress vary depending on factors such as uncertainty, structure, and future outlook.

What is the mental health situation among female prisoners and other marginalised groups?

Female prisoners frequently face multiple psychosocial challenges. Many have limited family support and remain deeply worried about their children and family responsibilities, which can cause significant emotional distress. When women are imprisoned, family structures are often disrupted more severely compared to when men are imprisoned.

Women may also experience increased stress due to a lack of privacy within prison settings. In some cases, children stay with their mothers inside prison. Although this helps preserve the mother-child bond, the prison environment is not ideal for child development and can increase stress for mothers as well.

Young prisoners are another vulnerable group. Their stage of emotional and psychological development, combined with separation from family and exposure to prison environments, can increase emotional distress and the risk of mental health problems.

Transgender prisoners often face stigma, discrimination, and difficulties relating to placement within appropriate facilities, which increases psychological vulnerability.

Foreign prisoners also face significant difficulties, including language barriers, cultural differences, the lack of family support, and the limited understanding of the legal system. These factors can contribute to isolation, anxiety, and difficulties in accessing both legal and healthcare services.

Why is it important to provide proper mental healthcare to prisoners?

Ensuring the health of prisoners is ultimately the responsibility of the State. Imprisonment itself is the punishment; it should not mean stripping people of their basic rights, including the right to healthcare. In some respects, prisoners may even require greater attention than the general population. An ordinary citizen can independently seek treatment wherever they choose, but, prisoners don’t have that freedom and depend entirely on others for access to healthcare.

Providing healthcare to prisoners should be viewed as a shared responsibility involving the Government, healthcare workers, and society as a whole.

Prisoners are a particularly vulnerable population, and because their liberty is restricted, the responsibility to ensure equitable care falls even more heavily on the State and healthcare professionals. Doctors also have a duty to advocate for patients who cannot advocate for themselves and to ensure that they receive care equivalent to what is available in the wider community.

This issue is influenced by multiple factors, including social inequality, economic disadvantage, limited access to healthcare within the community, and broader systemic gaps in mental health services. These factors contribute to why many individuals enter prison with significant unmet health needs.

Improving prison healthcare also improves the health of the society as a whole because the majority of prisoners eventually return to the community. If a person with a substance use disorder does not receive proper treatment inside prison, they return to the society carrying the same untreated condition, which can negatively affect families and communities.

Many prisoners come from economically disadvantaged backgrounds. Some individuals only discover that they have mental health conditions after entering prison because they never had proper access to healthcare outside. This shows that prisons sometimes become an important point of contact for identifying previously unmet health needs.

We also need to consider the impact on prisoners’ families. If someone leaves prison in poor mental or physical health, the entire family structure can be affected, and in some cases, this can contribute to serious strain or even family breakdown.

How is the identification and clinical management of prisoners with severe mental illness typically organised within correctional health systems?

In most correctional health systems, the identification of severe mental illness happens through a combination of entry screening, ongoing clinical observation, and referral pathways. Referrals may come from prison staff, healthcare personnel, or sometimes through self-referral by the inmates themselves.

Initial medical assessments carried out at the time of admission are an important opportunity for identifying mental health problems. This process is usually supported by periodic reviews or reassessments whenever concerns arise during custody.

Management generally involves stabilisation within prison healthcare facilities where available, along with referrals to specialised psychiatric services when necessary. Treatment approaches usually include medication, psychosocial interventions, and structured risk monitoring, with a strong focus on the continuity of care both during imprisonment and after release.

What kind of psychiatric and psychological services should be provided within prison healthcare facilities?

A prison mental health service should be comprehensive, evidence-based, and built around the principle that prisoners should receive care equivalent to what is available in the wider community. International and national standards such as the World Health Organisation and the United Nations (UN) Office on Drugs and Crime guidance, the UN Standard Minimum Rules for the Treatment of Prisoners (Mandela Rules), the UN Rules for the Treatment of Women Prisoners and Non-custodial Measures for Women Offenders (Bangkok Rules), the Convention on the Rights of Persons with Disabilities, and recommendations made by the Human Rights Commission of Sri Lanka provide important directions in this area.

These services can broadly be organised around three main functions: clinical care, health protection and prevention, and rehabilitation.

First, prisoners need comprehensive clinical mental healthcare. This includes systematic mental health screening at admission, ongoing psychiatric assessment during custody, and continuity of care during transfers and after release. Prison psychiatric services usually involve outpatient clinics, the management of acute psychiatric presentations within designated inpatient units where available, and referral pathways to external psychiatric hospitals for more complex or high-risk cases. Psychological interventions such as counselling, structured psychotherapies, and substance use treatment programmes are also essential.

