The article "Malingering or Real Illness? Prison Staff Learn Difference" in the October 20 issue addresses a vexing problem in correctional mental health. Elsewhere in the same issue ("APA Alerts Congress to Crisis in Prison Mental Health Care"), Steven Sharfstein, M.D., is quoted as saying, "There are nearly five times more mentally ill people in jails and prisons than in state psychiatric hospitals. . . ."

Yes, manipulation is a problem, and psychiatrists need to be wary about it, but they are typically too wary and unconcerned, and the prisoners who need care, including ones who figure out the only way to get care is to manipulate or exaggerate symptoms, are ignored on account of the staff’s belief that so many prisoners try to malinger or exaggerate symptoms to gain attention and privileges.

Correctional psychiatrists tend to err on the side of excluding possible fakers from their caseloads. There is a comment in the article about how dangerous that can be, but more attention needs to be given to the tragic consequences of making such errors. Whenever I am asked to evaluate the adequacy of a prison or prison system’s mental health services, I typically ask to see the files of successful suicides over the previous three years. Suicides are relatively common in prison, and intensive suicide prevention is mandated by all accrediting bodies. But in a majority of successful suicides I have reviewed, there were inadequate mental health services prior to the deaths, and there are notes in the chart such as "faking [or manipulating] to get attention." In one case that I report in my book, Prison Madness, the C.O. on rounds passed the prisoner standing on his bunk with a noose around his neck, and instead of ringing the alarm, he calmly completed his rounds. After rounds he returned to that prisoner’s cell and found the man hanging and dead. There were notes in the prisoner’s clinical chart from several days earlier that he was inappropriately seeking psychiatric help and didn’t really suffer from any mental illness.

Unfortunately, this is not an uncommon scenario. We know that in a total institution (prison, asylum, and so on), when mental health services are inadequate, people with bona fide psychiatric problems essentially have to create a ruckus to get the minimum level of care they need. People with schizophrenia or serious suicidality have to exaggerate or "fake" symptoms to get the attention of the overstretched mental health staff. In other words, they both suffer from psychosis and they manipulate—it’s not a case of either-or. But when the mental health staff see the manipulation and look no further, the prisoner’s condition is likely to deteriorate further, or he or she may successfully commit suicide. This tragic reality is especially prevalent in supermaximum security units and other sites of punitive segregation and near-solitary confinement, where prisoners with serious mental illnesses tend to collect while staff assume they are "bad" and not "mad."

Terry A. Kupers, M.D.

Oakland, Calif.