Second, prison mental healthcare must focus on health protection and prevention. This includes ensuring safe living conditions, adequate nutrition, access to physical activity, and reducing environmental and institutional stressors. The early identification of clinical deterioration and continuous monitoring are particularly important for high-risk groups, including inmates at risk of self-harm or suicide.

Third, there must be a strong focus on rehabilitation and recovery. This includes mental health education, structured recovery programmes, and integrated interventions for substance use and psychosocial rehabilitation. Increasingly, correctional mental health systems around the world are adopting recovery-oriented approaches that focus on rehabilitation, reintegration, patient engagement, and continuity of care after release. Collaboration with broader prison rehabilitation programmes is also important for long-term recovery.

From a systems perspective, international standards support integrating prison health services into the national healthcare system rather than operating them in isolation. This helps maintain clinical independence, professional standards, and the equivalence of care with community services.

Effective service delivery also depends on a multidisciplinary team approach involving medical officers, psychiatrists, psychologists, nurses, occupational therapists, psychiatric social workers, and addiction specialists. Additional attention is required for vulnerable groups including female prisoners, individuals with severe mental illness, and prisoners with disabilities.

Overall, the guiding principle should be that prisoners have access to equivalent, continuous, and recovery-oriented mental healthcare that is integrated with the wider health system and responsive to both clinical and rehabilitative needs.

What role do prison staff play in the early identification and referral of inmates with mental health needs?

Prison staff plays a very important frontline role in identifying inmates who may be experiencing mental health difficulties, mainly because they interact with prisoners on a daily basis.

Changes in behaviour, personal hygiene, mood, aggression, or social withdrawal are often early warning signs that something may be wrong. In many cases, prison staff is the first to notice these changes and raise concerns.

Referral pathways differ from one system to another, but usually involve communication between custodial staff and healthcare teams. Welfare officers, peer support systems, or designated focal points may also assist with early identification and referral.

The effectiveness of this process depends heavily on proper training, awareness, and having clear referral mechanisms in place.

What approaches should be used to train correctional officers in recognising and responding to mental health problems among inmates?

Internationally, correctional officers are usually given structured training programmes covering areas such as mental health awareness, suicide prevention, de-escalation techniques, and the recognition of psychiatric symptoms.

These programmes are generally introduced during induction training and reinforced through regular refresher courses. Some systems also use simulation-based learning or multidisciplinary training sessions involving mental health professionals.

The overall aim is to improve early recognition, reduce the risk of situations escalating, and ensure timely referrals to mental health services.

What are the key components of effective suicide risk assessment and prevention strategies in correctional settings?

Effective suicide prevention within correctional settings usually requires a layered and continuous approach rather than isolated interventions.

This begins with systematic screening at the time of admission, followed by ongoing risk assessments throughout custody. It is also important to identify high-risk individuals, including those with severe mental illness, substance use disorders, or a history of self-harm.

Certain periods are considered particularly high risk, such as sentencing, remand transitions, or receiving distressing personal information.

Other important components include environmental safety measures, staff training, crisis response protocols, and timely access to mental healthcare services. In general, a continuous monitoring system is necessary for long-term risk reduction.

What operational and clinical challenges are commonly encountered by mental health professionals working in prison environments?

Mental health professionals working in prison settings face a wide range of operational, clinical, and ethical challenges, many of which are reported internationally.

Common difficulties include limited privacy during consultations, inadequate clinical spaces, heavy caseloads, and restricted access to communication systems and specialist services. Security procedures, staffing shortages, and fragmented health information systems can also affect service delivery. The prison culture and safety concerns create additional operational pressure.

Clinicians may also experience what is sometimes called a “dual-role tension”, where they must maintain a therapeutic relationship while working within a custodial environment. This can create ethical stress, particularly in coercive settings or when witnessing the use of force.

Clinical decision-making may also become more complicated because of custodial restrictions. For example, when prescribing controlled medications, clinicians must balance the risk of misuse or diversion against genuine clinical needs. Limited access to inpatient psychiatric beds and specialist services can further disrupt continuity of care.

Despite these challenges, clinicians generally adapt their practice in order to provide essential mental healthcare within the available resources while maintaining professional and ethical standards.

What are the main policy considerations when designing or reforming prison healthcare systems, particularly regarding mental health service delivery?

Policy development in prison healthcare generally focuses on ensuring the equivalence of care between prison and community settings, the continuity of treatment, and stronger integration with national healthcare systems.

Other important considerations include governance structures, workforce planning, training standards, and clear referral pathways for specialised care. Many systems also place importance on maintaining clinical independence while ensuring effective coordination between the correctional authorities and the health authorities.

Mental health is now increasingly recognised as a central component of the prison healthcare policy, especially in relation to suicide prevention, substance use disorders, and severe mental illness.